Protecting the Perineum

Little Willie has made it to 37 weeks, which is considered full-term, but we are now finding that there are mild risks to being born before 39 weeks.  So we don’t perform elective C-sections or inductions without a medical indication before 39 weeks.  I’m hoping he wants to stay in my uterus until 39+ weeks for selfish reasons- so that I get a little more time before he comes.

Now that I’m on maternity leave, I was hoping to have a chance to look into some of the less medical aspects of labor and delivery.  Today I wanted to focus on the voodoo around preventing perineal/vaginal tears during the delivery.  The perineum is the part from the vagina to the rectum.  This part tends to tear the most, and is where we use the grading system for the extent of the tear (1st degree is good, 4th degree means it tore all the way to the rectum) but many women can get tearing elsewhere in the vagina and vulva.

Anecdotally, my colleagues and I have noticed that some vegetarians have poor tissue.  What we mean by this is that some women get the normal perineal lacerations after a vaginal delivery.  When we are performing the repair, their vaginal tissue is very fragile and tears easily, and doesn’t stitch up well.  Sometimes the sutures keep tearing and pulling through the tissue and it’s not helping stop the bleeding, so I’ve had to just pack the vagina with vaginal packing, which is kind of like gauze in tape form.  It provides pressure to help tamponade the bleeding.  I think it goes to show that if some women aren’t having adequate protein sources in their diet, it can affect the quality of their tissue.  This also affects tissue for C-sections as well, and it’s actually more scary if things are hard to suture during surgery.  This definitely biases me towards staying Paleo and eating good quality meat.

I’d recently heard about a balloon that some people use to help stretch the perineum and vagina prior to delivery.  I have no idea how well it works, but it’s called the Epi-No, and is a balloon that you inflate daily in the vagina to gradually stretch it.  It costs about $140:

I previously mentioned a book I got called Gentle Birth Method by Dr. Gowri Motha.  I have found her entire regimen to be unrealistic for most- you’d have to make it a full-time job to do everything she recommends.  Even the dietary recommendations alone of avoiding too many carbs, particularly wheat and sugar, have been tough for me.  I do agree it’s probably best to do so to discourage the baby from getting too big to push through one’s pelvis, but I haven’t been able to curb my pregnancy cravings to that extent.

In addition to that, she has recommendations based on one’s personality/body type, and for me she recommends avoiding spicy foods and garlic, acidic foods like tomatoes and citrus, and cheese which I find difficult.  Add to that recommendations for exercise, herbs/supplements, massage and body treatments, and self-hypnosis practice for labor.  Honestly, unless you live in England and are able to go to her center, aren’t working full-time and don’t have any other children, I feel like it would be damn near impossible to follow all of the recommendations.

With that said, there are some helpful tips in the book.  First off, I do appreciate that she stresses that as a physician, she knows that there is a time and place for an epidural and C-section.  She cautions women not to get so bent on having a medication-free vaginal delivery that they lose sight of the real goal- safe delivery of their baby.

In terms of reducing perineal tears, she recommends perineal stretching exercises.  Though a woman can do it herself, it’s much easier for her partner to perform it on her (gets kinda hard to reach down there with a full-term belly).  It involves pressing on the perineum repeatedly at the 4 o’clock, 6 o’clock, and 8 o’clock positions.  It’s done 6 times at each location as the woman is exhaling, and gradually the finger can be inserted deeper in the vagina and two fingers can be used as the perineum stretches.  Gauze soaked in her perineal massage oil can be placed prior to the exercises to help prep the area.  As opposed to buying a $140 balloon, I figured it’d be worthwhile to try the perineal stretches if I can maybe avoid excess tears.

In the course of my Google searching, I came across this great site written by a midwife:

It’s very thorough, and in addition to the Epi-No balloon and perineal stretching, she mentions other factors that can affect tearing during vaginal delivery.

Someone previously commented (see the Stress in Pregnancy entry) asking about birthing positions.  In my training in Western medicine, I can’t say I’m very familiar with alternative birthing positions.  I’ve pretty much delivered everyone in a hospital bed on their backs, maybe rarely on their side.  So honestly, it would throw me off to try to deliver a patient on all fours.  Also, in most hospital settings, women tend to get epidurals so they are limited in their mobility.  The midwives we work with in the hospital are much more familiar with the other positions for pushing and delivering.  According to the site above, delivering on the side or all fours is associated with less tearing.

For me, I’m planning on playing things by ear.  It would be nice if things go well and I can handle my labor without an epidural, but I’m not ruling it out.  It would also be nice if my labor remains uncomplicated and a midwife is taking care of me, in which case I can discuss positions.  Most likely due to convention, I’ll end up delivering in the standard position on my back, and I’m hoping between my diet that includes quality protein sources, the perineal stretches, and having a controlled delivery of the head, that I can reduce tearing.  I’m also aware that a lot can happen on Labor & Delivery, and things rarely go according to plan.

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s