Midwife's Guide to an Intact Perineum
-by Gloria Lemay. Originally appearing
in Midwifery
Today Magazine, Winter 2001.
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 both 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.
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