I really wanted to avoid tearing with the birth of my first. As I mentioned on the page on avoiding an episiotomy, I really wanted to avoid any damage 'down there' at all and fortunately, I came off with just a tiny tear, despite not knowing about some of the advice given here. Next time, Im hoping to survive intact, so this is advice to me as much as it is hopefully helpful information for you.
Well, I think its pretty obvious why you would want to avoid tearing of your perineum while pushing your baby out. (For the newbies, your perineum, or perineal area, is that arb yet important area between the vagina and the anus.) Its sore afterwards (albeit generally less painful than an episiotomy), it can make life uncomfortable for a while, and its something else youll have to bother you in the days after the birth when you want to be able to devote your time and energy to your new baby. Furthermore, it can hinder your initial attempts at sex after pregnancy.
While that sounds undesirable to say the least, an episiotomy is not the answer! Check the article on avoiding an episiotomy if you'd like to know why...
Below are some things that may help you avoid tearing, or at least minimize the severity of tearing if it does happen.
Sounds crazy, I know! But this really helped me my first time around. Next time you experience pain, just notice what your body does. Most of us tend to tense up and close up, especially in our shoulders and faces. As the baby is crowning (i.e. the edge of the vagina looks like a crown on the baby's head - cool picture hey?) it does cause a tingling or burning sensation, quite different to the sensation of contraction experienced before this.
Because its a new sensation, sometimes referred to as the 'ring of fire', most women tend to tense up, and as I mentioned before we generally tend to tense up in our shoulders and faces - think of the grimace of pain you normally see in movies where women are giving birth.
But, what people often fail to realize, or don't believe if you tell them, is that looseness in the jaw aids looseness in the pelvic floor area. That means no biting on sticks! Sounds weird I know, but it works! Wonderful things, these bodies of ours! So when you get that burning sensation, release it, relax your face, and feel your body opening to let your baby through. I found that really helped me avoid tearing badly with the birth of our first. I must have looked a sight with my chin dropped as far as it would go, making noises in my throat that sounded like a snorting horse. But it worked!
Anyway, Sheila Kitzinger also recommends doing pelvic floor exercises while pregnant where you not only work on toning the pelvic floor, but on relaxing or releasing it as well. Makes sense hey?
You can also do this exercise where the person doing the stretching hooks the thumbs slightly and gently pulls the perineum forward, mimicking the action of the baby's head. This version is much easier with a partner.
It is recommended that you do perineal massage for 5 minutes a day for the last 6 weeks of pregnancy. I don't know of anyone with that kind of discipline, and I certainly didn't do that much, although I might make a more concerted effort next time. The times that I did try it really helped me to have an idea of what to expect when the baby is crowning, and during the birth was actually almost a pleasant experience in that I knew things were progressing! You're probably thinking, "Crazy birth junkie!", but really, knowing what to expect makes a big difference!
If you're into gadgets that might help you avoid tearing, you might like to take a look at this perineum stretcher! http://www.epi-no.co.uk/
Perineal massage or perineal support in labour can also help. If the perineum is swollen, a cold compress can reduce swelling and make it numb. A warm compress on the other hand can help the perineum stretch and relax. Your care provider may also provide manual support (i.e. with his or her hands) to help slow down the delivery of the head and keep the perineum intact.
This is one I didn't know before I had my first! I went along with the instructions of the hospital staff and pushed out my little girl in 4 pushes, 15 minutes flat. It was great in that it didn't go on so long, but I think if we'd given it maybe another minute, maybe two, the perineum may have had a little extra chance to stretch and the tear could have been avoided.
Directed pushing, or the Valsalva manoeuvre is where you hold your breath and push as hard as you can while some one counts to ten. It is common practice in hospitals in South Africa as far as I know, even though evidence shows that it isn't necessarily the most effective way to push. I think it is popular because many doctors are wary of a long second stage (i.e. pushing stage), or just impatient, and have ended up being over cautious or trying to rush things. Directed pushing often just ends up making the mother tired, which increases the chance of needing an episiotomy and other intervention and also increases the likelihood of trauma to the birth canal and injury to future pelvic floor function. (1)
Maybe the water softens the perineum so it stretches more easily, maybe the relaxing effect of the water means moms aren't so tense and tired, who knows? I'll let you know when I try it next time...
Even though we're not exactly sure why, studies show that water birth, or laboring in water, significantly decreases the necessity for episiotomies and greatly reduces the number of 3rd and 4th degree tears. (2, 3)
My article on the best natural birth positions (coming soon!) has more information on this topic, but the most important thing in avoiding tearing is to not push while on your back. I know some hospitals encourage you to sit in a semi reclined position, which is somewhat more helpful, but squatting (supported or unsupported, with knees shoulder-width apart) opens the pelvic outlet considerably, as does giving birth on all fours, and thus can also help prevent tearing. Assuming the side lying position can also help. (4, 5, 6)
Studies have shown that women who don't get pain meds in labour are more likely to survive with their perineum intact. This is for a variety of reasons. An epidural prevents you from assuming the best positions for giving birth, and you are usually left lying on your back. Furthermore, you may struggle to sense what is happening in your body and may not experience the urge to push so you have to rely on everyone else telling you when to push, even though your body may not be ready. Both of these are risk factors for tearing. (7, 8)
Yes, you can expect an article on the benefits of having a doula soon, but until then just know that a doula (usually a woman) is someone who stays with you during labour. She can be whatever you need her to be - moral support, physical support, perineal support - whatever! Studies have shown many concrete benefits to having a doula, one of which is a greater likelihood of avoiding tearing. Perhaps it is because you feel more relaxed, who knows? But it works!
The elastic-ness of your skin, in other words, the capacity to stretch without tearing, is also dependent on your diet so make sure you eat good skin-supporting foods, or take supplements to help. Vitamins A, E, K and B-complex vitamins will all help to avoid tearing!
I hope that helps! If you try any of these methods please let me know how it goes! Also, if you hear of anything else that can help moms avoid tearing, I'd love to hear about it so I can include it here.