Monday, February 21, 2011

Vaginal Tearing -- What You Should Know For Your Next Birth

When couples show up for the first night of childbirth classes, they want to know 3 things:  1) When do we go to the hospital?  2) What if my water breaks?, and 3) My mom says an episiotomy is better than tearing.  I don't want either.  Of course, I make them sit through 4 weeks of classes before we get to "the good stuff."  By the time we get there, they have a really good foundation.  For this post, we'll concentrate on item number 3.  (Yes, I've been inspired by my good friend, Sarah Clark, aka Mama Birth, with the humorous photos.)

Obviously, the tearing of the vagina as the baby is crowing does not sound enjoyable.  There is a lot of fear surrounding the possibility of this occurring.  The good news and bad news is all rolled into one sentence concerning this fear:  You'll think you tore, even if you didn't.  Some women feel better after learning this and some don't.  The skin typically burns (thus, the "ring of fire") as it stretches over the baby's head.  Once it is stretched, the skin is pretty numb, but before this, you will likely think that you tore.   I thought that with every baby and I've never torn. 

So what can you do to prevent tearing?

I live in the Fort Worth area now, but I lived in Albuquerque before moving here.  NM has almost the lowest  c-section rate in the country.  No coincidence that one in every three births is attended by a midwife.  When I taught Bradley® classes in Albuquerque, I had a number of students participate in a study that the midwives were conducting at UNMH (University of New Mexico Hospital).  The study was trying to find out what method at the time of birth was the most effective at protecting the perineum.  If you chose to participate, you were given one of three envelopes at the time of birth with one of the following options written on it:  1.) Do nothing as the baby emerges; 2.) Use perineal massage; or 3.) Use warm compresses on the perineum as the woman is pushing.

I always like to share a funny story in class from my third -- and hardest -- birth.  As I was pushing, my midwife was applying pressure to the perineum. She asked me if I wanted her to keep doing that -- actually, her exact words were, "Do you feel like your butt is going to blow out?"  Yes, that's exactly how I feel, and yes, please keep doing that!  Emotionally and physically I felt like I had something to push against.  I think women are always surprised at how hard they are pushing.  I have always been a big fan of warm compresses or support of the perineum, much more so than perineal massage.  I must admit, I thought warm compresses would be the big winner of the UNMH study.

I have someone in my current class that recently looked up the study.  Yes, I'm embarrassed to admit that I never looked it up to see the results.  Let me give you a few more details about the study before the exciting results.

Data was collected from 1211 births over a 3 year period.  There were several bits of data collected including maternal age, parity, race, years completed of education, body mass index, weight gain in pregnancy, and use of antepartum perineal massage (during the pregnancy).  Variables included use of pitocin and epidural, length of 2nd stage, style of pushing (coached or self-paced without prolonged breath-holding), position of the baby (compound presentation or posterior), and complications or unexpected birth events.

The most interesting thing about this entire study is the probably the c-section rate:  Of 1211 births, 98%, or 1187 had a spontaneous vaginal birth.  Only 25 of these women -- 2% -- had an operative delivery!  Nine cesareans occurred in late labor, and 16 women had vaginal operative births (3 by forceps and 13 by vacuum).  ONLY 9 CESAREANS IN 1211 BIRTHS WITH THE MIDWIVES! 

Take a minute to recover from that and let's move on.  There are a number of other items I found interesting within the study.  The first one is that 13% of the women that were receiving perineal massage requested that the midwife "stop."  With the other two methods, it was 2.2% (warm compresses) and 1.7% (hands off).  Again, I'm not a fan of perineal massage (I think I've said that a time or two!) and neither were 54 of the 400 women who drew this envelope.

*Less than 40% of the women in each group had an epidural and the use of pitocin was between 32-36%. 

*At least 77% from each group gave birth sitting upright.  About 10% were flat on their backs with stirrups.  Less than 1% in each group gave birth in a squatting, hands and knees, or standing position.

*The vast majority (each group over 77%) did not participate in Valsalva pushing (holding breath excessively long causing capillaries to burst, etc.) and between 30-34% of the mothers delivered the head between contractions.

*Approximately 94% of the babies was born in an occiput anterior position, while about 10% were born with a compound presentation (hand by the baby's head).

Other things that should be noted:  40% of the participants were first-time mothers.  There was a wide range of ethnic diversity as well.

Some interestingly low numbers include:

*92 births with nuchal cord
*42 births had meconium
*34 with extreme fetal heart rate abnormalities
*10 with postpartum hemorrhage
*9 with shoulder dystocia (.7%)  -- Side note -- I hear this all the time for a reason for c-section or induction.  True shoulder dystocia is rare!
*2 with manual removal of placenta

The Results:

*Only 10 episiotomies were performed, due to severe fetal heart rate abnormalities.

*23% off all women experienced no trauma at all to the genital tract, regardless of which envelope they drew.

*20% had major trauma, defined as 2nd, 3rd, or 4th degree tearing.

*57% had minor trauma, defined as 1st degree tearing, affecting the external genitalia, or the outer vagina.

Other studies have defined an intact genital tract as "no trauma, or minor and unsutured trauma."  If this definition was applied to this study, the midwives' rate of "intact" would be a whopping 73%!  In all fairness, too, these 12 midwives who were involved in this study already had a high degree of expertise at minimizing trauma in vaginal birth.  I met with a couple of them when I was teaching in Albuquerque and was extremely impressed.  In fact, the obstetric culture at UNM teaching hospital is patient, calm and controlled, and emphasizes slow expulsion of the baby. 

Ultimately, there were 2 care measures that were associated with a lower risk of genital tract trauma.  1.) "A sitting position allows the mother greater comfort and autonomy at delivery.  It allows face-to-face proximity and direct visual contact between the mother and midwife."  2.) "Delivery of the head between contractions requires communication, synchrony, and shared responsibility for a slow and gentle expulsion of the infant."  

So ladies, be patient at the time of birth.  Ban the cheerleaders!  Don't let anyone count to 10 for you like they do in the movies.  Just let the baby come.

As for the 3 methods?  It's really up to the woman and her midwife.  The results were all similar in findings.  If you'd like to read more about the study, you can find it here.


Kristi said...

I guess there must be something wrong with me. I knew I did not want an episiotomy, but the thought of tearing never bothered me. I pushed the "wrong", way and my midwife did "something" (not exactly sure) down there while I wash pushing and I actually liked it. I never experienced the ring of fire. And I never would have guessed that I tore. Well, I did. 2nd degree. At my 6 week checkup there was a little bit of tenderness when tugged on but no pain. And "ahem" has not bothered me. I am surprised at how quickly I felt back to normal. But I always worry that there is something wrong with me for the lack of issues with tearing. Maybe I should just count my blessings. But I can't help but wonder if my hoo ha is numb or something.

Regina said...

Somethin must be wrong with me too for having to have the placenta removed manually! I can't believe only 2!! I didn't know it was so rare. And I wouldn't say it hurt when she came out either. No ring of fire. But MAN did I tear and it took forever to heal. Like forever. I am definitely going to do more (what??) to minimize tearing, but likely i will just re-tear in the exact same spot for the 3rd time. NOT looking forward to that!!

Kristi said...

BFBS do you have a post about manually removing the placenta? I'd like to know more about that too.

Sarah said...

I swear, and I mean SWEAR that Ann single-handedly (Ok, she had to use both her hands & probably her all the muscles in her back) saved my bottom while pushing J. 10lbs, 11 oz & no tear but the counter-pressure that she was doing was intense & SO necessary. That alone is enough reason to feel immensely grateful to her, for caring for me & my poor bottom enough to help me stay intact!

Lorelei said...

Did I miss where it said which group did the best, hands off, massage, or warm compresses? I'm glad I have a pretty good chance of no (or minimal) trauma, but I'd really like to know which group did best!

Donna Ryan said...

Lorelei, it was a confusing study because we all expected one of the three to be the big winner. Unfortunately, they all had about the same results. The two things that seemed to make the biggest difference in minimal tearing were using a sitting position for the birth and letting the head be born between contractions. I hope that helps.

Regina, not necessarily. There are different things that could have affected the way you tore. That's probably a topic for another day here. Plus, since I know you, we can actually talk about this! Ha!

Momma Jorje said...

I think the slow expulsion was the key! I was given an episiotomy with my first. I then proceeded to "tear the muscle you use to stop pooping." (That really is what they told my 17yo self.) Of my 3 births, that was the WORST aspect of all! Not so much the tearing, but the recovery; sitting on the toilet, bawling.

We learned about perineal massage through our Bradley classes with our 2nd (and 3rd) child. I don't know if my 1st husband was just too rough, but I did NOT like antepartum perineal massage! So we gave it up. I tore and bled horribly with #2.

With my 3rd, however, I had expressed my concern about tearing with my doctor in advance. He simply helped pace me on pushing. It isn't a race to the finish! With slow pushing, I didn't tear at all! He thought I might need a stitch, but then said it was just abrasion.

I've had trouble with some sex positions since my 1st, so I wish I'd known then what I know now! Great read!