As a doula I also often see the medical members of birth teams (Midwives, OBs and nurses) support the perineum during pushing and birth in different ways.
So here's some information to help you avoid unnecessary tearing:
[WARNING: pictures of actual perinea (perineums?) perineal massage and baby emerging. Don't scroll down if you don't want to see this.]
There is wide variety in expertise and approach between different medical professionals, so talk to the medical members of your birth team about this topic.
Ultimately, YOU and your partner are the "protectors of the perineum". It's your job and you are the best ones to do it. You have the most invested in the outcome, so be prepared!
Perineal massage during pregnancy
The evidence is mixed. There’s a great review on Lamaze’s web site Connect the Dots titled “What is the evidence for perineal massage during pregnancy to prevent tearing?” Also, for more detailed step by step directions check out MamaNatural's article on Perineal Massage during pregnancy.
In short: If you are massaging yourself, place your thumbs up to about 2 inches inside the lower vaginal opening. Or, partners use your first and second fingers. There are two stretches you can hold for 1-2 minutes, then relax. Stretch until you feel a slight burning or tingling and hold that (see diagram below).
1. Gently press downwards (towards the anus)
2. Gently press outwards
It is only a gentle stretch – it should not be painful.
1-4 times a week starting at 34 weeks is enough. That’s ALL! More may be harmful!
You are trying to get used to the sensation of the stretch and to get your tissue to be more stretchy. Remember, the evidence is that this maybe helps a little. So if you don't like it or don't want to, don't! It's YOUR vagina after all!!!!
- Warm compresses: High-certainty evidence indicates that warm compresses reduce the incidence of third- or fourth-degree perineal tears (4 trials, 1799 women, RR 0.46, 95% CI 0.27–0.79). The absolute effect on third- or fourth-degree tears is estimated as 24 fewer per 1000 (with a range of 9 to 33 fewer) (photo on the left below)
- Perineal massage during labor: High-certainty evidence indicates that perineal massage reduces third- or fourth-degree perineal tears (5 trials, 2477 women, RR 0.49, 95% CI 0.25– 0.94). The absolute effect is estimated as 5 fewer per 1000 (range of 2 to 22 fewer).
What does Perineal Massage during labor look like? During the second stage of labor the provider uses lubricant and inserts two fingers into the vagina and applies mild, downward pressure to the vagina towards the rectum, while moving the fingers with steady strokes from side to side. Massage in some studies was performed only during contractions in the second stage and in others was continued during and between pushes.
The photo on the right, below, may be mild or may not. But it's definitely more than two fingers! Ultimately, YOU are the judge of deciding if they are doing it right! How does it FEEL???!!!!
Watch what they are doing? Does it look gentle? Is it hurting your partner? A little? A lot?
If you think it's too rough, use the word STOP.
The evidence supports MILD pressure. Too much pulling and tugging can actually INCREASE the chances of a tear. So if your partner says it hurts more than just a little bit, that's too much. AND, the benefit of doing this is not too big. So if your partner wants them to stop, make them stop.
Warm compresses appear to be MORE effective, and they FEEL GOOD!!!!
Doing nothing is also a reasonable option!
Finally, one more question? Who's hands should be there anyway?
Happy birthing! ~Dalia