Ah, the ‘E’ word that every makes every mother-to-be tremble in her boots.
Of course, tension and fear is not the best way to help a baby come out! Birth is complex and mysterious and beautiful, and driven by hormones. These hormones are strongly connected to your thought processes: for example, take oxytocin, aptly nick-named named the love hormone. Those feelings of warm affection, vulnerability, acceptance, enjoyment – are they present in the face of fear? No.
We want to create a birthing situation where you have done your utmost to set fears aside and know that you are ready to be open, wide, soft, accepting and ready to welcome that baby into your arms! Closing your eyes and hoping that if you don’t look and wish hard enough things will go away is not going to improve the chances, either. Here are practical steps you can take to making yourself ready.
1. Have a dad or other close family member with you in the birthing room! That doesn’t negate a doula, and a good doula with a calming presence who can switch out coping ideas, provide warm encouragement and a wealth of options is priceless. However, as much as many women hire a doula to be your advocate, in reality there is a limit to the amount of voice that she can use in the delivery room. Yes there are appropriate times when a doula will be vocal and stand up for your rights, but we walk a fine line. Plenty of doctors, nurses and midwives are wary of a doula who is ‘pushy’, and we are well aware that a doctor or midwife who is annoyed is NOT one you want to be looking at your soft parts when a baby is coming out! Talk about feeling tense down there. Therefore, when I work with a mama, I try to foster a warm, welcoming, inclusive atmosphere in a birthing room. I may make gentle suggestions, I may successfully help make staff aware of the mama’s desires, but I will be non-confrontational. I find that this approach works best, because when hospital staff feel lovingly welcomed into the mother-doula bond in that birthing room, they are MORE likely to be flexible when it comes to birthing position/waiting the baby down/cutting the cord late etc. However, when it comes to using the scissors on a perineum, in actuality the best person to advocate for the mom (who is feeling very vulnerable and word-less at this stage) is her Birth Partner: the dad, or even another close family member. That Birth Partner should be given the authority beforehand by the mom, (almost an edict!) that even if they are queasy about birth and feel out of place, their job can be to be as involved as they want or even just stand by the mom and love and compliment and cherish her throughout the birth – but – if they see scissors, their job is to firmly say ‘No’. There is no need to be aggressive, no need to shout, but to feel confident and take this one task of standing up for the mother and own those words. The father of the baby (or another close family member) who gently but firmly reminds staff that the mother would rather tear than be cut* will usually be much more readily listened to than a doula at this one particular moment.
2. Only hire a practitioner that has a low episiotomy rate in your area, make that one of your hiring criteria! A good example of a low episiotomy rate is in the testimony of CPM Pamala Hunt in More Business of Being Born, Conversations With Ina May Gaskin, where the well experienced midwife quietly states that she has not done an episiotmy in 25 years. And this is a woman who has attended over 1,000 births. The video (also found on Netflix) is excellent to watch, if only for the part where both Ina May and Pamela speak confidently and simply about waiting for the baby to slowly crown, and how this slow back and forth progress of the head gently stretches the perineum, naturally. Truly inspiring.
For mothers who read this in Israel: when you arrive at the hospital the first thing you ask for is to please have a midwife who believes in and enjoys natural birth, or is a native English speaker, before you even hand over your forms, in the same breath as ‘Hi.’ This doesn’t ensure that you will have someone that doesn’t do episiotomies, but it does heighten the chances that you will have someone who will give you more leeway to do things your way and birth in a position other than flat on your back, or who will be gentle, or with whom you can build a good rapport! Those are all things that will help take you one more step away from the scissors.
3. Write a birth plan that will be paid attention to. A birth plan can be short and to the point, highlighting the things that are MOST important to you. Of course we are not ‘planning’ the birth, we are simply communicating to your birth team what kind of a birthing mother you are and how you wish to be treated. Here is how to write an effective birth plan. It is an important element of being heard and understood.
4. Put positive words in your mouth! As you approach the end of your pregnancy make sure that you practice the belief that you will be wide, that you will be soft and stretch, that the opening will be huge! Repeat those words to yourself, make it something that you hear/say/think so often that you believe it with all your heart. If you take a Hypnobirthing course, then that is wonderful, because those words are used on tracks which you will listen to daily. Otherwise, find a relaxation or affirming birth track you can listen to, or read ONLY encouraging stories (such as are in the first half of Ina May’s Guide to Childbirth) or write those words on a sticky note and say them to yourself ever time you look in the mirror! Say it to yourself so often that it’s written indelibly in the deepest parts of your brain. Words we practice grow physical ‘branches’ of memory in our brain, almost like deep wagon ruts in a homeward path. Make this belief your path, and as the baby’s head is moving down and out of your birth canal say to yourself that you are big and wide and soft down there, and believe it in your heart. Have your birth partner whisper those words of belief to you. Remember, it is your brain that sends messages to your body to complete functions and actions – make those communications be soft and wide and your body will respond in that direction! It is very interesting to note, that even the rate of tearing is far less with hypnobirthing mothers. Your body does respond to what you believe.
5. Don’t tell anyone you are pushing. Now that I’ve shocked you, let me explain. If this is your first baby, then it may take you 2-3 hours or more to birth the baby after you are fully dilated. If it is your second or more, then it may take much less, but it will still take some pushing. After you are fully dilated, the baby needs to slide past your cervix, and come a few inches down the birth canal to where it will slowly dilate the vaginal opening and perineum and finally the rest will follow. Slowly is good! Slowly means that there is time for the exchange of fluids necessary for your skin and muscle cells to expand and grow without tearing or bunching up and cause injury. Make it part of your birth plan to use Mother-Led-Pushing. With mother led pushing, there is no “Okay! You are at 10 cm, now give me a really big push!” No. When a mom is allowed to push as her body requires her to, (such as is usually done at a homebirth) then there is often no need to check and ascertain every time that she is at 10 cm. She will start making different noises, with little grunts at the end of contractions. Her breath will catch a little, ending in a grunt, and her body will move involuntarily as if someone were pulling on her ‘tail’. Bit by bit these signs start to become more pronounced, as the pressure builds and the ‘need’ to push become more urgent. Is okay to feel with her own fingers (or someone else can peek) and be sure that the baby’s head isn’t pressing against the opening, just to feel safe. If you feel the urge is very strong and you are pushing hard, then it is time to let everyone know. The next time you see hospital staff, state that the mother is feeling pushy during contractions, without alarm in your voice. Pushing in this way is much more gentle on the mother, and on the baby, thus possibly avoiding a situation of foetal distress and maternal exhaustion after hours of ‘purple pushing’. I am not suggesting that you birth the baby without the presence of medical staff- I’m only suggesting that there is no need to panic when 10 cm is reached. When a mother is already pushing according to her body’s direction, then she has more of a chance of continuing with Mother-Led-Pushing. Once purple pushing is begun, it is nearly impossible to go back and follow your own instincts.
It is interesting to note that with an epidural it is much more common for hospital staff to give the mother an hour to ‘wait the baby down’ after reaching 10 cm, and let her body work the baby past the cervix on the power of it’s own contractions, without purple pushing. Why not wait with un-medicated births too, before jumping to instructing hard pushes straight away?
6. Use an EPI-NO. There are plenty of devices out there to help tighten a woman up ‘down there’, and finally here is one that helps to relax you in preparation for birth. The official site for the EPI-NO gives more information and distributes to the US. In Israel, experienced midwife Ilana Shemesh is a direct distributor for the company. The reason I suggest using this product rather than perineal massage, is that there is controversy over whether or not perineal massage actually works. I have a suspicion the reason for this is that with perineal massage you have little control over the actual dilation you achieve during practice; there will only be benefit if you stretch to 10 cm. With the EPI-NO, you can see your progress, and every couple of days you will be able to stretch a little bit further, with the aim of achieving 10 cm before giving birth. I have heard a midwife criticize the tool, and the reason she disproved was that with women who used the EPI-NO, their vagina looked like a woman who had given birth two times already even if she had not. I cannot figure out how this is a negative thing – in the end, the first time mother is the one at greatest risk for an episiotomy, and after she gives birth she will have to stretch to accommodate the baby, why not have the advantage of gaining the shape of a woman who has birthed before? It is worth considering. Here is a link to a conversation between number of pregnant moms about the EPI-NO. It is also recommended to use if you have torn badly or had an episiotomy previously, to help the scar tissue learn to stretch One more thing: If you purchase the more expensive model, you can also use it for pelvic floor strengthening exercises post birth, which is excellent.
7. Keep changing position. The baby has to move a lot, and flex her head, then make a quarter turn in the process of being born, so it makes sense that you should move your body to help your baby along! Many times a mama will seem to feel ‘stuck’ in one position, often because she was told to stay put, and when all the blood in the body is focusing on the uterus and birthing this baby, the brain lacks a little bit of decision making room. But when I ask her to listen to her body and see if it would like to change position, often times after a moment’s reflection she is emphatic that she definitely wants to assume another particular position. We so often forget to ‘listen’ to what our bodies are whispering when there is so much business and adrenalin going on in the room around us, when in fact, the actual process of birthing is going on INSIDE. That is where we really should be focused. So, right now, I am giving you permission, as the birthing mom, to take any position that your body asks you to. When told to move onto your back etc, you can firmly and quietly decline with a shake of your head. Listen closely to what your baby and your body are asking you to do; you are the ones giving birth.
Changing position regularly is especially important when having an epidural! After an epidural, the mother will often get comfortable and take a nap, and even though her position may be shifted a couple of times, she is much less mobile than a mother without an epidural. She is also pumped full of bags of fluids, to counteract the drop in blood pressure (a side effect of the epidural) which just compounds the situation – this mama is FULL of fluids. And since she is not moving, they pool on the lower half of her body. After the longer hours of pushing, this usually means that the perineum (on the lower side of her body since she is on her back) is completely saturated with fluids. It is puffy and thick, and has already stretched so much that it cannot accommodate a baby’s head, hence the need for an episiotomy to make more room. Key word for epidurals: rotissary**. Keep her turning, from side to side, to back, to supported kneeling or all fours if possible. (There must be two birth partners to actively help with these last two positions. Never let her chest drop lower than her abdomen, or the epidural could possibly flow upwards.) Turn, ever 15-20 minutes, to keep those fluids from pooling, and avoid birth path oedema!
8. Give birth in a birth pool. When immersed in the water, your tissues are soaked and warm, so they are soft and pliable. It is uncommon for a mother who gives birth in a pool to tear badly, and obviously you is not going to be given an unnecessary episiotomy underwater – which circles back to point number two. If you are birthing at home or at a Birth Center, then you have already made your caregiver choices very carefully, haven’t you!
It is important to note that yes, there are occasional situations when an episiotomy is needed. But once you’ve made choices that lessen the chances of finding yourself in that situation, you can eradicate some of that fear. Embrace the stretching, opening, widening, of your body, gently and at the perfect time, releasing your precious baby. Many of us have been there before you, and birthed with joy! You can, too.
*As a general rule, a ragged tear grows more organically back together than straight cut cells, with less pain. Also, cuts may sometimes extend beyond their bounds to become worse than a tear would have been in the first place. The cases where an episiotomy is the best option should be very rare, according to the practices of many midwives.
**Rotissary – it is an unflattering word, I know. But I find that it sticks in the mind, which means it is more likely to be followed!