The word “perineum” conjures up a feeling of uneasiness in me.
What exactly is a “perineum? It sounds icky.
Should it hurt before, during, and after childbirth? I hope to settle any confusion about the perineal area and share my personal experience with childbirth preparation and healing.
What and where is the perineum?
The perineum is the tissue (meaning skin, fascia, and muscle) between the vulva and the anus.
During childbirth the perineum (as well as all the other surrounding tissue of the vagina) is meant to stretch to allow for the child to exit the female body. This perineal area seems to be the point of least resistance as it will often “tear” as the baby’s head squeezes through during childbirth.
The perineum is also the area where a doctor or midwife may perform an episiotomy, and then stitching after the baby is born. One study shows that as much as 85% of mothers who birth vaginally are left with some kind of perineal trauma. With this being said, there are varying degrees of perineal tears.
Grades I-IV of tearing are ranked on severity based on length of the laceration and by the involvement of the muscles which are torn. I have heard grade I tear called a “paper cut” or a “skid mark” (meaning as the baby’s head emerged, it left a little “skid mark” on the way out). In general, grade I tears do not need stitches, whereas grade II, III, and IV need stitches to assist healing.
Can you prevent tearing of the perineum?
There are many ways that are thought to prevent perineal tearing that a mother-to-be may perform during pregnancy.
Perineal massage.
Perineal “massage” is controversial in its effectiveness to prevent perineal trauma. But, anecdotally this technique helps the mama to be. Perineal massage is where the mom or her partner or a healthcare practitioner places a finger just inside the vagina and gently places pressure toward the anus to stretch the tissue that is vulnerable to being torn.
I did practice this technique with my first pregnancy. My husband would assist and I would provide feedback as to whether the pressure was too light or too firm. We performed this a few times a week, 3-4 weeks before the baby’s due date until he was born.
I remember feeling the burning more intensely the first few times we practiced perineal massage. But after these first few times there was hardly any burning or stretching sensation at all! So I do know that my tissue “down there” changed. However during childbirth, this baby was vacuum extracted in a hospital setting with a resulting grade II tear which needed stitching to heal.
I did experience pain in the perineum while sitting (which made breastfeeding very difficult!) for 6 weeks after birth, which I attribute to the tearing. As a side note, first time moms are more likely to tear than moms who have birthed a baby before.
Birthing Position.
Another technique to reduce the likelihood of tearing is birthing position. From my research reading many birthing books, the optimal birthing position for decreasing the likelihood of tearing is any upright position.
Personally I feel the hands and knees position is optimal. My second baby was born in a birth center. I labored for about an hour in a tub of warm water before I felt the need to push.
I requested to birth the baby in the tub, but the midwife wanted me to exit the tub so that she could check my cervical dilation. I got out of the tub (very hard to do in active labor; I wish I would have just pushed the baby out when I felt the urge in the tub!) and laid down in the bed. Yep, I was at 10cm dilation and ready to push!
My husband and doula helped me sit as upright as possibleon the edge of the bed. After a couple of contractions my second little boy entered peacefully into the world.
Unfortunately, I had another grade II tear and needed stitches.Fortunately healing with this tear was less painful and resolved quicker than the first.
Exercise and Nutrition
By the time I was pregnant with my third (and most recent baby in December 2017), I had a goal of doing everything I could to prepare my perineum to prevent not tearing during the labor and delivery.
My interest in pregnancy health and exercise had piqued and I was well into my practice as a pregnancy and postpartum physical therapist. During this pregnancy I was sure to perform lots of deep squats and pelvic floor exercises .
I also had excellent eating habits. I was eating white sugar/pasta/bread only once a week. I was eating 100g of protein per day. I was drinking up to 200 ounces of water a day.
When my daughter was ready to be born, she made her entry fast! I birthed that baby within 1 hour of arriving at the birth center. With one big contraction and a push she almost fell out of me. This time I birthed in a kneeling position on top of the bed with my upper body arched over a birth ball.
To my, my midwife, and my doula’s surprise - there was only a “skid mark” (grade I) tear, which meant no stitches!
I attribute the birthing position and my pelvic floor exercise preparation to the minimal tearing. My midwife attributed my healthy nutrition (and a small miracle!) to the minimal tearing. It is thought that a slower second stage of labor would decrease the likelihood of tearing, but this is something the mother can not control. A slower second stage of labor didn’t seem to matter in my case of minimal tearing.
Other factors that may affect tearing
Topics which are not covered in this article that may affect tearing of the perineum include: continuous labor support, midwife assistance with stretching the perineum during the second stage of labor (hands on, use of heat and oil), water birth, and use of breath-holding versus spontaneous pushing.
Please refer to my website under the resources section for several of the pregnancy and birth prep books that I love, to learn more about the above topics.
If a mother experiences any tearing, she ought to be evaluated and treated by a postpartum physical therapist to prevent pelvic pain, pain with sex, incontinence, and be educated about safely returning to exercise. Please let me know if you have any questions by emailing me at becky@budandbloomptaustin.com
Resources:
Kettle C, Tohill S: Perineal care. Clin Evid (Online). 2008, [http://www.ncbi.nlm.nih.gov/pubmed/19445799] (accessed 24th July 2018)).