Guide to an Intact Perineum

Midwife’s Guide to an
Intact Perineum *
by Gloria Lemay

An intact perineum is the goal of every birthing woman. We love to have whole, healthy female genitalia. Many people consider the health of the vagina/perineum to be a matter of chance, luck or being at the mercy of the circumstances of the forces that prevail at the time of the birth.

Folklore abounds about doing perineal massage prenatally. No other species of mammal does this. Advising a woman to do perineal massage in pregnancy implies a lack of confidence that her tissues have been designed perfectly to give birth to her infant.

The intact perineum begins long before the day of the birth. Sharing what the feeling of a baby’s head stretching the tissues will be like and warning the mother about the pitfalls in pushing will go a long way to having a smooth passage for both baby and mother.

The woman will be open and receptive to conversations in prenatal visits about the realities of the birth process. Here, in point form, is the information I convey for the second stage (pushing):

1. When you begin to feel like pushing it will be a bowel-movement-like feeling in your bum. We will not rush this part. You will tune in to your body and do the least bearing down possible. This will allow your body to suffuse hormones to your perineum and make it very stretchy by the time the baby’s head is stretching it.

2. The feeling in your bum will increase until it feels like you are splitting in two and it’s more than you can stand. This is normal and no one has ever split in two, so you won’t be the first. Because you have been educated that this is normal, you will relax and find this an interesting and weird experience. You may have the thought, “Gloria told me it would be like this and she was so right. I guess this has been going on since the beginning of humankind.”

3. The next distinct feeling is a burning, pins-and-needles feeling at the opening of the vagina. Many women describe this as a “ring of fire” all around the vaginal opening. It is instinctive to slap your hand down on the now-bulging vulva and try to control where the baby’s head is starting to emerge. This instinct should be followed. It seems to really help to have your own hands there. Sometimes women like to have very hot face cloths applied to their perineum at this point. If you like the feeling of this, say so, and if you don’t, say so. We will do whatever you feel like.

4. Most women like pushing more than dilating. When you’re pushing, you feel like you’re getting somewhere and that there really is a goal for your efforts.

5. This is a time of great concentration and focus for you. Extraneous conversation will not be allowed in the room. Everyone will be silent and respectful in between sensations while you regather your focus. Once you begin feeling the ring of fire, there is no need for hurry. You will be guided to push as you feel like until the baby is crowning (the biggest part of the back top of the head is visible). All that will be touching your tissues is the hot face cloth and your own hands. It is important for the practitioner to keep their hands off because the blood-filled tissues can be easily bruised and weakened by poking, external fingers. This can lead to tearing. We will use a plastic mirror and a flashlight to see what’s happening so we can guide you. We won’t touch you or the baby.

6. This point of full crowning is very intense and requires extreme focus on the burning-it is a safe, healthy feeling but unlike anything you have felt before. You may hear a devil woman inside your head who will say to you, “All you have to do is give one almighty push here and it will all be over-who cares if you tear . . . just give it hell and get that forehead off your butt!” This devil woman is not your friend. Thank her for sharing and then have your higher self say, “Just hang in there. It’s OK. Panting and rising above the pushing urge will help me stay together, and I will have less discomfort in the long run.” Your practitioner will be giving only positive commands at this point, and she will be keeping them as simple as possible to maintain your focus.

Typically the birth attendant’s instructions are “Okay, Linda, easy . . . easy . . . easy . . . pant . . . pant with me . . . Hah . . . Hah . . . Hah . . . Hah . . . Hah . . . Hah. Good, that one’s over. You’re stretching beautifully; there’s lots of space for your baby. This baby’s the perfect size to come through.”

7. You will be offered plain water with a bendable straw throughout this phase because hydration seems to be important when pushing, and you can take the water or leave it, as you wish.

8. Once the head is fully born, you will feel a great sense of relief. You will keep focused for the next sensation, which will bring the baby’s shoulders out, and the baby’s whole body will quickly emerge after that with very little effort on your part. The baby will go up onto your bare skin immediately, and it is the most ecstatic feeling in the world to have that slippery, crawling, amazing little baby with you on the outside of your body. Your perineum may feel somewhat hot and tender in the first hour after birth, and believe it or not, the remedy that helps the most is to apply very hot, wet face cloths. This is in keeping with the Chinese medicine theory that cold should never be applied to new mothers or babies. Women report that they feel instantly more comfortable when heat is applied, and any swelling diminishes rapidly.

9. When you push your placenta out, the feeling will be like that of a large, soft tampon just plopping out. It is a good feeling to complete the entire process of birth with the emergence of the placenta.

When a new mother has an intact perineum, she recuperates faster and easier from birth. I like to twist a diagonally folded bath towel into a very tight roll and coil that into a ring for the woman to sit on when breastfeeding. Lovemaking can resume whenever the couple is ready; it feels good to use a little olive or almond oil as a lubricant the first few times.

Gloria Lemay is a Private Birth Attendant in Vancouver, British Columbia, Canada.

* Originally published in Midwifery Today Magazine

Drugs: Black Box Warnings and Product Inserts

This is a work in progress.  If you are interested in helping with this project, an offshoot of our Conscious Activism program with Jim Turner, please email us at info@consciouswoman.org.

Drugs Used for Labor Induction

Click here to review the product insert for Cytotec/Misoprostol. 

Click here to review the product insert for Pitocin/Oxytocin Injuection, USP (Synthetic). 

Click here to review the product insert for Cervidil/Dinoprostone.

{pullquote}We have two online courses that discuss Labor Induction.  Sarah J. Buckley, M.D.’s Gentle Birth: The Science and the Wisdom includes a session entitled “The Impact of Interventions” and Gloria Lemay’s Essentials of Maternal-Infant Care includes a workshop entitled “Induction of Birth”.{endpullquote}

Online Resources

(In development)

Click here to read an article (adobe pdf) published in the International Journal of Obstetrics and Gynecology, entitled Routine Induction of Labor at 41 Weeks: Nonsensus Consensus.

Click here to view tips for 10-Month Mamas.

Click here to view Ina May Gaskin’s collection of articles on Cytotec (among other things).  

Postdate Pregnancies: Personal Accounts

 ”I have given birth to seven children. My first five were born in the hospital- one was a c-section; my other four were induced. Most were induced for postdates.With my sixth child I simply could not go back to the hospital to give birth again. All those inductions, and the cesarean, hurt me very deeply in ways; especially in how I had no confidence in my body to do its most basic female act- giving birth.

This self-doubt stayed with me for the pregnancy of my sixth child… but my midwife was very strong for me, and spoke with me about how many women actually do not give birth by the medical rule book; that just as all babies and children mature at different rates when outside the womb, so they do inside it. I struggled to believe her.

I was worried about my placenta deteriorating- not being able to nourish my baby. She said in over 700 births she had never seen a “bad” placenta because of postdates… she spoke of how she herself gave birth at 43 and 1/2 weeks to a beautiful, healthy baby at home.

Then, at 44 weeks pregnant, I gave birth in my own home to a big, beautiful healthy baby- then pushed out a big, healthy beautiful placenta afterwards.

Then I gave birth to my 7th child at home at 46 weeks pregnant; he weighed 12.6 pounds. My longest pregnancies produced my healthiest children, and smoothest births….”

- Leilah McCracken

                  
 

Online Presentations (Videos and Selected Resources)

Here are a few short video segments from some of our online presentations. For those whose browsers could not support the media files during the live presentations, those who wish to see these again, and for the curious among you as well! 

What Would Mammals Do? with Diane Wiessinger

Headstand nursing (from U-Tube)
Gorilla expressed milk snack (from U-Tube)
Chimpanzee holding baby and placenta (from U-Tube)
Human newborn crawling to breast – mother does nothing (from U-Tube)

Would you like to purchase related DVDs?
Birth in the Squatting Position, a 10-minute classic video of squatting births in the 1970s, has been reissued as a DVD by the Bradley Method of Childbirth® (1-800-4-A-BIRTH),  and is available through Cascade Health Care Productions

Baby-led Breastfeeding – The Mother-Baby Dance is a fabulous new DVD by Christina Smillie, MD, IBCLC.  Mother after mother is shown following her baby’s lead to comfortable, simple breastfeeding.  It is available at Geddes Productions.

Freedom of Expression: Supporting Breastfeeding Moms in the Workplace with Cate Colburn-Smith

Videos:
Log rolling ad.  
Mechanical bull ad

Ad Campaign:
National Breastfeeding Campaign
      *  This article was based on the latest data from the CDC (Aug 2007) about breastfeeding rates and exclusivity. 
      *  Note that the CDC conducts their breastfeeding rate research in phone surveys that are primarily about national immunization participation.
Washington Post article: Health and Human Services (HHS) Toned Down Breast-feeding Ads” (Aug ’07)
A direct link to the graphics for the ads that never saw the light of day. 

Other Resources:
American Academy of Pediatrics policy on breastfeeding

Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries
     * This is the study that quantified the risk factors for various diseases for breastfed babies vs. formula fed babies, and for breastfeeding mothers.

Study that revealed more say formula is as good as breastmilk

Article about “Moms Too Quick to Reach for Baby Bottle”

CDC site on breastfeeding.

Breastfeeding Promotion Act (Federal)

MomsRising.org statement of support for breastfeeding moms (for Breastfeeding Promotion Act).

50 state summary of breastfeeding laws.

CDC Lactation Support Program Toolkit:  (includes info for documenting workplace lactation policy) 

The National Women’s Health Information Center web site, June 2005.   

La Leche League web site.

kellymom  Breastfeeding and Parenting website. 

Childbirth “Humor”

Monty Python Birth Scene (from YouTube)

The Obstetrician Song (mp3)

Sexual Abuse History/Childbearing Women

Cesarean Prevention and VBAC Support

Books and Online Resources

  • Cesarean Voices (an International Caesarean Awareness Network publication)
  • Wainer, Nancy, Silent Knife: Cesarean Prevention and Vaginal Birth After Cesarean (VBAC)
  • Wainer, Nancy, Open Season: A Survival Guide for Natural Childbirth and VBAC in the 90s
  • The International Caesarean Awareness Network (ICAN)
  • www.VBAC.com
  • Online support groups through ICAN and Shanon Mitchell’s Birth After Cesarean website. 
  •  

    Definition of VBAC

  • Vaginal Birth After Cesarean (this term was coined by Nancy Wainer in the early 1980s)
  • Very Beautiful And Courageous (adapted by Gloria Lemay in the 2000s) 
  •  

    RECIPE FOR A CESAREAN SECTION
    by Gloria Lemay

    1 nice, well behaved woman
    1 impatient obstetrician
    ½ doula
    Minced birth plan
    2 tsp prostaglandin gel
    2 tbsp pitocin (do not use the authentic oxytocin)

    Mix together slowly, monitoring as you go along. Once pain is intolerable, add 1 generous epidural (to freeze the well behaved woman from her breasts to her toes. )  Check with an ice cube for sensation. This epidural will be helpful in the cutting process to follow.

    An external fetal monitor and contraction belt will help to move the process along. Once distress is induced in the inner cavity of the well-behaved woman, an amni hook can be used to puncture the protective lining. Some cooks prefer to insert a spiral screw into the scalp of the infant within the cavity to insure a certain outcome.

    When it comes time to insert a knife, have all gadgets and implements for removing the infant at hand. Cover well behaved woman with green cloths and screens exposing only a small strip of belly area.

    Watch the finished product carefully for several hours after completion of the cesarean section to make sure that the recipe has performed as promised.

    Postpartum Depression

    This list is current being compiled. 

    Healing from Trauma (Resources to Help Children Heal)

    The following is a list of recommended reading for helping children heal from traumatic experiences.  A special thank you to Conscious Woman presenter Stephanie Mines, Ph.D. for compiling this list.  To learn more directly from Dr. Mines, attend our Helping Children Find Resilience and Balance after Trauma online workshop!

     

    Blechschmidt, Erich, The Ontogenetic Basis of Human Anatomy, Berkeley, CA, North Atlantic Books, 2004.

    Bowlby, John, Attachment, Loss, Separation (three volumes), London, Tavistock Institute of Human Relations, 1982.

    Chamberlain, David, Babies Remember Birth, Los Angeles, Tarcher, 1988.

    Eliot, Lise, What’s Going On In There? – How The Brain and Mind Develop in the First Five Years of Life, NY, Bantam, 1999.

    Fitzpatrick, Jean Grasso, Once Upon A Family: Read-Aloud Stories and Activities that Nurture Healthy Kids, NY, Penguin, 1998.

    Gerhardt, Sue, Why Love Matters: How Affection Shapes A Baby’s Brain, NY, Routledge, 2004.

    Hallowell, Edward, MD, Driven to Distraction, NY, Simon and Schuster, 1994.

    Hallowell, Edward, MD, Answers to Distraction, NY, Bantam, 1994.

    Hersch, Patricia, A Tribe Apart: A Journey Into the Heart of American Adolescence, NY, Ballantine, 1999.

    Levine, Peter and Kline, Maggie, Trauma Through A Child’s Eyes: Infancy through Adolescence, Berkeley, CA, North Atlantic Books, 2007.

    Liedloff, Jean, The Continuum Concept: In Search of Happiness Lost, London, Penguin, 1986.

    Mahler, Margaret S., The Psychological Birth of the Human Infant, NY, Basic Books, 1975.

    Mines, Stephanie, The Dreaming Child: How Children Can Help Themselves Recover from Illness and Injury, CO, The Dom Project, 2000.

    Mines, Stephanie, We Are All in Shock: How Overwhelming Experience Shatters You and What You Can Do About It, NJ, New Pages, 2003.

    Moore, Robin, Awakening the Hidden Storyteller: How to Build A Storytelling Tradition in Your Family, Boston, Shambhala, 1991.

    Moberg, Kerstin Uvnas, The Oxytocin Factor: Tapping the Hormone of Calm, Love and Healing, NJ, DaCapo Press, 2003.

    Perry, Bruce, MD, The Boy Who Was Raised As A Dog: What Traumatized Children Can Teach Us About Loss, Love, and Healing, Cambridge, MA, Basic Books, 2006.

    Remen, Rachel Naomi, Kitchen Table Wisdom: Stories that Heal, NY, Riverhead, 1996.

    Siegal, Daniel and Hartzell, Mary, Parenting From the Inside Out, NY, Penguin, 2003.

    Share, Lynda, If Someone Speaks, It Gets Lighter: Dreams and the Reconstruction of Infant Trauma, NJ and London, Analytic Press, 1994.

    Stepansky, Paul E., The Memoirs of Margaret S. Mahler, New York, Macmillan, 1988.

    Stepp, Laura Sessions, Our Last Best Shot: Guiding Our Children Through Early Adolescence, NY, Penguin, 2000.

    Upledger, John, A Brain is Born, Berkeley, CA, North Atlantic Books, 1996.