“What can I do to help BEFORE I give birth to decrease the likelihood of tearing or having perineal trauma?” and “What can I do AFTER birth to decrease the discomfort from perineal trauma?”  are questions often asked.  Even after ACOG ( The Americann College of Obstetrics and Gynecologists) made a recommendation in 2006 for a “Restricted Use of Episiotomies”, in the USA today, 25 out of every 100 women who give birth have an episiotomy. Perineal trauma includes lacerations that occur from spontaneously tearing in your perineal area during birth and episiotomies that are performed by your provider. Ask your caregiver about their statistics for episiotomy and if they are willing to allow you to help you decrease your risk for a perineal laceration or episiotomy.  Perineal lacerations, where you tear in your perineal area spontaneously, have been shown in multiple studies that the pain from lacerations are significantly less than pain from episiotomies and lacerations also heal more quickly than those from episiotomies. What can you do to prevent episiotomies and tearing?  There are studies out that that have found ways that can decrease your risk and degree of perineal trauma in birth. Here they are:

Prenatal perineal massage is a technique which slowly and gently stretches the skin and tissues around the vagina and perineum. The perineum is the area between your vagina and rectum. Perineal massage helps reduce both the risk of tearing during birth and the need for an episiotomy where your provider may have to cut the tissue between your vagina and rectum.

Several research studies have shown that perineal massage can be helpful in preventing lacerations and episiotomies. In 1999, there was an article in the American Journal of Ob/Gyn by Labrecque that evaluated the effectiveness of perineal massage during pregnancy for the prevention of perineal trauma at birth. Women in the experimental groups were requested to perform a 10 minute perineal massage daily from the 34th or 35th week of pregnancy until delivery. The massage consisted of introducing one or two fingers three to four centimeters into the vagina and applying and maintaining pressure — first downward for two minutes and then for two minutes to each side of the vaginal entrance. Women were given a bottle of sweet almond oil (Rougier Inc., Montreal, Quebec, Canada) to use for lubrication.

Among participants without a previous vaginal birth, 24.3 percent (100/411) from the perineal massage group and 15.1 percent (63/417) from the control group were delivered vaginally with an intact perineum, for a 9.2 percent absolute difference. The incidence of delivery with an intact perineum increased with compliance with regular practice of perineal massage.

Among women with a previous vaginal birth, 34.9 percent (82/235) and 32.4 percent (78/241) in the massage and control groups, respectively, were delivered with an intact perineum, for an absolute difference of 2.5 percent. There were no differences between the groups in the frequency of sutured vulvar and vaginal tears, women’s sense of control and satisfaction with the delivery experience. Perineal massage in the last weeks of gestation reduces the likelihood of perineal trauma (mainly episiotomies) and ongoing perineal pain.*

Perineal massage helps prepare you for the feelings of pressure and stretching that come as your baby’s head is born. Knowing what some of the sensations will be like can help you to relax and give birth instead of tensing up and fighting the sensations such as stinging, tingling or burning that you may feel as your baby’s head is born. Perineal massage can also encourage you to relax when you have a vaginal exam.

It is also helpful to learn relaxation techniques, information about your anatomy and what will happen during labor and birth. Childbirth preparation classes can help you become more aware of your body and how you can help yourself during birth.

CAUTIONS:

1. Avoid the urinary opening (see diagram) to prevent urinary tract infections.
2. Do NOT do perineal massage if you have active herpes lesions, as you could spread the herpes infection to other areas.

General Hints:

• The first few times It’s helpful to use a mirror to find the vagina and perineum and see what they look like.
• If you feel tense, take a warm bath or use warm compresses on your perineum for 5 to 10 minutes.
• If you have had an episiotomy with a previous birth, concentrate part of your massage on that area, scar tissue isn’t as stretchy as the rest of your skin and needs extra attention.
• The position in which you give birth can affect the likelihood of perineal tearing and the need for an episiotomy. Upright positions (sitting, squatting1 kneeling) or side-lying positions reduce the strain on the perineum. Lying on your back with feet up in stirrups makes an episiotomy almost inevitable.

After childbirth, tone up the stretched muscles in the vagina by continuing the pelvic floor (Kegel) exercises that you learned in childbirth preparation classes.

Directions:

	1. Wash your hands.
	2. Find a private, comfortable place and sit or lean back in a comfortable position.
	3. Put a lubricant such as KY Jelly, cocoa also butter, vitamin E oil, sweet almond oil or pure vegetable oil on your thumbs and around the perineum. You can also use your body’s own natural lubrication.
	4. Place your thumbs about 1-1 1/2″ (3-4 cm) inside your vagina Press downwards and to the sides at the same time. Gently and firmly keep stretching until you feel a slight burning, tingling, or stinging sensation.
5. Hold the pressure steady at that point with your thumbs for about 2 minutes until the area becomes a little numb and you don’t feel the tingling as much.
	6. Keep pressing with your thumbs. Slowly and gently massage back and forth over the lower half of your vagina, working the lubricant into the tissues. Keep this up for 3-4 minutes. Remember to avoid the urinary opening.
7. As you massage, pull gently outwards (forwards) on the lower part of the vagina with your thumbs hooked inside. This helps stretch the skin as the baby’s head will stretch it during birth.
8. Do this massage once a day starting around the 34th week of pregnancy. After about a week you should notice an increase in flexibility and stretchiness.   PARTNER MASSAGE: General Hints for Partners: You may use either your index fingers or your thumbs. Sometimes only one finger or thumb will fit into the vagina until the skin has become stretched. Listen to your partner. It is her body. Be sensitive to what she wants you to do. Massage firmly but gently. She will tell you how much pressure to apply Directions: Wash your hands. Put some lubricant on your fingers and on your partner’s perineum. Place your fingers gently inside her vagina about 1-1½” (34 cm). Press down until she tells you that she is experiencing pressure and that it is beginning to sting and burn. Hold the pressure there for about 2 minutes until she tells you it is getting numb. Gently and slowly sweep your fingers from the center to the sides and back to the center again, pulling forward slightly as you massage. Give extra attention to any episiotomy scar. Remember to avoid the urinary opening. Massage for about 3-4 minutes once a day.  This information for perineal massage has been prepared by Elise Fleming, MA, CCE, with illustrations by   Leigh Landskroner. Published by ICEA.

Do this massage once or twice per day, starting around the 34th week of pregnancy. After about a week, you should notice an increase in flexibility and stretchiness.

Perineal massage during the second stage of labor was also found to reduce third and fourth degree lacerations at birth.  The physician, midwife or nurse can apply mineral oil, jojoba oil or sweet almond oil while massaging your perineum to aid in stretching your perineum as the head delivers.  This has been found to reduce the extent of the lacerations that may occur. **/***

A slow, controlled delivery is the key to an intact perineum and reduced incidence of laceration. The baby must not suffer any form of fetal distress and the mother and partner must listen closely to the midwife or health care provider for advice on when to push and when to stop pushing.  As your provider slowly guides your baby out, you are less likely to experience lacerations in a controlled delivery.**

Warm Compresses– Significantly decrease the risk of third and fourth degree tears with application of warm compresses to the perineum during the second stage of labor.  The heat from the compresses also aid in relaxation.  Many of our midwifery births are delivered with minimal tearing if any at all when warm compresses are applied to the perineum between pushes. **

Postpartum Care:

You may notice some uncomfortable swelling and pain in the perineum due to the stretching required to deliver your baby. To reduce swelling you can use ice packs. Be sure to wrap the ice pack with a washcloth or other soft, absorbent material. Direct application of ice can damage tender tissue in this area if prolonged.

You can also take sitz baths. Your health care provider may have sent you home with a special tub made for this. If not, you can simulate this bath by sitting in a tub with 2-3 inches of warm water for about 15 minutes two to three times a day.   Hydrotherapy has been proven to aid in providing increased blood flow to the tissues that need healing. Some herbs placed in your sitz bath may help.  Calendula, Plantain or Arnica sachets or oils can be used in your sitz bath to help soothe your perineum. Add a few drops of calendula, plantain or arnica oils to your bath to aid in healing. Here in DC, Claudia Booker of www.birthinghandsdc.com has an awesome custom-made herbal sitz bath that can be purchased for use after birth. (http://www.birthinghandsdc.com/BHDC-Sitzbathpage.html)

Demetria Clark is the director of Heart of Herbs, an herbal and aromatherapy school founded in 1998 in Vermont. Visit her Web site: www.heartofherbs.com Additionally, she is a labor support professional in hospital, high risk (preterm, disabilities, etc) and homebirth settings.  Demetria wrote an article in Midwifery Today about “Herbs for Postpartum Care” (2005) These are herbal remedies for perineal healing that she recommends:

Arnica (Arnica montana) used topically is a very effective remedy for bruising. I suggest using it in an infused oil blend. This can be used on perineal muscles and leg muscles if they are sore. Arnica in an infused oil form should not be used directly on the opening or any broken skin. It should not be taken internally unless in a homeopathic remedy.

Plantain (Plantago off.) has vulnerary, demulcent, anti-inflammatory, astringent and anti-microbial properties. Plantain can be incorporated into a sitz bath, compress, poultice or infused oil.

Calendula (Calendula off.) has anti-inflammatory, astringent, vulnerary and anti-microbial properties. This will assist with wound healing by softening the skin and reducing inflammation. Its healing power appears to be based in part on the presence of terpenes. A triterpene glycoside called calendulozide B exerts a marked sedative and anti-ulcerous action. Calendula can be applied in a sitz bath, infused oil and compress.

Lavender (Lavandula off.) is well known for its pain relieving properties and for keeping infection at bay. Lavender can be applied as a compress and sitz bath.

Calendula (Calendula off.) has anti-inflammatory, astringent, vulnerary and anti-microbial properties. This will assist with wound healing by softening the skin and reducing inflammation. Its healing power appears to be based in part on the presence of terpenes. A triterpene glycoside called calendulozide B exerts a marked sedative and anti-ulcerous action. Calendula can be applied in a sitz bath, infused oil and compress.

Chickweed (Stellaria media) has vulnerary, emollient actions. Chickweed is commonly used as an external remedy for cuts, wounds and, especially, itching and irritation. High in vitamin C and bioflavonoids, it assists in reducing scarring. Chickweed can be applied as a sitz bath, compress, poultice and infused oil.

Raw honey is a great remedy for first-degree tears. Honey’s thick consistency forms a barrier defending the wound from outside infections. The moistness allows skin cells to grow without creating a scar, even if a scab has already formed. Meanwhile, the sugars extract dirt and moisture from the wound, which helps prevent bacteria from growing, while the acidity of honey also slows or prevents the growth of many bacteria. An enzyme that bees add to honey reacts with the wound’s fluids and breaks down into hydrogen peroxide, a disinfectant. Honey also acts as an anti-inflammatory and pain killer and prevents bandages from sticking to wounds. Laboratory studies have shown that honey has significant antibacterial qualities.(2) Significant clinical observations have demonstrated the effectiveness of honey as a wound healing agent.(3) Glucose converted into hyaluronic acid at the wound surface forms an extracellular matrix that encourages wound healing; honey is also considered antimicrobial.

Aloe vera applied topically fresh from the plant has superior wound healing abilities. Allantoin, a substance in aloe vera, has been considered a cell proliferant, an epithelial stimulant and a chemical debrider. (The authors of some studies have claimed that aloe vera delays wound healing, but these results are debated.)(4) It has been shown that aloe vera increases collagen content and degree of collagen cross-linkage within the wound. Studies showed that collagen increased 93% with topical aloe vera treatment and 67% with oral treatment, compared to controls.(5) Because aloe vera has a high water content, allow the area to dry after application. If using a prepared aloe formula, the presence of preservatives may cause stinging.*****

Your health care provider may have prescribed pain medication. It’s advisable to take this as directed. You can avoid the pain if you stay on top of your dosing (for example every 4 hours) rather than waiting until the pain starts again before taking another dose. Some providers prescribe ibuprofen which helps not only with pain relief, but helps manage swelling, so you should take continue taking this as long as your provider has recommended, even if you aren’t in pain.

Other pain relief measures may include sprays like Dermoplast that you can apply after using the bathroom or changing a pad. Some providers also use a foam such as Epifoam to reduce swelling and itching if you’ve had stitches in the area.

Tucks medicated pads are infused with witch hazel which helps decrease swelling and can be placed on your pads and then applied to your perineum or hemmoroids. To decrease pain and swelling.

These helpful tips are here to decrease your risk for perineal trauma and to help aid you with healing after birth.  Thank you for allowing me to be a part of your birth journey.

*Kalichman, L. Perineal Massage to Prevent Perineal Trauma in Childbirth. IMAJ 2008;10:531-533.

**Aasheim, V, Nilsen, A, Lukasse, M., Reinar, L. Perineal Techniques during the second stage of labour for reducing perineal trauma. The Cochrane Library: DOI: 10.1002/14651858. CD006672.pub2.Dec 2011

***Stamp, G. Perineal massage in labour and prevention of perineal trauma: randomized controlled trial. BMJ 2001 May 26; 322 (7297): 1277-1280.

****Labrecque, M. Perineal massage in pregnancy. BMJ. 2001 September 29; 323 (7315): 753.

*****Clark, Demetria. Herbs for Po