Prep to Push: How to Have a (relatively) Pain-Free delivery & Recovery

Being pelvic floor physical therapists, Erica and I have treated many women that have had a traumatic childbirth. For example, pushing for a very long time, large tears, pubic bone separation, use of forceps or vacuum, as well as prolapse. These new moms were not sleeping much, we’re dealing with hormonal changes and now have a very painful and uncomfortable vaginal area to deal with. I have so much sympathy for these women – the birth of a child is supposed to be a very happy time. The question is, what went wrong? 

There are several known risk factors that can lead to birth trauma:

• Precipitous labor, ie. from start of labor to finish it is 3 hours or less.  

Short labor is an issue because labor allows for the fetal head to massage the pelvic muscles with each contraction. Without this massage, the pelvic muscles and perineum do not warm up and are more apt to tear or rip.

• Forceps/instrument delivery

The  use of forceps or vaccum  can damage the perineum and can lead to larger tears and injuries to the urethra and external anal sphincter. These tools are usually used if labor is not progressing, and/or a medical situation emerges where the baby needs to be born quickly.

• Delivery Age >35 

At age 35 and older the mom is at higher risk for gestational diabetes, preeclampsia, uterine rupture and/or placenta previa (placenta sits over cervix and does not move during pregnancy- this will result in a c-section). With any of these risk factors, delivery may become unsafe and your provider may opt to use forceps or a vacuum to get the baby out and/or opt for a c-section.

• Prolonged stage 2 pushing

Labor has 3 stages. Stage 1- contractions start when the cervix is fully open.  Stage 2- pushing baby through the birth canal. Stage 3-delivery of placenta. Stage 2, pushing phase, can last anywhere from 20 minutes to 2 hours. The longer this portion of labor is, the greater the risk of birth trauma. The longer a woman is pushing the more likely the provider will have to use forceps/vacuum or perform emergent c-section. 

• Heavier baby-birth weight

  Due to the larger size of a baby, the perineum may tear more to accommodate the size of the baby.

• Episiotomy

  A cut made by your OB into the perineum prior to the delivery of the baby - this was thought to help avoid larger perineal tears. Now the ACOG (American College of Obstetrics and Gynecology) does not recommend the use of routine ​episiotomy​ for delivery as they found that it did not prevent maternal and fetal complications.

So what do we know can prevent birth trauma?  

As pelvic floor physical therapists and having both gone through pregnancies, Erica and I know what can help. We stayed as active as we could during our pregnancies - walking and doing yoga throughout. We started perineal stretching and massage, on each other, at pregnancy week 34. (A disclaimer - we both had uncomplicated pregnancies without any gestational diabetes or hypertension). We also practiced bearing down and pushing properly.

Although we both know personally that this can work, what does the research say?  First of all, as you can imagine, researchers often do not love to do research on pregnant women due to the risks to the baby.  One research study I found reviewed all the literature and studies that had been done and it did find that avoiding episiotomy, spontaneous or vacuum assisted birth rather than forceps delivery did preserve the perineum.  It also noted that in nulliparous (never had a baby before) women, perineal massage did help to protect the perineum.This study was fairly comprehensive, but was published in 2000.  

A more recent study in 2012 looked at assistance during the second stage of labor (pushing).  This study also reviewed literature and found that massage and warm compress to the perineum can prevent grade 3 and 4 tears of the perineum.  

Although there is some evidence to prove that perineal massage can reduce tears, there have not been enough studies done to prove that it will definitely work.  This might be why your OB does not recommend this to you.

We strongly recommend all pregnant women learn how to do perineal massage themselves.  It is easy to do, low-risk, and can really help save your perineum. If you are unsure or have questions, we are happy to teach you in person.  We can also teach you about childbirth, proper pushing positions, as well as how to properly push when it comes time.  All of these things will be helpful in having a successful delivery and speedy recovery.  

If you have any questions or want to come in for a session, please email us at info@solsticept.com or call us at 929 269 2505.  If preferable, we can do a telehealth session in lieu of coming in.