by Cynthya Dzialo, Doula, Educator and Owner of The Happiest Doulas
An excerpt from Cochrane.org:
Vaginal births are often associated with some form of trauma to the genital tract, and tears that affect the anal sphincter or mucosa (third- and fourth-degree tears) can cause serious problems. Perineal trauma can occur spontaneously or result from a surgical incision (episiotomy). Different perineal techniques are being used to slow down the birth of the baby's head, and allow the perineum to stretch slowly to prevent injury. Massage, warm compresses and different perineal management techniques are widely used by midwives and birth attendants.* Read the evidence here.
In an article by Evidence Based Birth about optimal birthing positions for the second stage, a recent 2017 Cochrane review and meta-analysis, Gupta et al is referenced. The analysis combined the results of 32 randomized, controlled trials that included more than 9,000 birthing people in hospital settings. In comparison with non-upright positions, people who were randomly assigned to upright positions in the second stage of labor were:
25% less likely to have a forceps or vacuum-assisted birth
25% less likely to have an episiotomy
54% less likely to have abnormal fetal heart rate patterns
More suggestions to limit tearing during the second stage of labor
Support your skin throughout pregnancy. Avoid processed foods, focus on nutrition, and eat a well-rounded diet.
Plan on a waterbirth or water immersion for a long period of time right before delivery. Explore what underwater birth can offer and seek out medical facilities and care providers that offer inflatable tubs or birth pools for labor and delivery. For further reading on waterbirth, checkout this article from Evidence Based Birth.
Get off your back for the crowning phase. Squat, kneel, stand or lay on your side while pushing.
Breathe the baby down and focus on completely relaxing your pelvic floor. Bear down gently when you feel the urge to push at the peak of a contraction. Use mind-body relaxation techniques such as guided meditation (hypnosis).
If an epidural is used, you likely will not feel an urge to push with contractions and must be directed how to push and how long to do it for. This is called purple-pushing or Valsalva pushing, and increases your risk of tearing and/or for the need of an episiotomy and perhaps later on, other issues such as urinary incontinence.
Read about natural tearing when pushing verse a midline or medio-lateral episiotomy. The degrees of lacerations are explained and photos are posted.
Since the current evidence shows there may be a benefit to applying warm compresses to the perineum during the crowning phase/second stage of labor, you may wish to discuss this option with your care providers. Many people looking to use this technique will have to apply it themselves. (Another role for your partner.)
The below video explains how to use warm compresses safely. Discuss this method with all of your care providers before labor begins. During labor, talk to your nurses (and later, the OB or midwife) about using warm compresses (wet washcloths) to support the perineum during the crowning phase. Compresses are used during contractions and many washcloths will be needed as well as an electric kettle and a large bowl. While the hospital can provide several washcloths to you, MANY will be required. I suggest you purchase a few bundles of pre-cut cloths made from a soft material, which will be disposed of after use.
*Excerpt from Cochrane.org.
