Protect Your Perineum – Part Three

Lisa Baker

 Lisa Baker is a childbirth educator and mother of two in Calgary, Alberta. You can reach her by email at lisabakerlcce@gmail.com

In our first post of this three-part series, we listed several factors related to perineal trauma during childbirth. They are as follows:

1.  Practice perineal massage;
2. Avoid an episiotomy unless medically necessary for the health of you and your baby;
3. Relax the pelvic floor muscles when pushing;
4. Consider upright positions for giving birth; and
5. Have the birth attendant apply warm compresses to your perineum during the pushing stage of labour.

In today’s post we will discuss the final three factors and how they are related to episiotomy and tears during childbirth.

Relax the pelvic floor muscles when pushing

 Soft, relaxed tissue stretches more easily then tight, rigid tissue. This basic principle has inspired techniques to protect the perineum in childbirth. The benefits of perineal massage and warm compresses are directly related to the fact that they soften and relax the tissues of the perineum.  As a labouring mother, you can make a conscious effort to relax the perineum during childbirth. A simple way to keep this in mind is to take note of your jaw during contractions. Generally speaking, if you have a tight jaw then you have a tight perineum! Have your support people also keep an eye and gently remind you to relax if they see you clench your jaw.

Consider upright positions for giving birth

 In early 2012, a Cochrane review entitled “Position in the second stage of labour for women without epidural anaesthesia” was updated and released (1). This review compared women who were in a mostly horizontal position (side-lying, flat on back, laying down with back slightly raised) to a mostly upright position (sitting, kneeling, and squatting).  The reviewers concluded that the rates of episiotomy were lower in women who birthed in an upright position. Although the risk of second-degree tears was higher in the upright group, it did not outweigh the lowered risk of having an episiotomy. In other words, there is evidence to suggest a lower risk of perineal trauma for women who birth in an upright position. Further research is needed to fully explore this relationship, however birthing mothers should be free to consider upright positions when giving birth.

Apply warm compresses to the perineum during the pushing stage of labour

 A common tool used by midwives and physicians during the pushing phase of labour is a warm compress. A warm compress can simply be a clean washcloth with hot water in it, pressed onto the perineum during the later stages of pushing.  The application and pressure of a hot cloth on the perineum can help to increase circulation in the area and help to relax the muscles.  It also helps to ease the burning sensation that is felt during crowning of the baby’s head.  There is strong evidence to suggest that the use of a warm compress can lower the risk of third and fourth degree tears (2). Not all labouring women should use a warm compress, however. Women with an epidural will not be able to feel if the warm compress is too hot and would therefore be at risk for burns. Nevertheless, warm compresses can be an effective protective measure for many labouring women.

Protect Your Perineum

Perineal trauma involves many factors and some, such as ethnicity, cannot be modified (2).  It is difficult to predict if you will end up with an episiotomy or tear, and there is no single technique that will guarantee an intact perineum through childbirth. Despite this, there are several things you can do to help reduce your chances of an episiotomy or tear. Practice perineal massage and relax the perineum during childbirth. Allow your care provider to use warm compresses on your perineum if you do not have an epidural for pain relief.  Avoid receiving an episiotomy unless medically necessary and consider trying upright positions for pushing. Finally, if you do wind up with an episiotomy or tear, be sure to practice self-care techniques that help improve the healing process.

(1)  Gupta JK, Hofmeyr GJ, Shehmar M. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database of Systematic Reviews 2012, Issue 5. Art. No.: CD002006. DOI: 10.1002/14651858.CD002006.pub3.

(2)  Aasheim V, Nilsen ABV, Lukasse M, Reinar LM. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database of Systematic Reviews 2011, Issue 12. Art. No.: CD006672. DOI: 10.1002/14651858.CD006672.pub2.