What have you heard/experienced about preventing tearing?

[sste]

Obviously alot of this depends on birth position but among the controllable items, I was wondering what everyone had heard/experienced. In meeting with our new doula/midwife last night she said the following when I asked:

1. Provider catching the baby - - she said that the biggest impact you can have on reducing or preventing tearing is that the provider catching the baby does not do a lot of "swiping" or finger movements other than pressure as it causes inflammation which makes tissue more susceptible to tears. Apparently, some recent research on this - - many doctors were trained that repeated swiping is helpful.

2. Not squatting during the pushing out phase which she says most women naturally opt not to do anyway. Apparently, squatting and to a lesser extent hands and knees are great for all of labor but during active pushing/crowning it increases tears. She said encouraging women to squat in the final stages of pushing had been a practice at her prior birthing center but they discontinued it when this research came out (and she noticed more tearing in her personal experience).

3. Avoiding overly forceful, unnatural pushing at the end.

Does this sound right to all of you? Any other ideas?

[Katigre]

That all sounds right to me. Though I would say for the pushing stage to choose whatever position feels most comfortable - that turned out to be different positions for DS and DD (with DD the only way that I felt remotely 'comfortable' to push was on hands-and-knees) but I had minimal tearing with each - DS it was one stitch and DD no stitches.

I think the fact that I had longer pushing phases both times (2 hours DS and 1/2 hour DD) and that the midwife did warm compresses and actively supported my perineum during pushing helped a lot too.

[MegBoz]

Yup, that all sounds right to me as well.
Some other things:
-epidurals increase the risk of tears
-"Coached pushing" aka "purple pushing" also increases the risk of tears. --Having them yell "PUSSSSSSH" & count down from 10, telling you to hold your breath.
Women naturally sometimes hold their breath, but not for as long as they do with the whole 'purple pushing' business. (It also deprives the baby of oxygen - but I digress.)

Do NOT push at the time of crowning, just 'breathe the baby out'.

There is some research that perineal massage *during pregnancy* decreases tears - but that is not the same as "vagina wrenching" (referred to as "perineal massage" IN Labor - docs trying to yank apart the vagina. PULLING outward at 9 and 3 o'clock and swiping down towards the anus to stretch - that is what DOES increase tearing due to the swelling, as your MW said.

[Tanya]

Hmmm, I'm not sure I totally agree. I was on my side to push out my first and had only minor tearing through the skin. For my second, I was either on my knees or in a squat and I had no tearing at all.

I think it's what position feels right and the pushing should be controlled. I listened to my body and to my midwife. She'd tell me when to stop pushing to allow for stretching. She also lubricated me and provided counter-pressure.

I think it helps being able to truly feel everything vs. having an epidural, but I don't have any personal experience with an epidural. I just know that my friends that had epidurals tore a lot and I didn't. It may have to do with your own body and the baby too.

[wellyes]

I had two epidurals and only very minor tearing with #1, none with #2.

I think the real key is having a skilled OB/midwife to help coach you through the pushing stage. Pushing is very, very intense. I hope this isn't offensive, just trying to come up with an analogy.... it's kind of like when you have the flu and are about to throw up. Your body is making you do it. While you have a certain degree of control over how it happens, you're not your normal rational self at that moment: your whole world is "this sucks" and waiting for it to happen and dreading when it WILL happen. So having someone there to coach you through it is enormously helpful, because you're so focused on just getting through that moment.

Since you'll have a doula you're working with in advance you're already ahead of the game.

Let me offer a little reassurance: I absolutely dreaded tearing, was so scared of it, prior to it happening. But when it happened it was really not that big of a deal, truly. MOST women who tear get a first degree tear (a superficial one) that heals quickly and doesn't really hurt much. Or, maybe it would have hurt, but I took a ibuprofen every 6 hours for a week or so after giving birth. I'm not sure if that was for the tear or just general soreness from the birth experience. The worst part is that it stings a little when you pee.

[sste]

Thank you everyone! I feel better too knowing most tears aren't a big deal . . . its just if I am lucky enough to be able to vbac it would be nice not to have stitches from vbac and of course from the old c-section (though thanks to my ob I will say the c-section scar is practically indiscernible).

It is kind of a strange birth for me because I am a second-time mother but I experienced nothing of a normal birth last time . . . water broke but not one contraction that I could feel for 12 hours and then when I got to the hospital baby had completely flipped to breech, failed inversion (my ob tried to make me happy but 12 hours after water broke we had no luck and baby's heart rate dropped scarily for a few seconds during that attempt) and the window of time to get him out was closing so I had a c-section.

So, the first contraction I ever felt was this month with a BH!!

[brittone2]

I had coached pushing with DS1, despite asking to not have it in my birth plan. I was fortunate that I only had a small tear (a few stitches) but I honestly think had I not had coached pushing, etc. I might have even avoided that.

With DD, I asked the birth center staff (different midwives) to skip the coached pushing. Pushed in sidelying, did the whole "breathe the baby down" thing ala Hypnobabies. It was only a few pushes and she was out (like under 5 mins). No tearing. Was a little sore/swollen but nothing like #1. DS1 and DD were the same size (8lbs, 4oz).

As an aside, I showed up to the birth center when I was in labor at 10 cm and completely effaced. No urge to push though. Membranes were still in tact. Most of my labor w/ her was waiting to feel any urge at all to push, which actually took like an hour? The CNMs just went w/ that. It worked out well because in a traditional setting I'd likely have been told to push when "complete" and I think I likely would have had to push for quite a bit, kwim? Following my own urge was really nice.

With DS2 I had a water birth, no coached pushing, no check to see if I was "complete". I didn't "push" until I couldn't NOT push. I felt myself getting a little grunty and figured I must be getting close but it was nice to follow my own body. 2 pushes w/ one contraction and he was out. No tears, no swelling at *all* which was weird. No need to use a peri bottle at all post partum. Felt fantastic. He was my biggest at 9lbs. I pushed kinda semi sitting/semi squatting and maybe on my side a little? I think I had one knee pulled up toward my chest in the pool and slightly rotated to my side.

[maestramommy]

I had a teeny bit of tearing with #2 and 3. With #2 the OB had to use forceps, so I don't know if that had anything to do with it. With #3, the OB squirted some kind of oil on my perineum, "to help prevent tearing." Laurel's head was smaller than the other two, but I was pushing pretty actively. I mean, one push got her head out, the next push got her the rest of the way. I don't know what would've made the outcome any different.

With Dora I had an epsiotomy, and if I didn't I might've had a huge tear. Dh was watching and said her head was just stuck, pressing against the whole area, and it was obvious she wasnt' coming out without some help.

[brahms]

Hypnobirthing gives very detailed instructions on perineal massage. I used it for all 3 of my kids, had 2 stitches with DD1, none for DD2, and one stitch for DS. It's essentially the same things the OB does to your perineum while you're pushing, but you do it for 5 minutes a day, starting at about 34 weeks, using some sort of oil or lube.

My best friend followed the hypnobirthing perineal massage and had zero stitches for her first. She didn't bother doing it for DD2 and had 2nd degree tears. Yikes.

[sste]

Just met with my OB yesterday and she said two helpful things:

1. In assessing tearing and provider tear rates, you should focus on first-time vaginal birth. So, I guess overall people tear less with subsequent vaginal births (obvious exceptions for certain baby birth positions/extenuating circumstances). This was interesting b/c my doula mentioned that when she was a practicing midwife at a water birth center her tear rate was 7% - - which is pretty freaking amazing. She is a skilled provider, perhaps water birth is more supportive (?) . . but also her numbers may have been helped *if* more second-time moms opted for water birth than first-timers.

2. My ob does perineal massage and does not swipe, forcibly spread. *But* she told me that while she strongly encourages laboring at home, I may not want to cut it too close because if I get to the hospital with the baby literally coming out then she may not be able to get there in time. And she felt that medical residents are far, far more likely to forcibly spread or cut an epiosotomy because they are scared and want the baby out. After hearing this, I have now appointed DH "Vagina Police" and am thinking about making a t-shirt for him.