How to prevent tearing??

[Drewsmom]

I had a wonderful birth with ds 11 months ago and we're not expecting another one for a while yet but the one thing that did not go well was my 3rd degree tear. I had him naturally but in a hospital setting. I asked my MD if he could help me to not tear b/c I absolutely did NOT want an episiotomy (99% ep. rate in the Utah where I delivered). He didn't do the episiotomy, the baby came extremely slowly, he was crowning for a long time, and still I tore. I know it was because of the inexperience of my dr. so my question is...

For the next time around, what should I ask a dr. or nurse-mid-wife (since I understand they are mostly like dr.s) to REALLY know if they know how to prevent tearing. I felt like I was perfectly able to do everything else but I did need help with this one. Is it a possibility to have a mid-wife work with a dr. and have her do the actual delivering? I live in VA. That may be an option too. I would like to know what resources are out there to know exactly how to prevent tears. That's the only thing I'm terrified of for the next birth. However, homebirth isn't an option for me.

Thanks

[lisamarie]

I am really sorry to hear about your 3rd degree tear! Hope you have healed well.

Yes~I think the next time around, interview midwives. Ask about how they prevent tearing. I suggest perineum massage. I did this during the last 6 wks. of my pregnancy and it really helped. It helps to prepare the tissue to be stretched and it also helps prepare you for some of the feeling that you feel there during labor and delivery. That can help. Also, if the midwife applies warm compresses to the perineum during labor/pushing, it can also help stretch the tissue. Both of these things can help prevent tearing. Of course, if the baby is in distress, they still might have to cut to get the baby out ASAP.

Best of Luck~

Lisa

[candiland]

Sorry to hear about your yucky tear!
To help prevent tearing (there is no guarantee of not tearing), the midwife or doc should probably know how to use olive oil (or some other substance similar to it) to massage and stretch the perenium while you are pushing. Also, nice warm, wet compresses applied to the perenium can help. Another thing to consider is your position. If you birth in an active upright position, such as standing or squatting, it gives the tissues more room to spread, thus helping to avoid a tear. Delivery of the head should be done slowly and the midwife or doc should know how to stretch and support the perenium. Also, many women, including myself, actually tear with the shoulders being born, so care should be taken to support the perenium during this time, as well. Hope this helps :cool:

[Drewsmom]

Thank you for your concern and replies. I think probably the biggest help will be trying to change my position. I used a birthing bar during much of my transition period but because the contractions were so intense and b/c it was my first birth I ended up sitting up for the delivery. What about lying on your side, that's probably what I would have rather done (didn't know it until I got in there) but it was too intense for me to move. I tried perineal massage but was not able to do them as much as I wanted to due to premature labor b/c of bladder infections (another story). Every time I tried doing them I had contractions. I will try some other things to help prevent that next time. Thanks, I'd be really interested to know anything about how to hold the perineum to help stretch & hold while the baby is crowning. That's what I intuitively felt needed to be done & really should've just reached down there myself . He did have very large shoulders too.

[cottonwood]

Drewsmom, position is very important, and warmth and moisture definitely help the skin to stretch. The effectiveness of stretching the perineum during labor is highly debatable -- in my case, I felt like it actually had a negative effect because the discomfort of having it done (both psychological and physical) made me tense up.

I personally feel that the most important thing you can do to avoid tearing is to just let your body automatically push the baby out. As long as there has been no interference (physical or psychical), and you are paying attention to your body's cues (for instance, squatting if you feel like squatting,) your body will operate according to a delicate hormonal feedback system, and will not begin pushing the baby out until the perineum is stretchy enough.

[kama'aina mama]

Positioning is pretty important. Don't spread your knees too far apart. Try to point them at your ears, if you can. Out is not better, up is. If you spread a lot side to side the perineum is already taut and then the baby comes down and stretches it further still. Recipe for disaster. Gee, you know what spreads your legs REALLY far apart? Stirrups.

[EarthWind]

Hi, I'm training to be a midwife - just took Elizabeth Davis' Heart and Hands Midwifery Intensive and am currently looking for an apprenticeship. From my understanding, you will want to ask what kind of perineal support your doctor/midwife will be doing. You want to make sure that they will be keeping your perineum supported with warm compresses and lubricated with olive oil throughout the pushing stage. Warm compresses keep circulation in your perineum thus helpful in preventing tearing. You might want to do a little bit of research yourself about perineal support to prepare yourself. You could check out the book Heart and Hands by Elizabeth Davis (a very good book) and just check out the chapter Assisting At Births (I'm sure there are other good books out there, but I know this one). Since forced pushing often causes tearing (along with no knowledge of perineal support and positioning) you will also want to make sure that they won't have you do forced pushing -- that they will let you wait for the urge to push. There is really no need to rush the pushing stage of labor if the baby is not in distress. I would also agree with finding better positioning for the pushing stage. Also, I would recommend that six weeks before your due date you begin massaging the scar on your perineum with evening primrose oil two times daily for twenty minutes a session. Evening primrose oil breaks down scar tissue making the perineum nice and supple and thus helping to prevent another tear at the same place. If you have a history of premature labor, don't begin evening primrose oil massage until your 37th week. I had a second degree tear (almost 3rd degree) and will be doing the evening primrose oil massage when the time comes, as dh and I will be trying to get pregnant again soon. From what I understand, it is very effective.

I hope this is helpful.

Michelle

edited, again, to add you might want to check out Midwifery Today's e-zine at Midwiferytoday.com and type in preventing tears in their "Search Midwifery Today" section. I bet you'll come up with lots of information from them.

[Drewsmom]

Thank you, thank you so much for such informative responses. This gives me some great resources to gain information. In thinking back on the birth and watching the video again, I believe that I tore when ds's shoulders came out, maybe not but he didn't have any fresh blood on his head (except from a minor tear that started in the initial stages of crowning). My dr. had my husband get out from behind me and threw me back, legs up to get his shoulders out. It was all so quick. This is why I'm trying to be more informed for the next child so this doesn't happen. I really had intended on standing up for the birth but that's not what my body wanted to do during transition. I had spent too much time I think on the birthing bar in the initial stages of pushing (3 hr. pushing) and my legs were tired. I know that I will be a more effective pusher the next round. I knew what I needed to do the first time but in order to lessen the intensity of the pushing I didn't do it as effectively. As far as finding a provider who isn't into forced pushing, no worries, I did what my body wanted in that realm the first time around. I was laughing inside when they were counting and saying breath, I didn't have the words at the time to say, "yeah right" as my body's pushes lasted 20 sec.s with a 2 second break and then pushed again for 5 sec.s with a 30 sec. break in between. They were trying to tell me to push in between but even as the baby's head was crowning I just didn't have the urge so I didn't. That's why I say he was crowning for quite a long time. He in fact was 1/2 way out when I just didn't have the urge again so he went back in and we camped out for a few more minutes until we were ready to push again (he was pushing at the same time...an interesting feeling). Anyway, yada yada yada...thanks for listening/reading, and thank you again for all of the suggestions this really helps.

[Drewsmom]

One other qu. then for those who are familiar with what is allowed in hospital settings and what is not, etc. I asked them about using olive oil and warm compresses, I offered to bring in my own materials but they said that I would not be allowed due to hospital rules. They had (I don't know if this is with all hospitals) a policy that they could only use materials that were already in the hospital probably due to liability reasons for infections. I know, I know it's probably one more reason why I should consider having a home birth.

[veganmamma]

Originally posted by EarthWind
Hi, I'm training to be a midwife - just took Elizabeth Davis' Heart and Hands Midwifery Intensive and am currently looking for an apprenticeship.

Michelle-- I am taking it now, I am in advanced coming up. Are you local or did you do a module? Or is this Michelle from my class? :LOL

Okay, ON topic, re: tearing

IMO/E, perineal massage is uncomfortable and doesn't do much. You might want to massage some oil into your old scar to soften it though. Also a good way to try to heal emotionally from the disappointment of tearing.

I think choosing position and not pushing are mostly what prevents tearing, although I pushed pretty hard and was on my back and didn't tear, save for a tiny abrasion. I didn't really choose my back, either, long story. Anyway, I think tearing tends to occur when you are not able to follow your instincts.

Also, something I give lots of credit to was laboring in the water. It is extremely helpful in preventing tears because it is warm, moist heat on the perineum and the vagina, something a warm compress isn't. (in the vagina that is.)

I think that if you are able to choose a position and choose your own level of pushing, (some women don't even "push," their body pushes but not consciously,) you will not have a tear that requires stitches, hopefully no tear at all.

[veganmamma]

Originally posted by Drewsmom
One other qu. then for those who are familiar with what is allowed in hospital settings and what is not, etc. I asked them about using olive oil and warm compresses, I offered to bring in my own materials but they said that I would not be allowed due to hospital rules. They had (I don't know if this is with all hospitals) a policy that they could only use materials that were already in the hospital probably due to liability reasons for infections. I know, I know it's probably one more reason why I should consider having a home birth.

Well you can request wash cloths immediately after arriving at the hospital and make your own with their hot water. I wonder if olive oil from their cafeteria counts? :LOL

And sure, you should consider homebirth, I think just about everyone should consider it. You should give birth where you feel most safe and comfortable. If that's home, go for it. If that's the hospital, then that's where you should be. I wanted a HB from day 1 and because it was such a struggle to get DP and his family on board, then find a MW and pay for one, I decided to go to a hospital. After touring it and really evaluating my fears and desires, I realized that I was so stressed out after agreeing to go to the hospital I could barely enjoy my pregnancy at times. DP agreed that where I was comfortable was best and we had a HB. Now he is very pro HB, btw.

[pamamidwife]

I don't think that a provider can stop or prevent a tear by massage or perineal support much.

I have slowed down heads and held in hands that were up by the head as they emerged to help prevent tears, but I don't think that perineal massage does much to prevent tears.

Positioning is key - so is having the mother put her hands on herself to guage her pushing and when to slow.

Here is an article (rant) I wrote: http://magazine.motherspassion.com/tears.html

And, here is another great article from my favorite UK midwife, Sara Wickham: http://www.withwoman.co.uk/contents/info/tears.html

[Tanibani]

Originally posted by pamamidwife
I don't think that a provider can stop or prevent a tear by massage or perineal support much.

I have slowed down heads and held in hands that were up by the head as they emerged to help prevent tears, but I don't think that perineal massage does much to prevent tears.

Positioning is key - so is having the mother put her hands on herself to guage her pushing and when to slow.

As someone who suffered a 2nd degree tear to my vagina, and a 3rd degree tear to my perineum (there is a scar on my anus which caused a lot of constipation/BM elimination problems until I saw an acupuncturist last summer) who HAD the OB massage me with oil during my 2 hour pushing - the oil didn't help. I did do perineal massage up to the birth. What I did notice is that it helped my pelvic floor relax/open up a bit more - and not tense up so much for vaginal/OB exams.

I do agree it has all to do with positioning. I was in the worst possible position, flat on my back, knees pulled all the way back. I tried side pushing, but the weight of my belly didn't feel good. I didn't last long squatting by the bed. It would have helped to have someone (Doula) with that. (Not to discourage you, try it when you are in labor. I'm just telling you my experience.)

My OB was "Mr. Natural Childbirth." He knew I would tear and was busy applying oil all that time. (I was so angry with him, because if he knew it, then he also knew what would help prevent it - instruct others in the room to help hold me up!!!!!!! Or tell me to get on my hands and knees.)

But after 18 hour of being denied food and drink (I was starving, but DH didn't want to give me anything because he thought he was doing the right thing by following hospital rules. ) I was too exhausted to sit up or even vocalize "hey help me in a supported squat."

I was angry with my OB for a long time for the tear... because he should spoken up.

Another thing, I was getting a small drip of Pitocin to get contractions started again (they petered out after 10 cm). It was either that or get a C-section. So I was really pushing hard and I couldn't even hear the OBs voice anyway. I hated that my baby was getting hits of Pit and I wanted him out ASAP - not realizing that if I just PUUUUUUUUUUSHED, without stopping, pausing, not being able to feel a thing 'cause he probably numbed me down there, that made the tear worse. :

I'm having a homebirth and I'm not going to focus on fearing a tear now. I'm just going to focus on remaining upright and active (rather than passive - and eating and drinking as much as I want for energy) and letting the baby come out slowly, into my own hands, rather than the ridiculous coached pushing I did in the hospital. In the hospital, I couldn't see or feel anything, and I was DETERMINED to get my baby out ASAP. That was the part of the problem.

PS Drewsmom - try to find an OB that is more "natural birth" oriented. Ask your local childbirth educators who that person is. Rules schmules. To me, it looks like it's really up to the doc whether he/she wants to apply oil.

[stayinghome]

Pamela great article!

My perspective is this: I had an episiotomy with my first, and tore naturally with my second two. I just kind of take it as par for the course, kwim? I will say this- healing from a natural tear was much easier then an episiotomy. And for me, I found the perinial massage in the weeks before labor to be uncomfortable, so I stopped. teh "ring of fire" that women feel when the baby's head is crowning is nature's way of telling us to slow down and ease up. Warm compresses then felt really nice. Listen to your body- it knows what to do!

[Tanibani]

I preferred Pamamidwife's article to the UK one. And Pam, I LOVE your website!