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I'm a beginning doula and have just attended my forth birth. At the third and forth birth it was an ob attending and at both births the ob or nurse seemed to use a lot of force in "massaging" the perineum. (one had an epi, one didn't) Both ladies had bleeding tears before the baby even touched the perineum and both ended up with 2nd degree tears with 6 lb babies. Now the forth was posterior and was having some trouble descending, but is this practice helpful/necessary?

The nurse with the forth one claimed she was doing a shoe horn technique. As the mom had already been pushing for almost 2 hours, and it seemed to be helping in bringing the baby down, I didn't say anything, but it just seemed excessive.

Does anyone know if this technique is evidence-based? Is it a good practice or one I should recommend against to future clients?

Thanks,
Robyn
 

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Giving my *opinion* as mother on the other end of these massages. For me it WAS excessive. I had to BEG the nurse to remove her hand, my husband said I asked at the very least a dozen times, one of the most violating expierences of my first birth. It ended in a c-section so not only did I hurt from pushing so long, in agony both emotionally and physically from surgery, my vagina felt like it HAD stretched around a baby's head. Bleeding tears prior to birth due to a "massage" sounds awful. Again this is just opinion, no evidence to back it up, so take it with a grain of salt.

ETA: I had an epidural that wasn't working, and I had felt the urge to push from 9cm and it hadn't subsided so it wasn't helping me push. Baby was also OP.
 

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this practice is one of several that I find particularly hard to stomach during a hospital birth. It does seem to be common to have the provider inserting fingers (or hands) in the vagina to create rectal pressure to encourage the pushing urge, sensation to push. It can be very disturbing to watch the aggressive and extreme handling of this area. For women with an epidural, does it help them to push? I don't know. I honestly have a hard time with this! Does it create additional swelling, bruising and pp pain? I have to think so. Does it increase tearing? I have no evidence, but I too often see vaginal bleeding before the head is there.

I was at a birth once, where the nurse inserted BOTH HANDS into the vagina and pushed outwards, like a speculum. I had to look away.

This is one practice (of many) that I would love to see stopped during birth. At the OOH births I attend, this is not common practice and women seem to push out their babes just fine!.

Sharon
 

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Yes, some vaginal/perineal pressure can sometimes help a mom localize where to push, or to stimulate the push reflex in blocked moms. But perineal massage in general is not evidence-based, and particularly aggressive perineal massage in second stage. I think it makes the tissues much more friable and likely to tear (edema reduces elasticity).
 

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the shoe horn technique you describe is not really perineal massage- fingers are probably way in and there are a few ways I have seen or done -sometimes you use your fingers as resistence that the baby turns against to spin more- sometimes it is really more like a shoe horn so that mom's tissue is pulled out of the way and baby moves down to take up that space - your fingers may very well be as far in as the spines -- when I have pulled tissue out of the way -mom is pushing and what you see pushing includes walls of the vagina bunching up infront of the head and being pushed infront of instead of being pulled out of the way-- as maxmama there is also firm pressure that is done downward toward the bowel and can trigger better pushing/pushing reflex and/or as a place to push toward- I don't include any of these to be perineal massage-because they are intended to improve pushing or change baby's position but I guess some may consider it the same-

evidence for and against perineal massage has been 50/50 and if mom has a preference she should make it known-- I prefer to not do perineal massage as i don't think it usually prevents tears- atleast under my hands- although when I did my own perineal support during birth- I could feel what was effective and did not tear- I have seen though many different providers doing their own version of perineal massage- haven't really seen any tears before crowning from that massage- and some of what I have seen has been done very firmly so I have to wonder about how has your local technique been learned? I certainly have seen tearing with and without massage/support
 

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I'm seeing more and more vaginal/labial/perineal swelling when providers fiddle with the bottom during labors. It's not the pushing so much as the massaging/stretching that the providers are trying to accomplish that I see result in swelling.
 

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Quote:

Originally Posted by mwherbs View Post
the shoe horn technique you describe is not really perineal massage- fingers are probably way in and there are a few ways I have seen or done -sometimes you use your fingers as resistence that the baby turns against to spin more- sometimes it is really more like a shoe horn so that mom's tissue is pulled out of the way and baby moves down to take up that space - your fingers may very well be as far in as the spines -- when I have pulled tissue out of the way -mom is pushing and what you see pushing includes walls of the vagina bunching up infront of the head and being pushed infront of instead of being pulled out of the way--
yes, mwherbs, this is different than perineal massage. So, why is this necessary? can you let me know why a provider would do it? doesn't the pushing move the tissue away during descent. When would this technique make sense, under what circumstances? I would like to learn more about this!

TIA,
Sharon
 

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well when the tissue isn't being moved out of the way- I know usually it just all vanishes/melts away rarely it won't and then knowing you can try moving the tissues will help- I watch and wait - the other is about position- a posterior baby that isn't spinning and hasn't progressed in descent placing your fingers so that the baby feels resistence and tries to navigate into a path of least resistence - or sometimes it is asynclintic -- on the other hand if you have a medicated mom in hospital with a timetable that progress has to be achieved or else surgery then the tricks may come out at a different set of cues-- comparing types of practice can be very hard - it is like knowing how to cook with a gas or electric stove- you have to stir things differently and cooking times are different -- so although I may know several things and do them with my sense of timing and experience, there are things that another provider would do differently and perhaps with good reason.
 

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Quote:

Originally Posted by mwherbs View Post
the shoe horn technique you describe is not really perineal massage- fingers are probably way in and there are a few ways I have seen or done -sometimes you use your fingers as resistence that the baby turns against to spin more- sometimes it is really more like a shoe horn so that mom's tissue is pulled out of the way and baby moves down to take up that space - your fingers may very well be as far in as the spines -- when I have pulled tissue out of the way -mom is pushing and what you see pushing includes walls of the vagina bunching up infront of the head and being pushed infront of instead of being pulled out of the way-- as maxmama there is also firm pressure that is done downward toward the bowel and can trigger better pushing/pushing reflex and/or as a place to push toward- I don't include any of these to be perineal massage-because they are intended to improve pushing or change baby's position but I guess some may consider it the same-

evidence for and against perineal massage has been 50/50 and if mom has a preference she should make it known-- I prefer to not do perineal massage as i don't think it usually prevents tears- atleast under my hands- although when I did my own perineal support during birth- I could feel what was effective and did not tear- I have seen though many different providers doing their own version of perineal massage- haven't really seen any tears before crowning from that massage- and some of what I have seen has been done very firmly so I have to wonder about how has your local technique been learned? I certainly have seen tearing with and without massage/support
Agree with above...
I personally encourage the mom to reach down, and 'feel her baby be born with her hands'
I think that is the best support.
I do not do P massage at the birth
I too have seen it done so aggressive that like said by RobynFL, it cause more damage.
 

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I had 2 pushing at the same time so I left the primip pushing with the nurse to go be with my other pt. When I came back in the room the nurse was doing "the both hands in the vagina stretching thing." I hate that. Needless to say I asked her to stop.
 

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My opinion is to keep hands off the mom's vagina. If she doesn't have the urge to push she shouldn't be pushing (unless something urgent with baby). The vagina stretches just fine by itself, thank you, given the private, calm, loving atmosphere as for lovemaking.
I wish I could bring duct tape to tape the hands of care providers who feel they have to do something to the woman.
 
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