Birth is an internal process that is easily disturbed by unnecessary interventions. According to midwife Ina May Gaskin, “sphincters are shy”.
A woman’s dilated cervix can easily close in the presence of disruptive people or actions (also known as cervical reversal). In a normal birth, vaginal exams and other handlings of the perineum during labor are interventions that can interfere with the natural birthing process.
At any other time in our lives, our vagina is considered “private”. During birth a woman is told to lay back, open her legs and allow her body to be explored by strangers. A laboring woman loses her dignity, privacy and trust in herself in the hands of the people that she has hired to assist her in this sacred moment.
Gloria Lemay, Canadian birth attendant and birth activist, writes: “Why avoid that eight-centimeter dilation check? First, because it is excruciating for the mother. Second, because it disturbs a delicate point in the birth where the body is doing many fine adjustments to prepare to expel the baby and the woman is accessing the very primitive part of her ancient brain. Third, because it eliminates the performance anxiety/disappointment atmosphere that can muddy the primip (woman having her first baby) birth waters. Birth attendants must extend their patience beyond their known limits in order to be with this delicate time between dilating and pushing.” ~Pushing for Primips
Why Should We Care?
• Vaginal exams are the traditional clinical method to evaluate progress in labor. According to Freedman’s Curve (a 1955 study of 500 women), a woman should dilate 1 cm per hour after she has reached 4 centimeters of dilation. When a woman doesn’t perform to this standard, some birth attendants become frustrated and push for drugs such as Pitocin and other augmentation methods to speed labor to progress according to their expectations. This is another step in the cascade of interventions.
• A woman may become discouraged by multiple exams and mindless comments such as, “you are only __cm”. Labor then can stall giving way to interventions that often end in cesarean.
• Vaginal exams increase the risk of infection by bringing bacteria towards the cervix, even when done carefully and especially after the release of the membranes.
• Vaginal exams are not a reliable way to predict when labor will begin. Labor normally begins when the baby is ready and a wonderful cocktail of hormones begin to release.
• Vaginal exams are particularly painful during contractions and disrupt a woman’s concentration.
• Perineal massage during labor, besides being intrusive and invasive, according to research does not protect the perineum. http://www.bmj.com/content/322/7297/1277.full
• There is a higher incidence of perineal tears with the hands-on approach to perineal care during the pushing stage of labor than with the hands-off approach. http://www.ncbi.nlm.nih.gov/pubmed/12092017
• Some practitioners routinely do a stripping of the membranes, with or WITHOUT the woman’s permission. Using their fingers they separate the bag of waters from the cervix. The thought behind this is that it will stimulate the production of prostaglandins to help labor begin and irritate the cervix causing it to contract. This is a painful procedure, can leave you spotting or bleeding and has not proven to be effective for everyone. This is another step in the cascade of interventions.
• Informed consent means that you need to have all the information to accept or refuse treatment. Do not open your legs unless you understand why and agree with the reason. If you don’t agree, ask for the research.
How To Have A Gentle Birth And Protect The Perineum:
• Reprogram your mind by immersing yourself in images of normal gentle birth.
• Address past trauma. Sexual abuse, abortion, miscarriage and previous challenging births all leave an imprint in a woman’s body, mind and soul. Addressing past trauma with a sensitive practitioner will clear space for a more satisfying birth.
• Learn about laboring down and mother directed pushing.
• Hire a midwife who trusts the birth process and will support and encourage you to listen to your body.
• Review your birth plan with your midwife or care provider at every prenatal visit during your last trimester. (You are not being “difficult”. It’s your body, your baby.) You are not their only client, this is your only chance to experience this birth.
• Prepare your perineal muscles and tissues during your pregnancy by having a healthy diet and regular exercise.
• Walking, squatting, pelvic rocks, tailor sitting, kegels and swimming are useful exercises to strengthen the pelvic floor and stay flexible.
• Gentle perineal self-massage during the last weeks of pregnancy could help a first time mom get acquainted with different sensations in her perineum. Perineal massage is not necessary in pregnancy or labor.
• Try different positions to birth your baby. Stay vertical. Listen to your body!
• While laboring down, you can support your own perineum to help you stay in control of your body. Touching her baby’s head crowning gives some women a great sense of empowerment.
• Instead of vaginal exams, the most accurate way to judge progress of normal labor is by noticing the changes in the mother’s behavior. For that you need a birth attendant willing to be present and compassionate.
• Visualize: “I am stretching beautifully,” “There’s lots of room for the baby to come through,” “I’m doing this nice and easy”, “I’m getting huge.”
• Vocalize deep sounds by chanting, moaning, grunting. A loose jaw = a loose perineum.
• Apply warm compresses everywhere on the woman’s body so there is less focus on that one spot (the perineum). The woman relaxes, the midwife relaxes. -Naoli Vinaver, CPM, Mexico
• Refuse an episiotomy.
• Avoid an epidural.
• Hire a doula to be your advocate in the implementation of your birth wishes.
Step. Away. From. My. Vagina!
The Friedman Curve: An Obsolete Approach to Labor Assessment ~The authors conclude that the Friedman curve (developed over 50 years ago) likely represents an ideal, rather than an average, curve.
Reevaluation of Friedman’s Labor Curve: a pilot study. ~This study suggests that the parameters to determine if a labor is progressing satisfactorily may need to be expanded.
The Assessment of Progress ~Midwife Thinking
Take the Hint: Pitocin DOES NOT Reduce the Risk of Caesarean or Instrumental Birth ~Lamaze International
Perineal massage in labour and prevention of perineal trauma: randomised controlled trial ~BMJ ~Perineal massage in the second stage of labour did not have any effect on the likelihood of an intact perineum, perineal trauma, pain, or subsequent sexual, urinary or faecal outcomes.
Traditional care of the perineum during birth. A prospective, randomized, multicenter study of 1,076 women. ~Conclusion: a policy of hands-poised care is more suitable for preserving the perineum during birth and is a safe and effective birthing alternative for women.
Patience during stalled labor can avoid many c-sections, UCSF study shows ~More than 130,000 pregnant women could avoid cesarean deliveries each year in the US if they and their doctors simply wait a few hours more during labor, according to a study by researchers in the UCSF Center of Excellence in Womens Health.
Contemporary Patterns of Spontaneous Labor With Normal Neonatal Outcomes ~Allowing labor to continue for a longer period before 6 cm of cervical dilation may reduce the number of interventions, c-sections, and subsequent repeat cesarean deliveries in the US.
Midwife’s Guide to an Intact Perineum by Gloria Lemay
Cervical exam: What can it tell you? By Mary M. Murry, R.N., C.N.M. (Mayo Clinic)