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Birth Sensations & Protecting The Perineum Through It All

15 Mar

Birth-Sensations-&-Protecting-the-Perineum

Let’s talk about the perineum! (Yeah, high-five if you’ve got one – okay, it’s no secret everyone has one.) It’s a big concern among expectant moms, will my perineum make it out alive?

Sometimes in my childbirth classes I can literally see a huge floating question mark sitting on the tops of women’s heads. Like a thought bubble pleading silently, “Can you talk about vaginas, now!? Will mine ever look the same!? Will I be normal after birth? What will happen to my perineum during childbirth?”

Well, before we answer those questions we need to understand some of the sensations women may experience during childbirth and what we can do to protect the perineum through it all.

Alright, let’s dive right in, shall we? First let’s examine the vagina, or rather the vulva, and talk about the perineum and what happens towards the end of labor:

Screen shot 2013-03-14 at 1.33.42 PMThe perineum is the skin between the vagina and the anus, which thins out and stretches over the baby’s presenting part (usually the head) as it is born. (Source) During second stage (pushing) the perineum plays an especially vital role in the birth of the baby.

Okay, let’s talk about what’s going on down there as we approach second stage!

(“Down there” and “bottom” are lite and easy words that I use to describe the vagina, vaginal opening, vulva, perineum and rectum. These are the words my midwife used with me and I will use them with you! Okidoki?)

Building Pressure:

As baby descends and engages and labor deeply progresses, a woman will experience increasing pressure in her bottom as her pelvic passage begins to stretch open. Often, the stimulation sends a signal to a laboring mother’s brain that she needs to have a bowel movement. And sometimes that’s exactly what a laboring mother may do.

I’ve worked with a lot of moms who, while in the thick of labor, look up at me with urgency and quickly move to the bathroom. Baby’s decent stimulated her bowels. On occasion the laboring mother may have a genuine need to go (this is nature’s lovely way of making sure that doesn’t happen during second stage), or other times the mom may simply relax on the toilet, letting her muscles soften till she becomes more comfortable with these new sensations. Either response is totally normal.

Keep in mind, the pressure felt during birth is sometimes really alarming, because, let’s be honest here, we’ve spent our whole life learning to be discrete about the urge to poop. But in the case of childbirth (and possibly a few other occasions!) this sensation is cause for celebration, it tells us baby is descending and the mother is moving closer towards holding her baby in her arms.

Grunting:

Often at this stage in labor, you’ll begin to hear mothers grunt at the peak of their contractions. Imagine, mom is moaning through her contraction and suddenly her breathy bellowing goes like this, “ooooooooooooooh, oooooooooooooooooh, ooooo uh, uh, uh, uh, uhr, uhr, uhr, oooooooooh, oooooooh, oooooh”

Aha! That’s a great sound! Those short little grunty noises that mom just made in the middle of her contraction signal that her body is beginning to involuntarily push at the peak of her rush.

Stations-of-Presentation

As baby descends, increasing pressure is felt in the bottom and the rectum is stimulated.

Supportive Hands:

You’ll also sometimes see, as a laboring mother begins to feel that all-consuming pressure, that she will place her hands right on her bottom, cupping her groin and supporting her vulva. That’s wonderful and absolutely normal! Besides for giving her bottom additional support during this stage, it also allows the laboring mother to stay more in touch and in control of her body’s response to labor. What’s not to love!?

Pressure, grunting, and supportive hands are clear signs that birth is progressing…

Does that mean it’s time to push yet? No, not necessarily. It only means what she’s telling us from her body language: her bottom is feeling pressure, things are being stimulated, baby is descending and birth is progressing normally.

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Enjoy, Accept, Relax

At this transitional stage between first and second stage of labor, it’s ideal for mom to not add additional force (just yet!) as she begins to feel those early urges to push. As her uterus contracts, the bands of muscle thicken at the top of the fundus and begin to push down on their own, expelling baby further into the birth canal, this is the beginning of what will soon become a very strong urge to push.

It’s a good idea at this cross-road in labor to encourage mom to enjoy knowing just how well her body is working, accept the intensity of the change in sensations she’s feeling, and relax into her rushes a little more fully. This provides mom with an opportunity to wrap her brain around the idea of what the pushing urge feels like before diving right into it.

Powerful Pressure | Second Stage | Pushing

As labor thickens into heavy travail (an old Biblical word that I feel really adequately describes transitional labor) the intensity of pressure a woman begins to feel increases exponentially.

Baby’s head is now stretching the vaginal and pelvic floor muscles. Receptors in these tissues trigger involuntary pushing, and signal more oxytocin to the body – a complex hormone which stimulates contractions. (Source) A woman will now begin to feel the urge to push through almost the entirety of her contraction and not just the peak of it.

Mom will need reassurance at this point that she is okay, she needs to know that the pressure she feels is normal, and that even if she’s absolutely convinced she will birth her baby out of her butt, she will not. (Yeah, I said it.)

The intensity of the pressure is admittedly scary, but it’s also needed in order to bring forth baby into the world. And while it’s like nothing any first-time mother will have felt before, and can be utterly overwhelming, it is still very normal in terms of childbirth and not to be feared.

This is a doorway in labor that mothers walk through, there is no way around this passage of birth intensity, only through it. It is time to push!

Your-Baby's-Birth---Dr.-Miriam-Stoppard's-New-Pregnancy-and-Birth-Book

Please note, while these illustrations are fantastic, the information on step four regarding suctioning a baby is now contraindicated and outdated. Evidence now states that unless baby is unresponsive, suctioning is not necessary. Source: //www.ncbi.nlm.nih.gov/pmc/articles/PMC2666857/

Two Steps Forward, One Step Back

As mom pushes her baby down and out in that wonderful “J” shape of pushing, we’ll often see a little two-step dance, baby descends during the contraction, pressing on the perineum and the perineum begins to bulge and expand, and after the contraction ends, baby moves up and the perineum softens and relaxes. This happens over and over again.

This is a process my own midwives and mentors taught me to refer to as “two steps forward, one step back.” This dance is very important for the integrity of the perineum. It allows the skin to stretch slowly and gently, giving the perineum time to accommodate the baby’s head without tearing.

Ring of Fire

Once the head of the baby has firmly ducked under the pelvic bone, crowning will begin to take place. We use the term “crowning” to describe how the vaginal opening and vulva stretches around baby’s head looking like a crown.

As baby crowns, the labia and perineum begin to expand and bulge, this point is often referred to as the “ring of fire.” There is a lot of stinging and burning accompanied with the ring of fire, fortunately, it doesn’t last for too long, although we shouldn’t rush through it. This stinging sensation sends a message to the woman’s body to hold off on pushing. (Source)

(On a side note, sometimes as an exercise to describe the ring of fire to my students, I’ll ask them to stretch open the sides of their mouth with their fingers. I find this gives a good sense of the type of stinging that’s felt in birth. As a bonus, everyone looking ridiculous together usually gets us all laughing, which is always good when talking about crowning!)

During crowning it’s good for the laboring mother to stop adding additional force to her body’s own urge to push. Instead she should breathe out her baby and allow her body to do the work on its own. (This is something she has already practiced in birth during the transitional stage mentioned above. See, it all comes together now!)

You see, after the baby’s head is through the pelvis, only the tender perineal tissues are holding baby in (Source), and the mother needs to be mindful of not pushing too forcefully in order to protect this area of a her body.

How does she do that? She breathes her baby out…

Breathing Baby Out

Gentle, easy breaths that resemble panting allow the baby’s head to emerge slowly and tenderly, helping to keep the perineum intact. Actually, for many mothers breathing out her baby is an innate response to the ring of fire.

Think about it: a base response to pain, for all ages, are quick short breaths. I see my children do this all the time. A little high-pitched panting expression that happens when they’ve smashed their finger or stubbed their little toe.

Likewise, when mothers are left to labor without heavy coaching, at the point of crowning, you’ll sometimes see this panting and high-pitched breathing technique occur. (Watch some birth videos, and listen for that quick high-pitched breathy howl at crowning, and then you’ll start to see it all the time.)

Supporting The Perineum

Also, a mother’s hands may instinctively reach down again and apply pressure to her own perineum. Although, I should mention it’s quite common that you’ll see the midwife or OB apply slight counter pressure to a woman’s perineum at this stage too. Also, some care providers will apply a warm compress or olive oil to a mother’s perineum to assist in preventing tears.

To view a photograph of a crowning baby and a perineum stretching out beautifully in birth click this link from wisewomanchildbirthPerineum stretching in birth.

Once the baby’s head has fully crowned, it will only be another couple of pushes before baby is born. After the birth of the baby’s head, baby’s shoulders are delivered, and the rest of the baby’s body pours out from its mother shortly after.

It’s miraculous to see and testifies to the function and beauty of the female body.Women’s bodies are just amazing, y’all!

Mother-catching-her-baby

Image source unknown

There are a lot of things a woman can do that will increase her chances of having an intact perineum, here are a few of my tips, please note this list is not exhaustive or comprehensive:

  • Diet and hydration play a valuable role in the health of a woman’s perineum, for a great post on this go here: Protecting Your Perineum From The Inside Out
  • Practice pelvic floor exercises during pregnancy. (You may want to rethink Kegels, here’s a link that says why: Pelvic Floor Party, Kegels Are Not Invited)
  • A mother should avoid birthing on her back, but rather birth on her side, in an upright position, or on her hands and knees.
  • Warm compresses (not hot!) on the perineum during labor.
  • Avoid power pushing. Power pushing, or what is known as purple pushing, is when a woman holds her breath for long periods of time and pushes beyond what feels comfortable or natural to her body. This type of pushing increases a woman’s chance of tearing.
  • Avoid widely flexed legs. Knees should be pointing forward and not to the sides. Source | Source
  • Follow her own body’s cues during crowning and slow down her pushing.
  • Use a mirror, if she’s comfortable with that. Seeing what’s happening during second stage can help the mother connect to her body, and allow her to direct her body’s urges better.
  • The laboring mother should move to positions that are most comfortable for her during second stage. For example, the mother could say, “Before my next contraction starts, I would like to turn to my left side. Would you help me do this, please?”
  • Hire a doula! A doula reduces a woman’s need for an epidural and for forceps delivery, both of which increase the laboring mother’s odds of perineal damage.
  • The mother should find a care provider who supports birthing in ways which allow for an intact perineum.

Related articles

What You Don’t Know About Episiotomies Can Hurt You (parenting.blogs.nytimes.com)

Get Through Childbirth in One Piece!

Avoiding Tears and Episiotomies

Perineal Protectors (read the comments, too!)

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How I Learned to Support A Mother’s Choice Not To Breastfeed

10 Feb

bottle fed baby

It was a blazing summer evening two years ago and our weekly childbirth class was filled to the brim with parents laughing and talking over their meal. The last session of our six-week birth education course had arrived – it was graduation night (everyone could go have their babies now, we always joked). In celebration we all brought food and shared a meal together before the onset of class.

While all the expectant couples were enjoying their BBQ, lost in conversation and anticipation over how their lives would change, the midwives pulled the other instructor and me aside. They had something they needed to share with us.

There was one expectant mother in our group who was choosing not to breastfeed. The CNMs urged us to keep this mother’s choice in mind as we approached our teaching session on breastfeeding and the nutritional needs of a newborn. We were asked to use the phrase “feeding your baby” when we could instead of “breastfeeding” to help this mother, who already felt guilty and ostracized for her unusual choice in this natural birthing environment, feel included in the conversation.

I bristled at the idea that we were coddling a mother’s poor decision. I thought it was irresponsible of us to not speak openly and directly as we always did on the amazing and overwhelming evidence-based benefits of breastfeeding. Besides, if she’s going to make a choice to deny her newborn the very best nutrients he needs then she should at least face it full-on. My job isn’t to white-wash anything. Breast is best.

But she knew that, I was told, rather sharply. She was well-informed on the benefits of breastfeeding, even so, she had personal reasons not to breastfeed her son. (None of which they shared with me, by the way.) Besides, no one was asking me to shelter her from breastfeeding benefits, only to make room in my conversations for formula use.

I was reminded that my job in that moment was to offer the best education I could to this mother to fit her needs and choices, without judgment. After all, do I support birthing mothers, or do I only support mothers who birth the way I see fit?

After all, do I support birthing mothers, or do I only support mothers who birth the way I see fit?

As we taught our class and covered our material, Sarah (I’ll call her Sarah, but that is not her real name) sat quietly through it all. I tried not to give her eye-contact as I went over warning signs of things that she wouldn’t ever deal with, things like thrush, clogged milk ducts, and mastitis. (Or would she?)

That night, as couples said good-bye and we hugged each round-bellied mother, offering hopeful hearts that the seeds we’d sown would blossom into beautiful birth stories for each family, Sarah stayed behind.

The midwives suggested we spend some personal time after class explaining to Sarah how to dry up her milk and offer further resources to her on bottle-feeding. Sarah and her husband sat in the living room waiting sweetly for us to talk her through it all.

Knowing she could not control birth, knowing she could not control motherhood, but knowing she could control this: the choice to breastfeed.

Hot tea was poured into our mugs and we all sat cross-legged on the floor and began to discuss the best technique for drying up her milk. At some point, after everything had been said, Sarah looked up at us, a circle of women gathered around her, and with an open heart, shared her story.

With brief and sharp details, Sarah explained how she was a survivor of sexual abuse and that it was a dark line that cast a shadow over her body. For this reason, she could not bring herself to breastfeed her baby. The emotional memories connected to certain parts of her body were still all too real.

She loved her son, and she wanted the very best for him, and in her case, she knew the best for him was to allow these memories – which were deeply rooted into her body – to stay quiet. She could do this by keeping (some of) her body to herself.

Knowing she could not control birth, knowing she could not control motherhood, but knowing she could at least control this: the choice to breastfeed. Sarah understood that by making the choice to bottle-feed, she would be in a better place to bond with her son, giving him a love untouched by resentment.

I knew her name, but I did not know her story

I realized something that evening that I feel indebted to always remember in my work with women: after six weeks of classes with Sarah, I knew her name, I knew her due date, I knew the gender of her child, but I did not know her story.

We can never fully know the stories of the mothers we serve. As a doula and a birth educator, I’m privileged only to what a woman shares with me, and often it is simply a picture of her present life, not her past.

And if a woman shares her past with me, it is by comparison, only a tiny glimpse into the story that really occurred – a condensed version that she feels comfortable expressing on that day, at that particular time – there is much left unsaid.

The words left unspoken tell a deeper story than the words that are spoken. And because of this, I must trust that when a woman makes an informed choice not to breastfeed she’s doing so because she knows ultimately what is best for her and her baby.

In return, I must offer the best support I can give without judgement or assumptions – something that every mother is deserving of.

Our birth prejudices get in the way

Too often in the natural childbirth community we reward a woman with our support when she births like we do and breastfeeds like we do. And if she does not birth or breastfeed in ways we feel are best, we turn our back on her with our judgment, proving that we hold our birth ideologies in higher regard than the women we are committed to serving. We allow our birth prejudices to get in the way of our care.

(I hope you’ll read that statement again.)

I understand and support the unequivocal benefits of breastfeeding. I want to see breastfeeding normalized and embraced in our culture. I hope to see access to breastfeeding resources become more readily available. I happily celebrate that milk-banks are becoming slowly more common in the US. I’m a breastfeeding advocate to the core.

But first and foremost, I’m an advocate for women.

When a mother feels fully cared for – equipped with confidence and security in her abilities and choices – she is then enabled to offer better care to her baby.

I see no outcasts. I see no second-class mothers with bottles in hand. I only see mothers with babies who are in need of support and love.

And maybe when I offer her care that is free of judgment or pretense, she’ll tell me her story.

I hope so, because I’m listening.

………………………………………………………….

Something to think about:

How to Give Up Breastfeeding And Not Feel Guilty About It – Porch Philosophy

Links to explore for Bottle-Feeding Support and Education:

Baby-led Bottle Feeding

Bottle Babies

Fearless Formula Feeder

The Birth of the Placenta | Tips for the 3rd Stage of Labor

11 Jun


Be sure to read Part I of this post, Pushing and Beyond | Tips for the 2nd Stage of Labor, by clicking here.

The Birth of the Placenta | Third Stage

After the birth of the baby, others will be more interested in looking at the baby, taking pictures of the family, and oohing and aahing over the sweet new addition. However, as a doula, our job is to continue to tend to the mother. Even when you step away to give mom and her SO a chance to have their moment together, never stop observing and responding to the mother’s needs.

At this stage, the mother may begin to have strong contractions again (depending on if she’s a multip or primip the strength of those contractions may vary). As she begins to feel those contractions, come back to her side and help her through the birth of her placenta.

Again, stand close to mom and encourage her through it. It’s also good to keep an eye on the OB/Midwife and watch for their cues and try to follow any leads they provide about what they want mom to do (of course this is something you should be doing throughout the birth, to begin with).

When the placenta is birthed, if mom is planning on taking it home with her, you’ll need to help make sure that happens.

Also, keep in mind that the nurse or Dr./Midwife will begin to massage the mother’s uterus to help it clamp down. This is painful, and you’ll want to assist mom through this. I often will tell mothers to push out the pain with their breath, and I’ll keep my eye contact strong with mom as the procedure takes place.

In Case of Hemorrhage

I’ve also had some moms hemorrhage at that stage, which is another reason to stay close and keep an eye on mom’s color, all the while, quietly making note of  her blood pressure shown on the monitor. (Just for observational purposes only, it helps you get a sense of how stable the mother is.) Also, notice when the nurses come to check on mom’s bleeding – listen for their comments and watch their actions. You’ll get a good sense of how mom is doing based on the nurses energy in the room.

Should mom hemorrhage, go directly to her side and be the calming presence for her and her SO. You can talk her through the events that are taking place and remind her that she’s in good hands.

My experience as a CNM’s assistant taught me valuable lessons on keeping a watchful eye on the mother after she’s given birth.  Here I am, 8 months pregnant, working at Inanna Birth Center.

Keeping a Watchful Eye on the Mother During a Repair and Recovery

Also, after the birth of the placenta the OB or Midwife will inspect the mother’s bottom for any repair needs.  Stay close and present with the mother for this time. Keep her feeling safe and secure and do anything you can to help her feel calm and peaceful.  Talk her through the stages of the repair.

Be sure that if the mother birthed without an epidural that the Dr. or Midwife remembers the lidocaine (just observe, don’t pipe up unless absolutely necessary).  Tell mom she’ll feel a “prick and burn” with the application of the lidocaine and to breath through the procedure and to help make sure she can see her baby during the repair as a way to cope through the procedure.

Further Thoughts and a Breastfeeding Tip

Is the mother cold? Find a warm blanket for her.  Does she have any sweaty clothes on? Remove them for her. Is the mother thirsty? Ask if you can get her some juice. Tell the mother what a star she is and how proud you are of her. Then assist with getting baby skin-to-skin and breastfeeding with-in the first hour.

If mom has had lots of IV fluids her nipples may be flat as a result and a breast shell (not a breast shield) will be quite useful in helping to push back the fluids and push out her nipple. Ask if there is an IBCLC on staff who can assist mom with a shell if necessary.

Doulas and Baby Holding

Don’t expect to hold the baby. As a doula, we are often the last people who should be holding the baby. And sometimes this is a point of contention for any extended family who are there, and may notice if a “stranger” held the baby before they did.  You may not ever hold the baby and that’s okay, because our job is to help hold the mother (emotionally and physically).

When Leaving

I make it a point to never leave my client until I can see that baby has clearly latched on, without my help, and baby is feeding well. I also never leave until I know that mom’s bleeding is considered stable and normal – you can confirm this with the nurse if you can’t tell from observation.

I make sure that mom knows that if she needs Ibuprofen to ask for it ASAP- especially if she’s had a repair. I also like to make sure that mom has a meal on the way or is already eating. Plus, I want to be sure the mother has an ice pack on her bottom if needed, before I leave.  Please keep in mind there are very gentle and respectful ways to ask for these things without coming across as demanding or intrusive.

Before heading out the door, I double check to make sure that I haven’t left anything in the room. Then I make sure the the SO has my phone number should they need to call me and I remind them that I am still on-call for them at any moments need. I thank the nurses for all their inspiring work. I congratulate everyone that is present, and I thank the new family for the honor of assisting with their birth.

Pushing and Beyond | Tips for the 2nd Stage of Labor

11 Jun


The other day, a question was presented in one of the doula groups I am a part of that asked how we can best help a mom while she pushes.  I couldn’t help myself, my answer came tumbling out of me.  You see, pushing is actually one of my favorite stages of birth to serve in and witness as a doula and a midwife’s assistant.

Perhaps it’s connected to the excitement a mom feels when she knows that she’s complete, and that the work of dilating is over with, and soon she’ll have her baby in her arms (Although, we know that pushing is lots of work, too!).

Or maybe it’s how you can sense the absolute pure strength of a woman as she pushes her baby out of her body – it fills up the space around you and requires you to stand back and give praise.

And then of course, there’s that long-awaited and anticipated arrival, when life inside the womb finally meets life outside the womb, that moment is simply overwhelming and beautiful, every single time; there’s never a time in life that is so perfectly filled with equal amounts of relief and joy.

Question (completely paraphrased):

During pushing phases at hospital births, I feel a little lost. What should a doula do to help a mom? It seems everyone in the room is yelling at the mother to push, and how to push – I don’t want to add to that confusion. What can I do to best help mom and how can I prevent others from yelling at her while she’s pushing?

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