Protecting the Perineum

Many women ask about how to avoid tearing during birth.  Midwives pride themselves on achieving ‘intact perineum’.

This post looks at why tearing occurs and whether or not it is possible to avoid. It also looks at perineal anatomy and episiotomy, because an informed decision needs to consider all the pathways.

Some women describe a Ring of Fire during the final moments of birth.  At this point, your body is saying ‘slow down’.  Pant, actively prevent pushing, holding back until the fire is out, may avoid a tear.  Pushing through the fire may result in a tear.  This involves being VERY aware, and being supported not to rush.  It is helped by not being on your back or in a squat, not having an epidural and not having coached pushing.

When women are instinctively birthing, they tend to go to a hand and knees, or on knees leaning forward, position.  They will hold back and breath, slowing down and allowing their body to stretch before continuing.  If you have birth before, you are more likely to do this effectively.  

Perineal Protectors: Midwife Thinking is an indepth look into the evidence surrounding perineal care.  Covering the antenatal interventions (such as massage and ‘epi-no’) and some in birth interventions of various invasiveness.

If you have had an augmented labour, have an epidural and are birthing on your back, some of the perineal techniques described by ‘Midwife Thinking’ may be useful.  For example, a warm compress has been shown to reduce major tears, especially in first time birthers.  It may also help if your attendants encourage you to slow down, and not push through.  Gloria Lemay in the Midwife’s Guide to an Intact Perineum, describes what the pushing phase of birth is like, the thoughts you may experience and how your attendants can best help you.  

This conversation piece gives these insights (see the article for links to the research):
Perineal trauma is more likely:

  • Having your first baby
  • Having a forceps or vacuum birth
  • Being from certain ethnic backgrounds (such as India and China)
  • Having a long second stage (pushing part) of labour
  • Having an epidural
  • Having an episiotomy
  • Giving birth lying on your back, especially with legs in stirrups (lithotomy)
  • The baby’s head is in an abnormal position
  • The baby is very big, over 4kg in weight
  • A private obstetrician is the care provider (specific to episiotomies)

Perineal trauma is less likely when:

  • Having your second or subsequent baby
  • Being active during labour and birth and avoiding an epidural
  • Giving birth in a side lying or upright position
  • Perineal massage has been done in the late stages of pregnancy
  • Having warm packs applied to your perineum during the birth
  • Birthing the baby’s head slowly or between contractions
  • Having your baby in a birth centre or at home
  • Being cared for by midwives 

Perineal Stretching Massage by Carolyn Hastie describes the massage technique, but the caveat is this: YOU DO NOT NEED TO DO ANYTHING.  If it feels good for you or helps you to become familiar with your body, go for it – with knowledge and respect. 

For more detailed look at the perineum and the clitoris: Vicki Hobbs has written this comprehensive article.

and if you are wonder about the function of the clitoris in labour, see this research by Margaret Jowitt. This article is particularly interested, as contrary to the images below, it depicts a physiological labour, with a woman on her knees rather than her back. Does the clitoris provide a cushioning effect? Is this why women instinctively birth on knees or forward facing, rather than seeking to lay down?

What about episiotomy?

Research tells us that an understanding of perineal anatomy is important for decision making when considering episiotomy incision types, as the risk differ with different angles. In the event that an episiotomy is warranted, it is likely in Australia, that your episiotomy will be about a 30° angle. This is based on a goal to minimise a third or fourth degree tear, as a midline episiotomy can increase this occurring. However, this angle may impact the bulb of vestibule, which is part of the clitoris and is the “seat of female orgasm”. The Greater vestibular gland releases the pre-orgasmic secretions which lubricate and protect the vagina.

This image, from the research paper by Garner et. al. shows the anatomical parts for female genital anatomy
This image, also from the Garner et al paper, shows different angles for used episiotomy

The paper found that for a high (angle ≥45°) mediolateral angle, 100% of cuts impact the bulb of the vestibule (part of the clitoral anatomy, and critical to sexual health)

For the medium (angle 16-44°) mediolateral angle, the bulb was impacted in 80% of cuts. and for the low (angle 10-15°) mediolateral angle, it was 75%. The midline (angle 0°) does not impact the bulb, but has a significantly higher risk of third or fourth degree tearing after the episiotomy is cut. This can lead to fecal incontinence. These investigations occured in non-crowning circumstances.

In conclusion

The same suggestions to avoid tear will help to avoid an episiotomy. A key point for this, is avoiding an epidural. This is where childbirth education can be helpful and creating a birth map in conjunction with your birth partner and care provider. Taking the time to build an understanding of what the birth pathways look like, can help us to more confidently navigate and choose the safest path based on the circumstances unfolding.

Read more about the pathways here in The Flows of Modern Birthing.

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