# Perineal tearing: the controversy of hands on vs hands off



## Emilie (Dec 23, 2003)

Great article.
Lots to think about.
my mw was relatively hands off-- she did not touch me while i was pushing and i caught and pulled up my own baby. Cord around the neck and all.
If I was to do it again- I do wish she had checked for a cord for me- I was not aware to look for that- and I pulled her up out of the water with the cord around her neck.
But next time I could also check myself- now with what I know.
I tore a little- my mw rarely has tears- even with breech- huge babies- etc.
She does this puh puh puh technique. are you familiar- why does this work so well?
One of the main reasons she tries to leave the peri in tact is that she does not suture.... so therefore- if there was a tear that needed stiching- it would be off to the hospital- with no baby- not what we want!
i am glad that i did not tear much- my recovery was very easy.

nak- sorry!lol


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## Kathryn (Oct 19, 2004)

I believe in hands off. My midwife did massage, but I honestly was a bit annoyed by it even though it didn't hurt and if I wasn't busy contracting, I would've told her to keep her hands off.


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## pamamidwife (May 7, 2003)

I think that any woman will naturally slow down when crowning because of that "ring of fire" - women don't need to be directed to breathe a certain way or anything. Women just know. It works perfectly.

I think checking for cords as the head emerges is VERY painful for women and totally not necessary. Most women do like you do and just unwrap their babies as they bring them up. No harm!


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## Emilie (Dec 23, 2003)

oops - I did not unwrap it! I pulled her up- and knew things were not ok- but I would not let her go- so dh grabbed it off. She had a bit of a rough patch at first- but fared much better at home than she would have at the hospital!


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## Kathryn (Oct 19, 2004)

You know, I had no ring of fire. I slowed down horribly because the sensation of my bones moving to let the baby pass was overwhelming. The actual crowning didn't hurt at all. It was just the moving bones. It was scary because I had no idea to expect that, they'd never touched on it in prenatals or class. It was always only about the "ring of fire" which I never had.


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## pamamidwife (May 7, 2003)

I'll tell you right up front that I'm a pretty-hands off midwife, but I'm most hands-off when a woman is pushing her baby out. I'm including this article I recently wrote for Midiwfery Today for the mamas here - your birth belongs in YOUR hands, not your midwife's - not your doctor's. We are made perfectly to birth babies without too much perineal trauma and this is best done when those we are not intimately involved with keep their hands off our sexual organs during birth.

http://www.midwifemama.com/honoring.html

I welcome some discussion on this article, as there are still many women out there who believe a midwife/doctor can "save" them from tearing, as well as the general idea that small tears are to be avoided at all costs (and the resulting feeling that it's "bad" if we do tear).


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## sapphire_chan (May 2, 2005)

Okay I'm totally biased here, but your article is yet another reason you're my ideal standard of a midwife. When the time comes, my goal in interviewing midwives will be to find one that is as much like you as possible.


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## Emilie (Dec 23, 2003)

Smile. Smile Smile....
I am so sorry that not all midwifes are not like Pamamidwife.
I can not believe the things I hear on here.


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## crazyeight (Mar 29, 2006)

I had my ds in the hospital and am now prego. I can tell that i am VERY different down there since giving birth to a big boy. He was only 8 lbs but I was only 6 lbs 2 oz and his father was only 6 lbs 3 oz AND i was TINY when i got pregnant plus his head seemed large but i don't remember. Anyways when it reached the point of ring of fire, which actually was SOOO much LESS painful than contractions now that i think about it, i had to push about an hour to finally get him out. My OB was known for being a good one for natural births and the like and was actually transferred to her by my first OB my VERY last week of prego, so when ds wouldn't come out after pushing and the like she massaged, lubed and something else i think. finally she told me that i was going to tear up into the urethrea and down in a star shape quite badly. I believe that it wasn't pretty but have you heard of it being that badly stretched? She did finally make a cut and i think i got 2 or 3 stiches and i am totally ok with the fact that she made the cut, she didn't do it right away, and i was almost ready to suggest it even though I NEVER wanted to be cut down there and even put it in my birth plan. I am hoping that this child will not have that problem but i also wonder if was sewed up tighter or looser or if the stiches will affect what my body sees as the limit for birth.
So basically the questions are: Can previous peri cut influence other births and likelyhoods of cuts? Have you ever heard/read/seen a stretching and/or possible tearing to the extent she described?
I will be birthing at a free standing birth center this time.


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## DreamsInDigital (Sep 18, 2003)

I think Pam is a great midwife.


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## Brown Lioness (Dec 28, 2005)

WOOOOOOOOW.









omg, i learn SOOOO much on this site!

*scribbling notes*


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## littleteapot (Sep 18, 2003)

Wow, PAm. That was a fantastic article. I read it out loud to my husband, and when I told him it was written by a _midwife_ he was incredibly impressed.

I'm UC/UP, and the midwife I had with my first baby was very much like you. I consider her (and your) style of midwifery to be as close to true midwives as is possible in today's society. Certainly women have always had 'midwives' with them, but not all carried oxygen and needles: they were wise women, herbalists, support people, what today we'd consider a doula.

You're the kind of midwife I wouldn't mind seeing.







Way to go: absolutely awesome article. I'm going to bookmark it.


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## Stayathomemommy (Jun 7, 2002)

i just talked to my midwife about this at my 37 week appt because i had her for my last birth and while i was pushing i remember yelling, "how can i push with your finger down there!!" she didnt remove her finger, and though it wasnt the reason for my c/section it was definately a tense time where my body was unable to be completely efficiant.

anyway when i told her that last time i didnt like her finger down there she just told me that she was helping the perinium strech. and that was the end of that!! like i was silly and she had been doing me a favor. how do i tell her nicely that i dont want her doing it for this birth PERIOD!!


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## pamamidwife (May 7, 2003)

I swear the goal here is NOT to give myself kudos - believe me, I still have plenty to learn in midwifery. I really wanted to let women know that the idea that somehow someone else can "prevent" tears for them may not always - or most times - be true.

I remember what an OB once told me....he said, "if you put two sides of a vagina together in a forest, apart, they will always find each other!" - meaning that our body does a beautiful job healing any sort of tears in this part of our body. Evolutionarily this makes sense - to not heal well means that we risk reproductive and hygeine issues. I think even urine has healing properties when it comes to tears postpartum.

Plus, I think there is some benefit to being a bit tender down south after birth - we're more likely to take it easy for the first week or so (important when we're establishing a milk supply and recovering from birth).








Suturing should only be reserved for when the sides of a tear do not come together well - or if the tear (which is not as common) extends beyond the superficial surface or underlying fascia.


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## DreamsInDigital (Sep 18, 2003)

My most recent birth where I did not tear I found it quite difficult to stay in bed. It didn't cause me any problems but I certainly could have taken it a lot easier. I bet I would have if I'd had any trauma. Kind of scary that a 10 lb. baby came out and didn't hurt


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## Jade2561 (Jun 12, 2005)

I had the OB that was on call when my daughter was born and as I was pushing he told me that he is bad at cutting epis and doesn't do them. He did perineal massage and I only had a minor surface tear (I was birthing in the traditional lithotomy position







). My roomie at the hospital had a 4th degree epi (4th degree) and was miserable. I was carrying my baby and able to shower - no need for meds and she could barely walk and was taking pretty heavy pain killers. After spending time with her I was so greatful I had been spared.

I'm homebirthing this time and MW is hand off about almost everything.


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## mezzaluna (Jun 8, 2004)

thank you pam!









i've been reading and admiring your posts for a long time now, and this article nearly made me cry it's so beautiful and respectful - and hits close to home for me. makes me want to print off a copy and mail it to the OB who "delivered" me. i guess i should!


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## sapphire_chan (May 2, 2005)

Quote:


Originally Posted by *Stayathomemommy*
anyway when i told her that last time i didnt like her finger down there she just told me that she was helping the perinium strech. and that was the end of that!! like i was silly and she had been doing me a favor. how do i tell her nicely that i dont want her doing it for this birth PERIOD!!

"I need your help to be completely confident in this birth, when you dismiss my concerns it worries me. I like you in all other ways, but I do not like how you are handling my concerns about you touching me during labor."

She probably doesn't even realize she was being dismissive she probably thinks "oh well, I explained it, so she understands now and is fine." And probably also thinks that you're fine with a repeat performance.


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## LavenderMae (Sep 20, 2002)

Pamela, that was beautiful and full of so much truth. You are what midwives should be and I wish there were more like you!!!!!


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## InochiZo (Aug 17, 2004)

Posting from a birthing experience; no midwifery experience. I agree with the hands off completely but I don't think that it was natural for me to slow and take it easy even though I had a lot of burning. I ended up with a 2nd degree tear, almost 3rd. My MW was very handsoff since it was a breech, but me and baby surprised everybody by coming out all at once on the push after the butt crowned. I think, if I ever have another baby that I will have someone cue me to slowdown and not push too hard and/or birth in a different position. Handsoff but some direction would be good.


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## nadine (Oct 22, 2004)

great article! i loved it, you inspire me. i strive to be a very hands off midwife (i'm a student right now). i think the more we stay out of it and let the mama birth, the better it is. women are amazing and powerful, we need to trust them!


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## mamato3cherubs (Nov 30, 2004)

Wow, I read all the replys to this thread before reading the article and though, yeah ,yeah, nothing I havnt seen.
WOW! That was so nice to read, really got me thinking about the births I experienced with my own kids.

Now dont mind me, I just have to share and vent now!!!!!!!!

I can recall so clearly with my last baby(all OB care, although I still love that OB, in hospital), she was much more difficult than my first 2. When I finally got through all the hours of labor after refusing against drs orders the pitocin more than once, my very good and helpful nurse got my up on the bed on my hands and knees semi leaning over a pillow with the bed raised nearly upright.
I was 7-8 when I got up there, 3 VERY strong, long contractions(and lots of low screaming) later I felt my baby crown. I didnt want to stop. I didnt want to move, I wanted to be left alone to push this baby out as I wanted. The nurse looked when I yelled "It hurts and I cant make it stop!". she said oh, theres the baby! and told my DH to help me turn over while she got the dr.

It was this very moment that I said to my mom, "I wish I would have just gone to the midwives at the birth center, or let them give me that epidural!"

Over an hour later, most of which I spent with the largest part of my babies head nearly out, I delivered her. I was in so much pain from the prolonged crowning and the delayed turning of her head to the best direction that I could hardly even concentrate to nurse her right away.
If I could have been left to deliver on hand and knees semi upright as I was when she finally came down, I feel she would have turned soooner before I was forced to push her so far and would have been much faster.

*long sigh* I have always had an interest in pregnancy and birth but never thought I could do anything with it(the "Im not good enough, smart enough, wealthy enough, to do what I *want* syndrome I have always suffered from).

After that experience I really started rethinking and began reading. I will someday follow through and be a midwife with as good of values as yours. I will help women have the best experience they can have how they want to have it.
Thank you for sharing Pam.


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## cottonwood (Nov 20, 2001)

This needs to be said again and again and again:

Quote:

Did you know that your vagina has a built-in protective mechanism? We experience it when we are getting a pelvic exam-fingers placed right outside the vagina or inside the vagina will result in a contraction of the vaginal muscles. This response is normal and positive. Yet women are often told to "just relax" at this point, as if it's completely voluntary.

The midwife or doctor performing the exam may be a classmate, friend or trusted provider. It doesn't matter-the care giver's fingers are not our fingers. They are not the fingers of our lover. Our wise bodies resist touch that is not sensual or our own. A woman pushing out a baby will experience the same reaction. The resulting tension is counterproductive to loosening and opening the pelvic floor to birth her baby.

What happens when we midwives put our fingers inside the vagina as the baby is trying to emerge? Could it be hard for women to concentrate on pushing something out of their bodies when we are putting things in? Are we really helping women by dragging down on the perineum? By "pushing" tissue away as the head descends? Is the woman's vagina instinctively protecting her? How does it feel to the mother? Can we expect the body to respond naturally with the desired fetal ejection reflex and associated hormones when this is occurring?
I am just sick to my soul of reading birth stories in which midwives have their hands all over women's vaginas, and of women believing that it's good and necessary. I would like nothing better than to see the demise of this harmful myth.


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## Peppamint (Oct 19, 2002)

Fabulous article pamamidwife!









My last birth was hands free, except when I told midwife ds' head was crowning she did brush her fingers to see (NO ONE realized I was pushing







) that yes, ds was crowning. I liked it that way.







My first birth (OB w/perineal massage that hurt like hell and then an episiotomy) was not like that at all. I definitely prefer hands-off!


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## tinyshoes (Mar 6, 2002)

hands-off

for sure.

BUT

are there other crotch-preserving interventions that _are_ welcomed?

For example, I think of my own experience birthing my ds, and I wanted my mws hands "holding my butt" if you will. There was so much outward pressure/force from my baby's head, that I wanted counterpressure in the form of holding my a$$.

Is that hands-on? or hands-off? or requested hands: all hands on deck!

Another intervention, specifically aimed at preventing tears: puh puh puh breathing.

Am I grateful to my mws, for encouraging a "long crown" as they said? to help prevent a tear? (my mws are of the 30/30/30 Rule: tears are prevented 30% diet, 30% stretchy skin luck and 30% baby's position luck. that is their admitted bias.)

Could that "hands-off" yet completely interventive act really prevent a tear (causing a "long crown" to allow skin to stretch?) (PS I still had a small unstitched tear...and I indicated anticipating and wanting these interventions during prenatal visits.)

I read this cheeky advice for OBs somewhere: Don't just do something--SIT THERE!
Seems it can apply to "helpful" mws, too, I guess.


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## Peppamint (Oct 19, 2002)

Quote:


Originally Posted by *tinyshoes*
Is that hands-on? or hands-off? or requested hands: all hands on deck!









Sorry, this just had me rolling this morning.


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## LoveChild421 (Sep 10, 2004)

Quote:


Originally Posted by *tinyshoes*
are there other crotch-preserving interventions that are welcomed?

For example, I think of my own experience birthing my ds, and I wanted my mws hands "holding my butt" if you will. There was so much outward pressure/force from my baby's head, that I wanted counterpressure in the form of holding my a$$.

Glad to know I'm not the only one!


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## tinyshoes (Mar 6, 2002)

Quote:


Originally Posted by *LoveChild421*
Glad to know I'm not the only one!









Yeah--I remember being pregnant at a prenatal appt., asking my mws what they would do during labor.

They mentioned something about, "well, mostly we do a lot of holding women's butts."

and I thought, Hunh? I could understand English, and what they said....but indeed----after having that baby, I _really_ understood what they meant! And when they said it, they suggested it was more or less a popular request from birthing mamas....so I'm interested in hearing that you appriciated that too, LoveChild!


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## Desdamona (May 2, 2003)

Quote:


Originally Posted by *LoveChild421*
Glad to know I'm not the only one!




















For #3 I told my MW to "HOOOOOOOOOOOOOOOOOOLD ME!!" He was a big ol' baby presenting with a nuchal arm. I couldn't NOT be held. But there was no perineal massage or any of that. I just needed someone to hold a warm cloth to my bottom as I pushed out my 10lb baby with his hand up by his face! I actually feel like they could have been more attention to the "holding my butt" job! FWIW, I had a small tear along the epis scar from my first birth and a labial tear (which REALLY!!! hurt).

With #4 no one touched me, what so ever. I was in the kiddie pool and started pushing when my body felt like it. I felt his head before it started to crown and felt a thick rubber band like thing on his head (cervical lip). I told my mw and she encouraged me to either pant through a couple ctx or hold it with the next ctx as I pushed, which I did. And the baby's head slipped past that bit of my cervix, he came very quickly. I didn't want anyone's hands on me this time. I think being in the pool hand alot to do with it. There was already a warm presence around my bottom and didn't need anyone to "hold me" with a warm cloth like I did with the previous (land) birth. No tears, skid marks or anything. Totally intact... even with the almost 10lb baby being born. It was much harder for me to take the down time new mamas need because within 4 days I did NOT feel as though I had just had a baby.

I think it most important for any birth attendant to respect the needs and wishes of the mother. If mama wants someone to hold her bottom, then someone better be ready to hold her. If mama doesn't, they better be sitting on their hands if it is what it takes for the attendant to be hands off. It's all about listening to what the mama needs, not doing what they think it "best".


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## momsincmay (Mar 11, 2006)

Quote:


Originally Posted by *pamamidwife*
I swear the goal here is NOT to give myself kudos - believe me, I still have plenty to learn in midwifery. I really wanted to let women know that the idea that somehow someone else can "prevent" tears for them may not always - or most times - be true.









...I completely have to agree with you because during my pregnancy I did what my doctor said to prevent tearing, the massaging and everything (even during labor she massaged my perineum (very unhelpful) ) and I had 2nd degree lacerations anyways.


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## cottonwood (Nov 20, 2001)

Not to derail the thread, but what exactly does "butt-holding" entail? And why did you need it done?

If it just made it feel better, well shoot, I know Pam's not saying that you shouldn't do what makes you feel better. She's just making the case that perineal massage/support does not prevent tears and that it can actually create conditions for them to be more likely and/or hinder the birth if it inhibits the mother or causes her to tense up.

But if it feels better to have the midwife have her hands on your vulva or butt or bellybutton or whatever







, great!


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## Peppamint (Oct 19, 2002)

Quote:


Originally Posted by *Desdamona*
I think being in the pool hand alot to do with it. There was already a warm presence around my bottom and didn't need anyone to "hold me" with a warm cloth like I did with the previous (land) birth. No tears, skid marks or anything. Totally intact... even with the almost 10lb baby being born. It was much harder for me to take the down time new mamas need because within 4 days I did NOT feel as though I had just had a baby.

Yes, yes, yes! That's an interesting point... I didn't need perineal or butt







support because I did have the warm cushion of water. I was surprised I didn't tear because I was 9cm around 4am and then suddenly I could tell ds was past my cervix, he crowned at 4:32 and was born at 4:34 and I birthed the placenta at 4:36 so he and the placenta roared right through my perineum... I think it was thanks to the water softening my tissues and cushioning his head, and also the fact that no one was coaching the pushing phase.


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## tinyshoes (Mar 6, 2002)

Quote:


Originally Posted by *fourlittlebirds*
Not to derail the thread, but what exactly does "butt-holding" entail? And why did you need it done?

If it just made it feel better, well shoot, I know Pam's not saying that you shouldn't do what makes you feel better. She's just making the case that perineal massage/support does not prevent tears and that it can actually create conditions for them to be more likely and/or hinder the birth if it inhibits the mother or causes her to tense up.

But if it feels better to have the midwife have her hands on your vulva or butt or bellybutton or whatever







, great!

Very good question.

I've doula'd at my friend's two births, and both times, she liked counterpressure on her back during some of her laboring contractions (before 10 cm.) Technically, I gave this pressure on an area some would concider her butt. Pants off, buttcrack involved, but you know--it's low and on the coccyx area/what have you.

"Butt holding" is the next level....a bit lower than the above scenario (which I mention b/c I think we can all imagine counterpressure during labor more easily than this butt hold phenomenon) and during active decent.

The uterus is pushing, pushing, pushing that head out--powerful fundal force moving DOWN AND OUT.....to help counter that, my mws hands (3 of their hands) were supporting my bottom. My hand was in front, and their hands were literally on my butt, more butthole/butt/coccyx...not so much vulvar-area.

I wanted my butt held because it felt right at the time. In my homebirth video I demand "*do what you're doing!*" in a slur, when one of my mws was trying to adjust her position (crunched on my wood floor w/ her hands on my butt, which was elegantly draped over the couch back







) because it felt good to have the counterforce and solid-feeling support to balance the powerfully contracting uterus. (I always laugh at that part--it's such a classic LaborLand Demand!)

Maybe it's like a cough---when you have a violent, coughing cough you can't "control" it is less tolerable than a regular cough you can "work with", if that makes sense.

Totally different from the vulvar-sweep that these OBs and CNMs are constantly doing--blech. YET buttholding *is* hands-on.

I brought it up not to derail Pam's thread, but to add this aspect, because I thought it was a tangent that might be applicable to a lot of women who are in the "hands off!" boat but did appriciate butt holding during birth.

Also, I wanted Pam's esteemed opinion on this matter in particular--could such butt-holding actually prevent a tear? or is it an activity that simply supports a birthing mama (which in itself could prevent a tear, one could argue.) Does Pam hold butts? Does Pam have a comment on butt-holding?























HTH, 4 lil' birdies


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## NYCVeg (Jan 31, 2005)

Quote:


Originally Posted by *tinyshoes*
Totally different from the vulvar-sweep that these OBs and CNMs are constantly doing--blech. YET buttholding *is* hands-on.

Can you explain what a "vulvar sweep" is? Eek.


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## Brisen (Apr 5, 2004)

With my second babe, I had fledgling hemorrhoids that I didn't want exacerbated, and my mw knew about it and gave support there. With my third I don't think the mw did, but I was *really* pushing with my second -- my water didn't break until I had been pushing for a bit and I just wanted it to pop so the contractions would become more effective! So I think that had something to do with the hemorrhoids getting worse; with my third babe, I pushed on hands and knees and she came quickly without much actual pushing. That's what butt holding was, in my experience -- counter pressure for the area you're NOT trying to push a baby out of.

I also might want counter pressure on my labia because I have extensive labial varicose veins, and I would tense up and shy away from pushing if it were bothering them -- but again, birthing on hands and knees didn't really bother them. Squatting probably would.


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## pamamidwife (May 7, 2003)

I've been known to hold butts, but it seems to be more an issue of "grounding" a woman or because of the fear of poo, not to help prevent tearing. I've had women in water ask me to put my hands down there, but I do lightly and then as the baby crowns, I pull away. I think that's a grounding thing, too.


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## pamamidwife (May 7, 2003)

Quote:


Originally Posted by *NYCVeg*
Can you explain what a "vulvar sweep" is? Eek.

where the head is coming down the birth canal and the provider inserts the first two fingers and reams the tissues inside the vagina back and forth, while exerting pressure downwards. some providers call this massage, others call it "making room". i call it OUCH.


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## AngelBee (Sep 8, 2004)

Quote:


Originally Posted by *Kathryn*
You know, I had no ring of fire. I slowed down horribly because the sensation of my bones moving to let the baby pass was overwhelming. The actual crowning didn't hurt at all. It was just the moving bones. It was scary because I had no idea to expect that, they'd never touched on it in prenatals or class. It was always only about the "ring of fire" which I never had.

This is kind of what I experience as well....no burning, just spreading of my bones.


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## onlyboys (Feb 12, 2004)

Quote:


Originally Posted by *pamamidwife*
where the head is coming down the birth canal and the provider inserts the first two fingers and reams the tissues inside the vagina back and forth, while exerting pressure downwards. some providers call this massage, others call it "making room". i call it OUCH.

I watched a CNM do this in a hospital birth until the mama bled. When I expressed concern, she said, "Within normal limits."


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## Peppamint (Oct 19, 2002)

Quote:


Originally Posted by *pamamidwife*
where the head is coming down the birth canal and the provider inserts the first two fingers and reams the tissues inside the vagina back and forth, while exerting pressure downwards. some providers call this massage, others call it "making room". i call it OUCH.

OUCH only begins to describe it! She called it perineal massage!


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## mezzaluna (Jun 8, 2004)

Quote:


Originally Posted by *pamamidwife*
where the head is coming down the birth canal and the provider inserts the first two fingers and reams the tissues inside the vagina back and forth, while exerting pressure downwards. some providers call this massage, others call it "making room". i call it OUCH.

yup, my OB did this







: i was also guided into a semi-reclined seated position. 2nd degree internal tearing that not only took a long time to recover from, but also had me bleeding so much after delivery that i got a heck of a lot of interventions to try to stop it, only to realize i just needed more stitching up.

i thought that because i said i wanted to be free to choose my position in labor, that i didn't want coached pushing, and preferred to tear rather than have an episiotomy i'd done all i could do to be on the same page with my OBs. wish i'd had this to read then!

she did say a little regretfully that she would have done an episiotomy right where i tore, but she knew i didn't want that. [email protected] straight!


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## orangebird (Jun 30, 2002)

My midwives never touched me during pushing and I never tore. The midwives I work with OTOH can't seem to keep their hand off (or out) during the pushing phase (which honestly drives me crazy and I'm almost thinking of quitting that job because it bugs me so much) and it seems like they tear about half the time but usually never bad. I can't say I know what the truth is but I believe in my heart it's better to keep the hands off!

Quote:

That's what butt holding was, in my experience -- counter pressure for the area you're NOT trying to push a baby out of.
I asked my MW to put pressure there on my last birth too because it felt like he was trying to come out my ass. I think his elbow was the culprit as he came our with a hand by his face. (after the MW pushed it off his head, that was probably the only time she felt down there and it was because his heart tones were staying around 60 and not coming up)


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## CalebsMama05 (Nov 26, 2005)

wow this is amazing. my labor nurse put her fingers on my perineum to let me feel where she needed for me to push at and I liked it cuz it was helpful but she was very hands off and said i was doing a great job without it. my ob stood accross the room until i begged for an episiotomy and then he did that caught my son and stitched me up.

honestly though if i hadn't been ON MY BACK i probably could have done it without the episiotomy. in that situation though it was the only way my son was coming out as he came out in only 1.5 pushes after the episiotomy after 45 minutes of *almost crowning*

so in addition to hands off mamas need freedom of movement as well. I wanted to deliver squatting or sitting like on a toilet since it felt just like a bowel movement and I was more comfortable having a bowel movement (as it were) upright. I was told later (although this was not explained beforehand) that had i NOT gotten the epidural i could have pushed him out any which way.


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## cottonwood (Nov 20, 2001)

Quote:


Originally Posted by *brisen*
With my second babe, I had fledgling hemorrhoids that I didn't want exacerbated, and my mw knew about it and gave support there. [...] That's what butt holding was, in my experience -- counter pressure for the area you're NOT trying to push a baby out of.

Ohhhh... well, that I can understand.









Quote:


Originally Posted by *pamamidwife*
where the head is coming down the birth canal and the provider inserts the first two fingers and reams the tissues inside the vagina back and forth, while exerting pressure downwards.

God, this pisses me off.


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## homemademomma (Apr 1, 2004)

THANK YOU for posting that!
it always seems to me that the less we do, the better the outcome. i hate fingers in the vagina. my preceptor was all about pushing down on a woman's rectum through her vagina "to show her where to push" . oh yes, and the vulvar sweep is great too. talk about irritating to the tissues (and mom!)


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## tinyshoes (Mar 6, 2002)

Quote:


Originally Posted by *Brisen*
That's what butt holding was, in my experience -- counter pressure for the area you're NOT trying to push a baby out of.

Well said!! _succinctly_ said......









Quote:


Originally Posted by *homemademomma*
. i hate fingers in the vagina. my preceptor was all about pushing down on a woman's rectum through her vagina "to show her where to push"

yeah--uh....there *is* a baby's head in your vagina, hinting at where the "action" is!









Thanks for your butt-holding feedback, Pam.


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## pamamidwife (May 7, 2003)

it's interesting because I've done some pelvic floor pressure with women who have malpresentations (the worst was the mama with a brow presentation who was complete and pushing twice over a 24 hour period before she really pushed the baby out!). some women really want it, others not so much.

I think the poster who said, whatever the woman wants or requests - is right on. Nothing should be standard.


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## NYCVeg (Jan 31, 2005)

Quote:


Originally Posted by *pamamidwife*
where the head is coming down the birth canal and the provider inserts the first two fingers and reams the tissues inside the vagina back and forth, while exerting pressure downwards. some providers call this massage, others call it "making room". i call it OUCH.

THAT'S what they call "perineal massage"?!?







I thought "perineal massage" was the mw resting her hand on the outside of the perineum to provide counter-pressure and/or possibly rubbing the perineum (again, from the outside only) to relax the muscles.

Um, okay, off to revise my birth plan...


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## sapphire_chan (May 2, 2005)

Ye-eah. Ouchie...

And, um,







, wouldn't the fingers there make pooping *more* likely? I mean, it's going to happen anyway, but I'd think that'd push more out...


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## cottonwood (Nov 20, 2001)

Quote:

I thought "perineal massage" was the mw resting her hand on the outside of the perineum to provide counter-pressure and/or possibly rubbing the perineum (again, from the outside only) to relax the muscles.
I think different midwives probably do it differently.

I believe that the midwife attending my first birth did a light perineal massage on the outside alternating with support with warm compresses. I don't remember feeling it -- to be honest, I've blocked a lot of it out.







What I do remember was feeling very exposed and uncomfortable -- feelings that are counterproductive to getting the baby out. And of course her doing the perineal massage required that I be in a reclining position. So even if perineal massage did relax the tissues (which I don't believe) the other negative effects for me would have nullified that. In other words, the "massage" stressed me out and therefore tensed the tissues.


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## minkajane (Jun 5, 2005)

Wow, that article was a BIG eye-opener! I've heard nothing but good things about perineal massage and things like that. That makes me even more firm in my stance to be a VERY hands-off midwife (I'm a student now). Thank you!


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## channelofpeace (Jul 14, 2005)

A few questions...

Thanks for this article... it has given me a lot to think about.

I was at my sister's prenatal appt (i am her doula) with the midwife i am considering using and the midwife suggested that she do prenatal perineal massage. She said that it would help her be able to relax the muscles when there was a lot of pressure from the babies head pushing on it and to train the muscles to relax under pressure.

I have a history of sexual abuse and have issues with tensing those muscles anyways (sex took a lot of getting used to and relaxation on my part). Would perineal massage help in this case? I would love some input


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## pamamidwife (May 7, 2003)

Prenatal perineal massage has been shown to never improve the outcome of tearing.

IMHO, keeping your hands on your own body and everyone else's hands away will help you. Especially with women who have a history of sexual abuse, we need to be aware that any touch during labor and birth can be traumatic - not only emotionally, but physically as well.


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## tinyshoes (Mar 6, 2002)

Quote:


Originally Posted by *fourlittlebirds*
So even if perineal massage did relax the tissues (which I don't believe) the other negative effects for me would have nullified that. In other words, the "massage" stressed me out and therefore tensed the tissues.

I agree with you--that probably perineal massage does not relax the tissues.

Furthermore, the concept of perineal massage is just another "women's bodies are broken" message, but this time it is in disguise....."perineal massage" is a suggestion bandied about by the earthy-birth community, especially with CNMs and "crunchy" MDs.

But as we've discussed here, and have come to the conclusion here, perineal massage does not help, it hinders. It can cause a mother to tense up or feel self-concious, and does not prevent a tear.

"I need to massage you because your body is an inherent failure and will not stretch without deliberate intervention." (Or, "massage while pregnant because your body is a failure that will not stretch withough deliberate intervention.")

Anyway--I didn't realize I am ANTI-perineal massage until this point in this thread! Until just now, I've thought massage was silly/unneccesary, but always thought, "whatever floats your boat." Now I deem it another misguided attempt to control birthing women.








The more I think about it, the more I remember the image of the doctor's busy fingers during my friend's birth, I think unwanted vulvar touching is almost as bad as unwanted perineal cutting.


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## Arwyn (Sep 9, 2004)

My SIL (due in a monthish - really mainstream) was talking about having read "Birthing From Within" the other day (I was a little shocked she read something so out there, honestly), and we had this conversation:

SIL "The author obviously had some biases"

me "Oh, like what?"

SIL "Well, she's completely against episiotomy."

me "As well she should be - all the research says that routine episiotomy is harmful and that barring very very few real emergencies should never be used."

SIL "...... So, you're against episiotomy then?"

me "Yup." And I explained about how tearing was better, that episiotomy lead to more and worse tears than you ever get without it, mentioned that getting upright could help prevent tears, etc. Then she asked "So, how do you avoid an episiotomy?"

This is where I totally blanked. A couple years ago, before I knew better, I probably would have suggested pre-labor perineal massage (by herself or with a partner) or warm compresses or perineal support - all that hands-on crap. Now? After a pause where I marveled at the stupidity of the question (how does one avoid shooting oneself in the head? don't shoot yourself in the head!!!), I told her about an article I had read in Midwifery Today recently that answered that very question: "How do you avoid episiotomy? Don't do one." And told her it really was that simple - just tell her provider not to do an episiotomy under any circumstances without explicit consent in the case of an emergency.

But to someone like my sister in law, I might as well be telling her to jump over the moon. She's planning an epidural, with an OB, in a hospital that has a 40% c/sec rate. "Just do nothing" is not something she's interested in hearing, and there's no way she'll listen to "How do you avoid an episiotomy? Give birth at home with a hands off midwife and no drugs." What am I supposed to say to someone who _just doesn't get it??_

Anyway - Pamela, I can't believe you wrote that article! I remember reading it in MT and thinking "Oooooo, can I have this midwife, pleeeeeeeze? As midwife, preceptor, personal goddess, whatever!"


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## Brisen (Apr 5, 2004)

I had my first prenatal for this preg today. With a new midwife, in a new practice (I'm in Ontario, my understanding is they have to work in a group practice, but I could be wrong). She will be my primary midwife.

She was great! I was so happy. She was everything I wanted my past midwives to be but they weren't. I had heard she was very hands-off and I felt really at ease talking to her. She just came right out and asked if there was anything about my past births that I didn't want to have happen again, or that didn't happen that I wanted to have happen. So, I told her that so far, I've done most of the labouring myself, all alone, no fussing, she said she understood. I said that this time, I want to keep on doing it myself for the birth and, if I want to at the time, catch the baby myself. She was supportive of it, but with the way midwives are regulated here -- they have to document everything. She said it wouldn't be a problem, though. I think her biggest concern is the other midwives! She started talking about how some midwives in ontario are former RNs, some were midwives in Britain, and some -- like her -- were practising in Ontario as midwives before regulation. She then suggested that if I wanted, I could use their birthtub to create a personal space to discourage the midwives from interfering with me.







She also told me a story she had read in Birthing From Within about a woman in Mexico who would go into a room, lock the door, birth the baby, and when the baby was born she would tell people they could come in now. She didn't say "Hey you could do this," I don't know if she's *allowed* to or not, but it occured to me later, maybe she was dropping a hint to me









She seemed happy to have someone not looking for interventions, too. I declined u/s and doppler, and we had a chat about not using doppler in labour -- midwives in ontario "have" to check heart rate every 15 mins in active labour and every 5 minutes when you're pushing. I said, well, can I just decline? Will you get in trouble? (I figured checking with a fetoscope might be tricky!) She said I could decline, but for her, she would like to check it once to be sure the baby is head down (oh, Ontario midwives also can't home deliver a breech baby








: we would have to go to the hospital and have an ob actually do it, and from what I've heard, most are scared to do it and would just do a c-section.







: ) She talked about how I could kneel to catch the baby myself best and protect myself from too much interference.

Anyway, I was really happy with how it went!


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## the_lissa (Oct 30, 2004)

Quote:


Originally Posted by *Brisen*









I had my first prenatal for this preg today. With a new midwife, in a new practice (I'm in Ontario, my understanding is they have to work in a group practice, but I could be wrong). She will be my primary midwife.

She was great! I was so happy. She was everything I wanted my past midwives to be but they weren't. I had heard she was very hands-off and I felt really at ease talking to her. She just came right out and asked if there was anything about my past births that I didn't want to have happen again, or that didn't happen that I wanted to have happen. So, I told her that so far, I've done most of the labouring myself, all alone, no fussing, she said she understood. I said that this time, I want to keep on doing it myself for the birth and, if I want to at the time, catch the baby myself. She was supportive of it, but with the way midwives are regulated here -- they have to document everything. She said it wouldn't be a problem, though. I think her biggest concern is the other midwives! She started talking about how some midwives in ontario are former RNs, some were midwives in Britain, and some -- like her -- were practising in Ontario as midwives before regulation. She then suggested that if I wanted, I could use their birthtub to create a personal space to discourage the midwives from interfering with me.







She also told me a story she had read in Birthing From Within about a woman in Mexico who would go into a room, lock the door, birth the baby, and when the baby was born she would tell people they could come in now. She didn't say "Hey you could do this," I don't know if she's *allowed* to or not, but it occured to me later, maybe she was dropping a hint to me









She seemed happy to have someone not looking for interventions, too. I declined u/s and doppler, and we had a chat about not using doppler in labour -- midwives in ontario "have" to check heart rate every 15 mins in active labour and every 5 minutes when you're pushing. I said, well, can I just decline? Will you get in trouble? (I figured checking with a fetoscope might be tricky!) She said I could decline, but for her, she would like to check it once to be sure the baby is head down (oh, Ontario midwives also can't home deliver a breech baby







: we would have to go to the hospital and have an ob actually do it, and from what I've heard, most are scared to do it and would just do a c-section.







: ) She talked about how I could kneel to catch the baby myself best and protect myself from too much interference.

Anyway, I was really happy with how it went!

Where in Ontario are you, may I ask? Feel free to pm me if you don't want to answer publically.

I dind't know about the checking heart tones regulations. My midwives definitely did not check the heart tones during labour every 15 minutes- every few hours they did. They never checked during pushing, but I only pushed for 5 or 10 minutes.


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## Momof3Girlz (Aug 18, 2002)

Brisen:

Do you mind my asking you *who* is your midwife? Curious to know if we have the same one, Lol...


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## pamamidwife (May 7, 2003)

I admit I do have a bias against episiotomy - it's easy to have one when you have scissors taken to your vagina!


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## Brisen (Apr 5, 2004)

I had 2 homebirths in London -- they did check every 15 mins. It is once active labour starts, though, maybe that's the diff for you? They are supposed to enter it on the chart. My mw today said that they've only had one mom who didn't want doppler in labour, and they decided that they should ask her every 15 mins and have her verbally decline so they could record it. She said that they could probably just have me say no once & for all when they show up -- I think they just weren't sure what they were allowed to do with the first mom who declined.

I'm in Toronto now.


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## sapphire_chan (May 2, 2005)

Quote:


Originally Posted by *Arwyn*
This is where I totally blanked. A couple years ago, before I knew better, I probably would have suggested pre-labor perineal massage (by herself or with a partner) or warm compresses or perineal support - all that hands-on crap. Now? After a pause where I marveled at the stupidity of the question (how does one avoid shooting oneself in the head? don't shoot yourself in the head!!!), I told her about an article I had read in Midwifery Today recently that answered that very question: "How do you avoid episiotomy? Don't do one." And told her it really was that simple - just tell her provider not to do an episiotomy under any circumstances without explicit consent in the case of an emergency.

Well, I will say one thing for perineal massage/support. If the OB is doing that, they can't be doing an episiotomy. Hmmm...I wonder if episiotomy rates go down if the mother "accidentally" knocks over the tray of tools? Hmmm....


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## Peppamint (Oct 19, 2002)

Quote:


Originally Posted by *sapphire_chan*
Well, I will say one thing for perineal massage/support. If the OB is doing that, they can't be doing an episiotomy. Hmmm...I wonder if episiotomy rates go down if the mother "accidentally" knocks over the tray of tools? Hmmm....

Well, not really... I ended up with both.


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## Brisen (Apr 5, 2004)

MomOf3Girlz, it is Mary, at Community Midwives of Toronto

Edited to change ontario to toronto!


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## Momof3Girlz (Aug 18, 2002)

Hi Brisen,

I'm in Durham Region. We just may have the same midwife...

Anywho, getting back on topic I must say I quite appreciated the warm compresses during pushing with my 2nd daughter. I always tell folks that I felt that eased the "ring of fire" and gave me the confidence to really push her out. My midwife did *ask* before doing it and I said yes. I'm glad I did.

With my 3rd child there wasn't any time for that she came so quickly.

I've never had any tearing with any of my children so far...

This time I planning a home waterbirth so I'm thinking that bone-cracking and ring of fire sensation will be lessened in the water as one poster mentioned previously.

I guess whatever the labouring woman wants is what's best for her. Our bodies really do tell us everything we need to know.


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## Momof3Girlz (Aug 18, 2002)

Oh, I'm with Sages Femme. I have Lisa Weston.


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## the_lissa (Oct 30, 2004)

Quote:


Originally Posted by *Brisen*
I had 2 homebirths in London -- they did check every 15 mins. It is once active labour starts, though, maybe that's the diff for you? They are supposed to enter it on the chart. My mw today said that they've only had one mom who didn't want doppler in labour, and they decided that they should ask her every 15 mins and have her verbally decline so they could record it. She said that they could probably just have me say no once & for all when they show up -- I think they just weren't sure what they were allowed to do with the first mom who declined.

I'm in Toronto now.

No, they didn't check that often even when I was in active labour, and they used a fetoscope rather than a doppler. They did have a doppler in case I wanted to hear it, but I was fine.

I was with the Community Midwives of Hamilton. I am currently seeing a midwife at the St. Jacobs' Midwives, but I am moving back to Hamilton, and was lucky enough to call the CMOH when they were in the process of hiring a new midwife or else I wouldn't have got in.


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## Brisen (Apr 5, 2004)

Ah, I see. Did you find it uncomfortable being checked with the fetoscope? I've only ever had a doppler used to hear in the past, this is my first time declining the doppler. I have a friend who UC'd her last pg, and brought a borrowed fetoscope over to my place to see if I could hear the heartbeat. I totally failed. But, I'm not at all trained on it.


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## the_lissa (Oct 30, 2004)

No I didn't find it uncomfortable really. I actually prefer that to the doppler because the gel annoys me with doppler.


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## Belle (Feb 6, 2005)

Pam, thank you so much for that article. It was beautiful.

I had a perineal "massage" during my dd's birth and it was horribly painful. Maybe I'll have to drive down to Salem for my next birth


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## tinyshoes (Mar 6, 2002)

Quote:


Originally Posted by *Momof3Girlz*
Anywho, getting back on topic I must say I quite appreciated the warm compresses during pushing with my 2nd daughter. I always tell folks that I felt that eased the "ring of fire" and gave me the confidence to really push her out. My midwife did *ask* before doing it and I said yes. I'm glad I did.

Y'know how in movies about The Olden Days, when a woman was in labor, there were frantic cries to "boil some water!"

I once read somewhere that _the reason_ for boiling water was to create warm compresses for the perineum to facilitate birth.....and I've been searching for a "heck yeah! that's true" to support this theory that I have not heard of/read of anywhere since I first read it.

When I've spoken to others about it, they admit they thought the boiling water was to sterilze the equipment, which I also used to think. (_What_ equipment!?! But that's our current modern techno-mindset, assuming people who thought damp air could cause swamp flu or that excessive bathing is unhealthy would be sterilizing the nonexistant forceps/episiotomy scissors on the prairie.)

.....rambling....I hope I'm not too OT here.......







"warm compresses on/off" that's in line with hands on/off, right?!


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## orangebird (Jun 30, 2002)

Quote:


Originally Posted by *tinyshoes*
Y'know how in movies about The Olden Days, when a woman was in labor, there were frantic cries to "boil some water!"

I once read somewhere that _the reason_ for boiling water was to create warm compresses for the perineum to facilitate birth.....and I've been searching for a "heck yeah! that's true" to support this theory that I have not heard of/read of anywhere since I first read it.

When I've spoken to others about it, they admit they thought the boiling water was to sterilze the equipment, which I also used to think. (_What_ equipment!?! But that's our current modern techno-mindset, assuming people who thought damp air could cause swamp flu or that excessive bathing is unhealthy would be sterilizing the nonexistant forceps/episiotomy scissors on the prairie.)

.....rambling....I hope I'm not too OT here.......







"warm compresses on/off" that's in line with hands on/off, right?!









Where I work when the baby is about to crown the CNM has me got water "as hot as you can, so hot it hurts to touch it" and they use that for the compresses. I always wondered if it would hurt, it burns my hand as I bring it over yet they slap it right on the perineum. Who knows.

Yeah, you're right though, the old saying boil some water- there weren't "tools" back then, so what would they be sterilizing? Hmm.


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## Arwyn (Sep 9, 2004)

Depends on how far back - they might have boiled the string they used to tie the cord and the razor for cutting it.

Boiling water also helps keep the house (most houses had 1, maybe 2 rooms) warm and humid for the birth, which is a common ritual in a LOT of pre-industrial cultures (hmm....).

And then of course there's the "busy work" factor. (Oh, to be able to send the OB and L&D nurses out to boil a hundred gallons of water...







)


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## cottonwood (Nov 20, 2001)

Quote:


Originally Posted by *milkydoula*
I was at my sister's prenatal appt (i am her doula) with the midwife i am considering using and the midwife suggested that she do prenatal perineal massage. She said that it would help her be able to relax the muscles when there was a lot of pressure from the babies head pushing on it and to train the muscles to relax under pressure.

So you train yourself to relax at manipulating your tissues -- your body is not going to recognize the birth experience as the same sort of thing, so it's not going to react the same way. You can get to where you can be completely relaxed in a relaxing environment with nothing in particular happening to your body, in complete privacy with only your own hands on yourself. That is not going to hold for intercourse or rape. It's not necessarily going to hold for someone besides yourself touching your genitals, or for a baby's head coming through when you're having contractions. The way behaviorism works, if that's what she's after, it requires some degree of specificity. Certain conditions must be present for the learned automatic response to set in.

She's trying to solve the wrong "problem" anyway. The body's tissues don't have to be trained to relax -- they already know how to, and will, given the right conditions. Just like with sex. If a woman is fully aroused, that is, if the body's hormonal process is facilitated and undisturbed and the woman is healthy, the vulval tissues are not going to be traumatized during sex. Even assuming that a woman can train herself to relax while her vulva is being handled, it's going to be superfluous _unless_ she's expecting to _not_ have a normal sexual experience.

I'll leave you to make the parallel with birth.

Quote:

I have a history of sexual abuse and have issues with tensing those muscles anyways (sex took a lot of getting used to and relaxation on my part). Would perineal massage help in this case? I would love some input
Does it have more to do with issues of power and trust and inhibition at having others touch you, or with the sensation of being touched in itself? Can you masturbate? In other words, can you touch yourself without tensing up? When you are in a warm bath in private, say? If not, then yes, it would probably be very helpful to allow yourself to feel good things in your vagina, so your body has other associations with it beside sexual assault. (Although it sounds like you've already been doing that to some extent.) I don't know, though, how stretching and rubbing the skin is relevant to this, unless it makes you feel good!

(Directions for perineal massage are often qualified with, "if it doesn't hurt, it's not doing you any good." As pertains to a normal bodily function, this is just plain wrong. But especially for someone with sexual abuse issues, it's an especially irresponsible thing to suggest.)

If you are fine with certain types of touch, then I would say that what you really need to do is disassociate the working of your body in birth with the sexual abuse. They have nothing to do with each other, one is coming from the inside with your desire and consent, the other from the outside without it. And then set up the birth so as to allow you to remain in a place where those associations will not come up, where you are respected, where you feel completely in control, where you don't feel inhibited.


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## cottonwood (Nov 20, 2001)

Quote:


Originally Posted by *tinyshoes*
Furthermore, the concept of perineal massage is just another "women's bodies are broken" message, but this time it is in disguise....."perineal massage" is a suggestion bandied about by the earthy-birth community, especially with CNMs and "crunchy" MDs.

<nodding head>


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## Momof3Girlz (Aug 18, 2002)

Quote:


Originally Posted by *Brisen*
Ah, I see. Did you find it uncomfortable being checked with the fetoscope? I've only ever had a doppler used to hear in the past, this is my first time declining the doppler. I have a friend who UC'd her last pg, and brought a borrowed fetoscope over to my place to see if I could hear the heartbeat. I totally failed. But, I'm not at all trained on it.

Ah yes, the constant checking (with the doppler in my case). HIGHLY annoying especially when contractions are one on top of another...hmmm will have to talk to my midwife about that. I did not enjoy that. I thought they were just trying to keep the student midwife busy, lol...I know it's a "required by law" thing but who knows...maybe I can get out of it.


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## Peppamint (Oct 19, 2002)

Quote:


Originally Posted by *fourlittlebirds*
<nodding head>

I agree too. For a long time I've had that feeling <shudder> when women recommend perineal massage. In my DDC and here, when it's been brought up I've just been unable to recommend it for some reason.

This thread has been very enlightening to me... it's nice to explore the feelings I have about it and to have everyone back those up with sound reasoning. Great thread Pama!


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## Brisen (Apr 5, 2004)

Quote:


Originally Posted by *Momof3Girlz*
I know it's a "required by law" thing but who knows...maybe I can get out of it.

I think it is just a College regulation... It seems to me now that midwives who like the regulations don't present them as something you can decline.


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## Belle (Feb 6, 2005)

Quote:


Originally Posted by *tinyshoes*
Y'know how in movies about The Olden Days, when a woman was in labor, there were frantic cries to "boil some water!"

I once read somewhere that _the reason_ for boiling water was to create warm compresses for the perineum to facilitate birth.....and I've been searching for a "heck yeah! that's true" to support this theory that I have not heard of/read of anywhere since I first read it.

When I've spoken to others about it, they admit they thought the boiling water was to sterilze the equipment, which I also used to think. (_What_ equipment!?! But that's our current modern techno-mindset, assuming people who thought damp air could cause swamp flu or that excessive bathing is unhealthy would be sterilizing the nonexistant forceps/episiotomy scissors on the prairie.)

.....rambling....I hope I'm not too OT here.......







"warm compresses on/off" that's in line with hands on/off, right?!









I'm OT here, but I always just thought boiling water was something to keep the menfolk busy and from being underfoot.


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## mamacatsbaby (Jul 27, 2005)

Wow, what a great article! The more I read about perineal massage I just don't think it's for me. A month or so ago I was thinking about getting strarted with prenatal perineal massage but no, the whole thought of it just skeeves me out now, and I just find more and more evidence that for care providers to be totally hands off is the best way to let a woman birth. Makes sense to me. Thanks for the article pamamidwife and to all you lovely posters for your experiences and insights. This has been quite an enlightening thread!


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## QueenOfThePride (May 26, 2005)

I thought boiling water was to get a warm bath ready to clean up the baby and mama after birth.


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## SaveTheWild (Mar 14, 2003)

Quote:


Originally Posted by *pamamidwife*
Prenatal perineal massage has been shown to never improve the outcome of tearing.

I was actually just looking into this about a week or so ago and found this on the Cochrane site (it is a 2006 article, but looks at a bunch of studies done over time):

http://www.cochrane.org/reviews/en/ab005123.html

"*Plain language summary*
Antenatal perineal massage helps reduce both perineal trauma during birth and pain afterwards

Most women are keen to give birth without perineal tears, cuts and stitches, as these often cause pain and discomfort afterwards, and this can impact negatively on sexual functioning. Perineal massage during the last month of pregnancy has been suggested as a possible way of enabling the perineal tissue to expand more easily during birth. The review of trials showed that perineal massage, undertaken by the woman or her partner (for as little as once or twice a week from 35 weeks), reduced the likelihood of perineal trauma (mainly episiotomies) and ongoing perineal pain. The impact was clear for women who had not given birth vaginally before, but was less clear for women who had. There were no randomised trials on the use of massage devices. Women should be informed about the benefits of antenatal perineal massage."

I am still not sure how I feel about it, and it is interesting that the study notes that episomoties were reduced, but not necessarily tearing by all that much. still food for thought.

note thought that this is only about *prenatal* perineal massage, nothing at all about "massage" during delivery.


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## orangefoot (Oct 8, 2004)

I'm in discussion about this elsewhere and also read this research review.

My feeling is how reliable can evidence on perineal massage be in reality?

All our skins are different as can be seen in the way we age and that some of
us have stretch marks and others don't. Were all the perinea of the
same skin type and elasticity? Did all the women carry out exactly the
same massage - and is this possible as all our vulvas are different?
Were all the women well hydrated? What was their diet like? What was
the context of each labour(home/hospital/midwife unit)? What positions
did the women choose to birth in...........?

Surely there are too many variables to make this type of research valid
in terms of recommending that all women do perineal massage?

I agree with Tinyshoes in her assessment that this just encourages us to believe that our bodies are broken and need some training or 'breaking in' and that if I don't massage and I do tear then *I* am at fault.

I have been cut once and torn twice (not on the original scar) what does that say about me? That I tore - no more, no less. I would love to avoid a tear but maybe I am tearable? My first was an underwater totally hands off tear so whose 'fault' was it?

Sorry this tear vs no tear really bugs me and if I'm honest upsets me a bit because I feel that sometimes within the homebirthing community not tearing is seen as being at the top of some mythical hierarchy and tearing is close to the bottom or at least not far away from a failure in some way.


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## barbara (Feb 13, 2002)

I agree, how reliable can evidence on perineal massage be in reality? I think so much has to do with a woman's nutrition and hydration. Water works wonders to keep skin elastic, and I can't stress enough how important drinking plenty of water throughout pregnancy and birth is.

An interesting note is that I had a huge episiotomie with my first birth and tore on that scar line (slightly, not even needing to be sticth) for the following births, EXCEPT my last birth, where I did not tear! Now you must understand that this last birth was my 7th child and I was 40 years old! I gave birth on hands and knees, as I had with several of my other births, but I did take the time to breathe through those ring of fire contractions, where in the past births I had just pushed to get the baby out!

I'm also pretty sure that emotional factors have more to do with strecthing and tearing than prenatal massage can.

Anyway, I think the perinium is a wonderful part of a woman's body and it can do amazing things when it is allowed to.


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## QueenOfThePride (May 26, 2005)

That was a really great article. I'm trying to remember more details from giving birth, but I was in so much pain at the time, I wasn't really cognizant. My OB was doing some kind of 'massage' more like stretching. When I pushed, she was stretching my skin and it was painful. It hurt like I was tearing just a little straight down each time, so I would stop pushing. I told her to stop doing whatever she was doing, and she did. Now that I read that article and this thread, I see that 'helping' me to stretch was counterproductive to my labor. Naturally, my baby's head would have begun crowning, and I would have slowed down my own pushing to ease his head out, because it would have hurt. But the perineal stretching was hurting me before he was even crowning. I pushed for an hour, and it was exhausting. I also don't know if my OB applied counterpressure to my baby's head or not. I was pushing and pushing and pushing and I could not get him out. I wanted him out so BAD! I was very frustrated, I yelled out, "I feel like I'm not doing anything!" I have this sense that my OB was pushing on baby's head, not letting him come out 'too fast'. But I really don't know if she was or not.

I'm really glad I got to read that article. It helps me understand the birth I've already had, and plan better (hands-off!) for the next one.


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## cottonwood (Nov 20, 2001)

As I always say, I'd like to see these studies... too lazy to look for them at the moment, though.









Here's from the abstract:

_Three trials (2434 women) comparing digital perineal massage with control were included. All were of good quality. Antenatal perineal massage was associated with an overall reduction in the incidence of trauma requiring suturing (three trials, 2417 women, relative risk (RR) 0.91 (95% confidence interval (CI) 0.86 to 0.96), number needed to treat (NNT) 16 (10 to 39)). This reduction was statistically significant for women without previous vaginal birth only (three trials, 1925 women, RR 0.90 (95% CI 0.84 to 0.96), NNT 14 (9 to 35)). Women who practised perineal massage were less likely to have an episiotomy (three trials, 2417 women, RR 0.85 (95% CI 0.75 to 0.97), NNT 23 (13 to 111)). Again this reduction was statistically significant for women without previous vaginal birth only (three trials, 1925 women, RR 0.85 (95% CI 0.74 to 0.97), NNT 20 (11 to 110)). No differences were seen in the incidence of 1st or 2nd degree perineal tears or 3rd/4th degree perineal trauma. Only women who have previously birthed vaginally reported a statistically significant reduction in the incidence of pain at three months postpartum (one trial, 376 women, RR 0.68 (95% CI 0.50 to 0.91) NNT 13 (7 to 60)). No significant differences were observed in the incidence of instrumental deliveries, sexual satisfaction, or incontinence of urine, faeces or flatus for any women who practised perineal massage compared with those who did not massage._

Can somebody who understands statistics decipher these numbers?

And what the heck does this mean: "No differences were seen in the incidence of 1st or 2nd degree perineal tears or 3rd/4th degree perineal trauma." Well, what are they defining as "trauma", then?









ETA: Oh, okay. "Women who practised perineal massage were less likely to have an episiotomy." Not a _tear_. Okay, so what can we deduce from this? That those who do antenatal perineal massage are not less likely tear, but something is different that makes the doctor less likely to cut the tissue. What do you think? Maybe women having perineal massage are more tuned into their bodies and more likely to plan natural births, and therefore less likely to employ doctors who cut often?


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## SaveTheWild (Mar 14, 2003)

Quote:


Originally Posted by *fourlittlebirds*
ETA: Oh, okay. "Women who practised perineal massage were less likely to have an episiotomy." Not a _tear_. Okay, so what can we deduce from this? That those who do antenatal perineal massage are not less likely tear, but something is different that makes the doctor less likely to cut the tissue. What do you think? Maybe women having perineal massage are more tuned into their bodies and more likely to plan natural births, and therefore less likely to employ doctors who cut often?

yeah, that is my question too (the first part re: lss likely to be cut but not necessarily less likely to tear).

as far as being more likely to plan natural births... I don't know. these were randomized studies with a control, so women were assigned to be in one group or another, it wasn't their choice. So unless the act of massage led them to alter their birth plans, this shouldn't have an impact.


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## Arwyn (Sep 9, 2004)

Or more likely that their OBs new they practiced perineal massage, and through the power of their own beliefs decided that fewer of those women "needed" episiotomies.

There's also the power of the women's own belief that because of having practiced antenatal perineal massage they wouldn't tear and therefore requested no episiotomy (or otherwise believed that they didn't need episiotomy).

I wouldn't trust these studies to provide any relevence to a homebirth, especially one with a hands-off midwife. All they showed was that episiotomies were reduced, which when comparing OB-attended hospital births (who cut, what, 90% of first time moms?) and midwife-attended homebirths (variable, but usually less than 10%, ought to be less than 5%) would be like comparing the amount of sand in a desert and a rainforest.


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