Perineal tearing: the controversy of hands on vs hands off - Page 3 - Mothering Forums

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#61 of 87 Old 04-05-2006, 08:35 PM
 
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Originally Posted by Arwyn
This is where I totally blanked. A couple years ago, before I knew better, I probably would have suggested pre-labor perineal massage (by herself or with a partner) or warm compresses or perineal support - all that hands-on crap. Now? After a pause where I marveled at the stupidity of the question (how does one avoid shooting oneself in the head? don't shoot yourself in the head!!!), I told her about an article I had read in Midwifery Today recently that answered that very question: "How do you avoid episiotomy? Don't do one." And told her it really was that simple - just tell her provider not to do an episiotomy under any circumstances without explicit consent in the case of an emergency.
Well, I will say one thing for perineal massage/support. If the OB is doing that, they can't be doing an episiotomy. Hmmm...I wonder if episiotomy rates go down if the mother "accidentally" knocks over the tray of tools? Hmmm....
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#62 of 87 Old 04-05-2006, 08:41 PM
 
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Originally Posted by sapphire_chan
Well, I will say one thing for perineal massage/support. If the OB is doing that, they can't be doing an episiotomy. Hmmm...I wonder if episiotomy rates go down if the mother "accidentally" knocks over the tray of tools? Hmmm....
Well, not really... I ended up with both.

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#63 of 87 Old 04-05-2006, 08:46 PM
 
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MomOf3Girlz, it is Mary, at Community Midwives of Toronto

Edited to change ontario to toronto!

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#64 of 87 Old 04-05-2006, 08:53 PM
 
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Hi Brisen,

I'm in Durham Region. We just may have the same midwife...

Anywho, getting back on topic I must say I quite appreciated the warm compresses during pushing with my 2nd daughter. I always tell folks that I felt that eased the "ring of fire" and gave me the confidence to really push her out. My midwife did *ask* before doing it and I said yes. I'm glad I did.

With my 3rd child there wasn't any time for that she came so quickly.

I've never had any tearing with any of my children so far...

This time I planning a home waterbirth so I'm thinking that bone-cracking and ring of fire sensation will be lessened in the water as one poster mentioned previously.

I guess whatever the labouring woman wants is what's best for her. Our bodies really do tell us everything we need to know.
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#65 of 87 Old 04-05-2006, 08:56 PM
 
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Oh, I'm with Sages Femme. I have Lisa Weston.
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#66 of 87 Old 04-05-2006, 09:01 PM
 
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Originally Posted by Brisen
I had 2 homebirths in London -- they did check every 15 mins. It is once active labour starts, though, maybe that's the diff for you? They are supposed to enter it on the chart. My mw today said that they've only had one mom who didn't want doppler in labour, and they decided that they should ask her every 15 mins and have her verbally decline so they could record it. She said that they could probably just have me say no once & for all when they show up -- I think they just weren't sure what they were allowed to do with the first mom who declined.

I'm in Toronto now.
No, they didn't check that often even when I was in active labour, and they used a fetoscope rather than a doppler. They did have a doppler in case I wanted to hear it, but I was fine.

I was with the Community Midwives of Hamilton. I am currently seeing a midwife at the St. Jacobs' Midwives, but I am moving back to Hamilton, and was lucky enough to call the CMOH when they were in the process of hiring a new midwife or else I wouldn't have got in.

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#67 of 87 Old 04-05-2006, 09:29 PM
 
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Ah, I see. Did you find it uncomfortable being checked with the fetoscope? I've only ever had a doppler used to hear in the past, this is my first time declining the doppler. I have a friend who UC'd her last pg, and brought a borrowed fetoscope over to my place to see if I could hear the heartbeat. I totally failed. But, I'm not at all trained on it.

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#68 of 87 Old 04-05-2006, 09:30 PM
 
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No I didn't find it uncomfortable really. I actually prefer that to the doppler because the gel annoys me with doppler.

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#69 of 87 Old 04-06-2006, 04:45 AM
 
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Pam, thank you so much for that article. It was beautiful.

I had a perineal "massage" during my dd's birth and it was horribly painful. Maybe I'll have to drive down to Salem for my next birth

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#70 of 87 Old 04-06-2006, 11:35 AM
 
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Originally Posted by Momof3Girlz
Anywho, getting back on topic I must say I quite appreciated the warm compresses during pushing with my 2nd daughter. I always tell folks that I felt that eased the "ring of fire" and gave me the confidence to really push her out. My midwife did *ask* before doing it and I said yes. I'm glad I did.
Y'know how in movies about The Olden Days, when a woman was in labor, there were frantic cries to "boil some water!"

I once read somewhere that the reason for boiling water was to create warm compresses for the perineum to facilitate birth.....and I've been searching for a "heck yeah! that's true" to support this theory that I have not heard of/read of anywhere since I first read it.

When I've spoken to others about it, they admit they thought the boiling water was to sterilze the equipment, which I also used to think. (What equipment!?! But that's our current modern techno-mindset, assuming people who thought damp air could cause swamp flu or that excessive bathing is unhealthy would be sterilizing the nonexistant forceps/episiotomy scissors on the prairie.)

.....rambling....I hope I'm not too OT here....... "warm compresses on/off" that's in line with hands on/off, right?!
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#71 of 87 Old 04-06-2006, 01:15 PM
 
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Originally Posted by tinyshoes
Y'know how in movies about The Olden Days, when a woman was in labor, there were frantic cries to "boil some water!"

I once read somewhere that the reason for boiling water was to create warm compresses for the perineum to facilitate birth.....and I've been searching for a "heck yeah! that's true" to support this theory that I have not heard of/read of anywhere since I first read it.

When I've spoken to others about it, they admit they thought the boiling water was to sterilze the equipment, which I also used to think. (What equipment!?! But that's our current modern techno-mindset, assuming people who thought damp air could cause swamp flu or that excessive bathing is unhealthy would be sterilizing the nonexistant forceps/episiotomy scissors on the prairie.)

.....rambling....I hope I'm not too OT here....... "warm compresses on/off" that's in line with hands on/off, right?!
Where I work when the baby is about to crown the CNM has me got water "as hot as you can, so hot it hurts to touch it" and they use that for the compresses. I always wondered if it would hurt, it burns my hand as I bring it over yet they slap it right on the perineum. Who knows.

Yeah, you're right though, the old saying boil some water- there weren't "tools" back then, so what would they be sterilizing? Hmm.
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#72 of 87 Old 04-06-2006, 01:21 PM
 
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Depends on how far back - they might have boiled the string they used to tie the cord and the razor for cutting it.

Boiling water also helps keep the house (most houses had 1, maybe 2 rooms) warm and humid for the birth, which is a common ritual in a LOT of pre-industrial cultures (hmm....).

And then of course there's the "busy work" factor. (Oh, to be able to send the OB and L&D nurses out to boil a hundred gallons of water... )
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#73 of 87 Old 04-06-2006, 02:17 PM
 
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Originally Posted by milkydoula
I was at my sister's prenatal appt (i am her doula) with the midwife i am considering using and the midwife suggested that she do prenatal perineal massage. She said that it would help her be able to relax the muscles when there was a lot of pressure from the babies head pushing on it and to train the muscles to relax under pressure.
So you train yourself to relax at manipulating your tissues -- your body is not going to recognize the birth experience as the same sort of thing, so it's not going to react the same way. You can get to where you can be completely relaxed in a relaxing environment with nothing in particular happening to your body, in complete privacy with only your own hands on yourself. That is not going to hold for intercourse or rape. It's not necessarily going to hold for someone besides yourself touching your genitals, or for a baby's head coming through when you're having contractions. The way behaviorism works, if that's what she's after, it requires some degree of specificity. Certain conditions must be present for the learned automatic response to set in.

She's trying to solve the wrong "problem" anyway. The body's tissues don't have to be trained to relax -- they already know how to, and will, given the right conditions. Just like with sex. If a woman is fully aroused, that is, if the body's hormonal process is facilitated and undisturbed and the woman is healthy, the vulval tissues are not going to be traumatized during sex. Even assuming that a woman can train herself to relax while her vulva is being handled, it's going to be superfluous unless she's expecting to not have a normal sexual experience.

I'll leave you to make the parallel with birth.

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I have a history of sexual abuse and have issues with tensing those muscles anyways (sex took a lot of getting used to and relaxation on my part). Would perineal massage help in this case? I would love some input
Does it have more to do with issues of power and trust and inhibition at having others touch you, or with the sensation of being touched in itself? Can you masturbate? In other words, can you touch yourself without tensing up? When you are in a warm bath in private, say? If not, then yes, it would probably be very helpful to allow yourself to feel good things in your vagina, so your body has other associations with it beside sexual assault. (Although it sounds like you've already been doing that to some extent.) I don't know, though, how stretching and rubbing the skin is relevant to this, unless it makes you feel good!

(Directions for perineal massage are often qualified with, "if it doesn't hurt, it's not doing you any good." As pertains to a normal bodily function, this is just plain wrong. But especially for someone with sexual abuse issues, it's an especially irresponsible thing to suggest.)

If you are fine with certain types of touch, then I would say that what you really need to do is disassociate the working of your body in birth with the sexual abuse. They have nothing to do with each other, one is coming from the inside with your desire and consent, the other from the outside without it. And then set up the birth so as to allow you to remain in a place where those associations will not come up, where you are respected, where you feel completely in control, where you don't feel inhibited.
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#74 of 87 Old 04-06-2006, 02:33 PM
 
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Originally Posted by tinyshoes
Furthermore, the concept of perineal massage is just another "women's bodies are broken" message, but this time it is in disguise....."perineal massage" is a suggestion bandied about by the earthy-birth community, especially with CNMs and "crunchy" MDs.
<nodding head>
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#75 of 87 Old 04-06-2006, 02:45 PM
 
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Originally Posted by Brisen
Ah, I see. Did you find it uncomfortable being checked with the fetoscope? I've only ever had a doppler used to hear in the past, this is my first time declining the doppler. I have a friend who UC'd her last pg, and brought a borrowed fetoscope over to my place to see if I could hear the heartbeat. I totally failed. But, I'm not at all trained on it.
Ah yes, the constant checking (with the doppler in my case). HIGHLY annoying especially when contractions are one on top of another...hmmm will have to talk to my midwife about that. I did not enjoy that. I thought they were just trying to keep the student midwife busy, lol...I know it's a "required by law" thing but who knows...maybe I can get out of it.
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Originally Posted by fourlittlebirds
<nodding head>
I agree too. For a long time I've had that feeling <shudder> when women recommend perineal massage. In my DDC and here, when it's been brought up I've just been unable to recommend it for some reason.

This thread has been very enlightening to me... it's nice to explore the feelings I have about it and to have everyone back those up with sound reasoning. Great thread Pama!
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#77 of 87 Old 04-06-2006, 04:17 PM
 
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I know it's a "required by law" thing but who knows...maybe I can get out of it.
I think it is just a College regulation... It seems to me now that midwives who like the regulations don't present them as something you can decline.

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#78 of 87 Old 04-06-2006, 09:04 PM
 
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Originally Posted by tinyshoes
Y'know how in movies about The Olden Days, when a woman was in labor, there were frantic cries to "boil some water!"

I once read somewhere that the reason for boiling water was to create warm compresses for the perineum to facilitate birth.....and I've been searching for a "heck yeah! that's true" to support this theory that I have not heard of/read of anywhere since I first read it.

When I've spoken to others about it, they admit they thought the boiling water was to sterilze the equipment, which I also used to think. (What equipment!?! But that's our current modern techno-mindset, assuming people who thought damp air could cause swamp flu or that excessive bathing is unhealthy would be sterilizing the nonexistant forceps/episiotomy scissors on the prairie.)

.....rambling....I hope I'm not too OT here....... "warm compresses on/off" that's in line with hands on/off, right?!
I'm OT here, but I always just thought boiling water was something to keep the menfolk busy and from being underfoot.

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#79 of 87 Old 04-06-2006, 11:18 PM
 
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Wow, what a great article! The more I read about perineal massage I just don't think it's for me. A month or so ago I was thinking about getting strarted with prenatal perineal massage but no, the whole thought of it just skeeves me out now, and I just find more and more evidence that for care providers to be totally hands off is the best way to let a woman birth. Makes sense to me. Thanks for the article pamamidwife and to all you lovely posters for your experiences and insights. This has been quite an enlightening thread!

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#80 of 87 Old 04-07-2006, 02:15 PM
 
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I thought boiling water was to get a warm bath ready to clean up the baby and mama after birth.

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#81 of 87 Old 04-07-2006, 02:42 PM
 
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Originally Posted by pamamidwife
Prenatal perineal massage has been shown to never improve the outcome of tearing.
I was actually just looking into this about a week or so ago and found this on the Cochrane site (it is a 2006 article, but looks at a bunch of studies done over time):

http://www.cochrane.org/reviews/en/ab005123.html

"Plain language summary
Antenatal perineal massage helps reduce both perineal trauma during birth and pain afterwards

Most women are keen to give birth without perineal tears, cuts and stitches, as these often cause pain and discomfort afterwards, and this can impact negatively on sexual functioning. Perineal massage during the last month of pregnancy has been suggested as a possible way of enabling the perineal tissue to expand more easily during birth. The review of trials showed that perineal massage, undertaken by the woman or her partner (for as little as once or twice a week from 35 weeks), reduced the likelihood of perineal trauma (mainly episiotomies) and ongoing perineal pain. The impact was clear for women who had not given birth vaginally before, but was less clear for women who had. There were no randomised trials on the use of massage devices. Women should be informed about the benefits of antenatal perineal massage."

I am still not sure how I feel about it, and it is interesting that the study notes that episomoties were reduced, but not necessarily tearing by all that much. still food for thought.

note thought that this is only about prenatal perineal massage, nothing at all about "massage" during delivery.
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#82 of 87 Old 04-07-2006, 03:02 PM
 
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I'm in discussion about this elsewhere and also read this research review.

My feeling is how reliable can evidence on perineal massage be in reality?

All our skins are different as can be seen in the way we age and that some of
us have stretch marks and others don't. Were all the perinea of the
same skin type and elasticity? Did all the women carry out exactly the
same massage - and is this possible as all our vulvas are different?
Were all the women well hydrated? What was their diet like? What was
the context of each labour(home/hospital/midwife unit)? What positions
did the women choose to birth in...........?

Surely there are too many variables to make this type of research valid
in terms of recommending that all women do perineal massage?

I agree with Tinyshoes in her assessment that this just encourages us to believe that our bodies are broken and need some training or 'breaking in' and that if I don't massage and I do tear then *I* am at fault.

I have been cut once and torn twice (not on the original scar) what does that say about me? That I tore - no more, no less. I would love to avoid a tear but maybe I am tearable? My first was an underwater totally hands off tear so whose 'fault' was it?

Sorry this tear vs no tear really bugs me and if I'm honest upsets me a bit because I feel that sometimes within the homebirthing community not tearing is seen as being at the top of some mythical hierarchy and tearing is close to the bottom or at least not far away from a failure in some way.
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#83 of 87 Old 04-07-2006, 03:41 PM
 
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I agree, how reliable can evidence on perineal massage be in reality? I think so much has to do with a woman's nutrition and hydration. Water works wonders to keep skin elastic, and I can't stress enough how important drinking plenty of water throughout pregnancy and birth is.

An interesting note is that I had a huge episiotomie with my first birth and tore on that scar line (slightly, not even needing to be sticth) for the following births, EXCEPT my last birth, where I did not tear! Now you must understand that this last birth was my 7th child and I was 40 years old! I gave birth on hands and knees, as I had with several of my other births, but I did take the time to breathe through those ring of fire contractions, where in the past births I had just pushed to get the baby out!

I'm also pretty sure that emotional factors have more to do with strecthing and tearing than prenatal massage can.

Anyway, I think the perinium is a wonderful part of a woman's body and it can do amazing things when it is allowed to.
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#84 of 87 Old 04-07-2006, 03:42 PM
 
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That was a really great article. I'm trying to remember more details from giving birth, but I was in so much pain at the time, I wasn't really cognizant. My OB was doing some kind of 'massage' more like stretching. When I pushed, she was stretching my skin and it was painful. It hurt like I was tearing just a little straight down each time, so I would stop pushing. I told her to stop doing whatever she was doing, and she did. Now that I read that article and this thread, I see that 'helping' me to stretch was counterproductive to my labor. Naturally, my baby's head would have begun crowning, and I would have slowed down my own pushing to ease his head out, because it would have hurt. But the perineal stretching was hurting me before he was even crowning. I pushed for an hour, and it was exhausting. I also don't know if my OB applied counterpressure to my baby's head or not. I was pushing and pushing and pushing and I could not get him out. I wanted him out so BAD! I was very frustrated, I yelled out, "I feel like I'm not doing anything!" I have this sense that my OB was pushing on baby's head, not letting him come out 'too fast'. But I really don't know if she was or not.

I'm really glad I got to read that article. It helps me understand the birth I've already had, and plan better (hands-off!) for the next one.

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#85 of 87 Old 04-07-2006, 06:37 PM
 
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As I always say, I'd like to see these studies... too lazy to look for them at the moment, though.

Here's from the abstract:

Three trials (2434 women) comparing digital perineal massage with control were included. All were of good quality. Antenatal perineal massage was associated with an overall reduction in the incidence of trauma requiring suturing (three trials, 2417 women, relative risk (RR) 0.91 (95% confidence interval (CI) 0.86 to 0.96), number needed to treat (NNT) 16 (10 to 39)). This reduction was statistically significant for women without previous vaginal birth only (three trials, 1925 women, RR 0.90 (95% CI 0.84 to 0.96), NNT 14 (9 to 35)). Women who practised perineal massage were less likely to have an episiotomy (three trials, 2417 women, RR 0.85 (95% CI 0.75 to 0.97), NNT 23 (13 to 111)). Again this reduction was statistically significant for women without previous vaginal birth only (three trials, 1925 women, RR 0.85 (95% CI 0.74 to 0.97), NNT 20 (11 to 110)). No differences were seen in the incidence of 1st or 2nd degree perineal tears or 3rd/4th degree perineal trauma. Only women who have previously birthed vaginally reported a statistically significant reduction in the incidence of pain at three months postpartum (one trial, 376 women, RR 0.68 (95% CI 0.50 to 0.91) NNT 13 (7 to 60)). No significant differences were observed in the incidence of instrumental deliveries, sexual satisfaction, or incontinence of urine, faeces or flatus for any women who practised perineal massage compared with those who did not massage.

Can somebody who understands statistics decipher these numbers?

And what the heck does this mean: "No differences were seen in the incidence of 1st or 2nd degree perineal tears or 3rd/4th degree perineal trauma." Well, what are they defining as "trauma", then?

ETA: Oh, okay. "Women who practised perineal massage were less likely to have an episiotomy." Not a tear. Okay, so what can we deduce from this? That those who do antenatal perineal massage are not less likely tear, but something is different that makes the doctor less likely to cut the tissue. What do you think? Maybe women having perineal massage are more tuned into their bodies and more likely to plan natural births, and therefore less likely to employ doctors who cut often?
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#86 of 87 Old 04-07-2006, 06:47 PM
 
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Originally Posted by fourlittlebirds
ETA: Oh, okay. "Women who practised perineal massage were less likely to have an episiotomy." Not a tear. Okay, so what can we deduce from this? That those who do antenatal perineal massage are not less likely tear, but something is different that makes the doctor less likely to cut the tissue. What do you think? Maybe women having perineal massage are more tuned into their bodies and more likely to plan natural births, and therefore less likely to employ doctors who cut often?
yeah, that is my question too (the first part re: lss likely to be cut but not necessarily less likely to tear).

as far as being more likely to plan natural births... I don't know. these were randomized studies with a control, so women were assigned to be in one group or another, it wasn't their choice. So unless the act of massage led them to alter their birth plans, this shouldn't have an impact.
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#87 of 87 Old 04-07-2006, 06:50 PM
 
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Or more likely that their OBs new they practiced perineal massage, and through the power of their own beliefs decided that fewer of those women "needed" episiotomies.

There's also the power of the women's own belief that because of having practiced antenatal perineal massage they wouldn't tear and therefore requested no episiotomy (or otherwise believed that they didn't need episiotomy).

I wouldn't trust these studies to provide any relevence to a homebirth, especially one with a hands-off midwife. All they showed was that episiotomies were reduced, which when comparing OB-attended hospital births (who cut, what, 90% of first time moms?) and midwife-attended homebirths (variable, but usually less than 10%, ought to be less than 5%) would be like comparing the amount of sand in a desert and a rainforest.
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