Avoiding Perineal Trauma
Here are some ideas that may help you avoid perineal trauma. Perineal trauma means either an episiotomy, tearing, bruising or swelling. The enjoyment of a comfortable perineum immediately postpartum will enhance your mothering and your general well being during these challenging days.
- Good nutrition to promote healthy tissue
- Kegel or pelvic floor contraction exercise
- Pelvic floor relaxation and ‘bulging’ exercise
- Practicing various positions for the 2nd stage
- Perineal massage in the last month of pregnancy (see below)
- Education – what to expect during 2nd stage
- Treatment of vaginitis
During 2nd stage (pushing stage):
- Reassurance and encouragement
- Relaxation of the perineum
- Following your natural bearing down urges (don’t rush)
- Selection of positions for comfort or to promote or slow progress
Gravity neutral positions for rapid descent
These positions will tend to slow down the descent and birth. They are useful if the 2nd stage is progressing rapidly
- Side lying
- Hands and knees
Gravity enhancing positions to promote progress
These positions will speed descent and birth as gravity aids the pushing
- Semi sitting or sitting
Other ideas to enhance pushing, comfort and a gentle birth
- Use a mirror, touch the baby’s head to encourage efficient bearing down efforts
- Hot compresses applied by the midwife
- Cessation of bearing down when stretching and burning are felt in the vagina. Pant or blow instead. Your midwife will assist you in this effort by informing you when to slow the pushing down
Prenatal perineal massage may be beneficial to help women avoid episiotomies and perineal trauma. Current research is divided on whether or not perineal massage reduces tearing; there are no downsides, except that some women find perineal massage very uncomfortable. Perineal massage is believed to soften the tissue around the vagina and increase elasticity by taking advantage of the hormonal changes that loosen connective tissue in late pregnancy. More importantly, perineal massage seems to orientate women to their pelvic floor area simulating to some degree what she will feel during the 2nd stage and how her bottom should feel – relaxed! Perineal massage may be of particular benefit if your perineum has scar tissue from a previous delivery, or if you have particularly strong pelvic floor muscles (e.g., dancers and long-distance runners).
Note: It is important to check with your midwife if you think you have vaginitis, herpes or other vaginal problems before you begin prenatal perineal massage.
Either you or your partner can do the massage. Most women find it easier for their partner to do the massage. The first few times take a mirror and look at your perineum so you can see what you are doing. Be sure your fingernails are short. If you or your partner have rough skin, it might be more comfortable to wear disposable latex or nitrile gloves. Wash your hands before beginning.
Lean back comfortably on pillows, squat against a wall, sit on the toilet, or stand with one foot up on the edge of the tub or a chair.
Lubricate your fingers well with oil or water soluble jelly. Some people recommend wheat germ oil, available at health food stores, because of its high vitamin E content, but other vegetable oils or water based lubricants such as K–Y jelly can also be used. Do not use mineral oil or petroleum jelly. Put out a small dish and discard unused portion after massage. Do not replace in container.
If you are doing the massage yourself, it is probably easiest to use your thumb. Your partner can use their index fingers. Put the fingers or thumb well inside the vagina (up to the 2nd knuckle). Gently stretch the opening,
pressing down on the perineal floor towards the rectum and to the sides (3 o’clock to 9 o clock), until you feel slight tingling. At this point, stop, make sure your bottom is relaxed. Try doing a Kegel exercise, relax and then carry on maintaining the stretch and pressure for approximately 2 minutes. Then slowly and gently work the lubricant in using a sling-type motion, still maintaining the same pressure and stretch. Avoid the urethral area because of potential for infection. Massage for 3-4 minutes, concentrating on any previous episiotomy scar tissue, which is especially non-elastic.
In the beginning, you will feel tight, but with time and practice, there will be a noticeable increase in flexibility and stretchiness. Some women will find the motion of the fingers going in opposite directions to be more comfortable. Others will prefer the fingers to stretch the tissue in one direction at a time. You can also massage by rubbing the skin of the perineum between the thumb and forefinger (thumb on the inside, finger on the outside or vice versa).
Remember: practice both relaxing the perineal muscles completely and slow deep breathing while the massage is taking place.