The Un-Episiotomy Page-manage perineum ~ 1999

The Un-Episiotomy Page
The Un-Episiotomy Page ~ Protective Perineal Management Skills for Physiological Delivery	American College of Community Midwives A professional organization for Community Midwives General Content
Faith Gibson,LM,CPM
the "Perineal phase" explained, the Fetal Ejection Reflex Defined and principles and techniques identified that protect the mother's perineium while making the routine use episiotomy unnecessary
Background:	Perineal phase explained	Avoiding Episiotomy and Pelvic Floor damage

It is imperative that the truth about the historical and contemporary use of episiotomy become widely known so that corrective information can be disseminated and remedial action may be instituted by the medical profession.

Episiotomy is a painful, detrimental and potentially fatal surgical procedure unnecessary to normal childbirth. The only medical justification for its use is to hasten the birth of a baby suffering from fetal distress during the last few minutes of the birth process or in response to maternal exhaustion (and then only after informed consent information is provided and after obtaining the mother's permission). Its emergency use is extremely rare and when necessary is often a consequence of non-physiological (i.e., medical) management of the second stage of labor including the use of pain medications or anesthesia or requiring the mother to push lying on her back while instructing her in prolonged breath-holding.

Despite a total lack of scientific basis for its routine use and the pain and complications associated with its use, episiotomy has been the "management of choice" by the obstetrical community for the last 100 years. Episiotomy is associated with a statistically significant increase in 3 and 4th degree lacerations (into or through the rectal sphincter), perineal edema, inability to urinate after the birth (requiring caterization and increased rate of urinary tract infections), on-going perineal pain requiring medications and interfering with maternal mobility and breastfeeding and difficulty or pain in resuming normal sexual intercourse postpartum. Episiotomy does not protect the mother from pelvic floor damage or future incontinence of bladder or bowel. It does however increase the likelihood of immediate post-op infections and perineal lacerations in future pregnancies. It increase the cost of maternity care and the length of recovery for the mother.

In addition to the physical and psychological damage done to individual mothers by inappropriate use of episiotomy (extensively documented by in this treatise by Dr. Woolley), its historical acceptance by the medical profession as the basis of the "normal" management of birth resulted in a serious deficiency in medical education with long term consequences. Contemporary obstetricians have never been taught (nor chosen to learn on their own) these protective principles which are far more appropriate than episiotomy and necessary to preserve the normalcy of the mother's pelvic floor.

Appropriate non-surgical (i.e. midwifery-based) protective methods require a through understanding of how to facilitate the normal physiology of birth to the benefit of the mother's perineal tissue, which includes such principles as patience with nature, right use of gravity, physiologically favorable positions delivery such as side-lying and techniques such as maintaining flexion of the fetal head and supporting the perineum during the birth of the baby's head and again during the delivery of the shoulders. This delivery technique was recommended historically to the medical profession and demonstrated by Dr. DeLee in photographs in his 1924 obstetrical textbook "Principles and Practice of Obstetrics". However, its value in protecting the perineium and eliminating the need for episiotomy was never appreciated by the physician community. True to their training as obstetrical surgeons, doctors preferred episiotomy instead.

Having chosen to surgically cut open the perineum, the obstetrical profession has never acknowledged the traditional midwifery principles and non-medical management techniques which were naturally successful at preventing perineal trauma during childbirth, These protective principles requires that upright and mobile positions be used for second stage (right use of gravity) and that doctors do not place the mother in a position for delivery (i.e. on her back) which includes weight bearing on the maternal sacrum. This anti-gravitational position closes down the bony pelvis by approximately one third while requiring the baby to be pushed uphill against gravity at a 60 degree angle through a partially closed door. This can causes fetal distress, maternal exhaustion, unnatural perineal lacerations, edema, pain and inability to urinate immediately after the birth and pain in resuming normal intercourse postpartum. The baby as well as the mother may suffer from this institutionalized ignorance and require care in a neonatal intensive care nursery for several days after birth or even have permanent neurological damage from a trip through the birth canal make unnaturally perilous by imposing non-physiological positions, drug use and unwise protocols (such as prolonged breath-holding).

As if the inappropriate use of episiotomy for the last 100 years was not bad enough already, things have recently taken a desperate ( and potentially fatal) turn for the worse via a call by obstetricians for "prophylactic" cesareans as the delivery method of choice. Because obstetricians do not utilize "good technique" in managing the perineal stage of the birth (a combined problem of inappropriate use of episiotomy and failure to make right use of gravity with an increased rate of perineal lacerations when episiotomy is not done) there is a marked increase in pelvic floor difficulties, especially for older women, such as incontinence, uterine prolapse, etc. This problem is so pervasive that 33% of obstetricians in the United Kingdom who were asked for their personal birth preference (or for their wives and daughters) between normal vaginal birth or elective cesarean, identified elective cesarean as the one they would choose. They attributed this to a fear of pelvic floor damage subsequent to normal birth. Obviously these iatragenically-created problems are considered by doctors to be unpreventable and to represent the "collateral damages" of childbirth -- proof of a fatal design flaw that can only be overcome by avoiding vaginal birth all together!

The possibility of pelvic floor damage subsequent to vaginal birth is now being cited by the president of ACOG as a rationale for medically unnecessary "elective" cesarean becoming the delivery method of choice. However, cesarean surgery is a life-threatening surgical intervention associated with many complications for both mothers and babies and which can result in complications in a subsequent pregnancy such as placenta previa, placenta percreta and uterine rupture with fetal demise or permanent neurological damage. It is a classic domino situation in which ignorance by physicians of successful midwifery techniques for perineal management can, for some childbearing women, cause extremely detrimental or even fatal consequences. This situation must be rectified sooner rather than later.

The that end relevant midwifery principles for the physiological management of labor second stage labor are presented, including identification of the "perineal state" and techniques for the non-medical management of a spontaneous delivery of the baby's head and shoulders over an intact perinenum . This information may be printed out by cutting and pasting into another word-processor file (please delete the critical text above) and provided to obstetricians and other birth attendants unfamiliar with these protective measures.

The Un-Episiotomy Page ~
Perineal Protective Management Skills for Physiological Delivery,

The Perineal Stage -- a new name for a very old phenomenon: Certain predictable problems are created when there is no distinction between the 2nd state of labor (initial pushing urges at or near complete dilatation) and the perineal phase of labor (when the fetal head fills the birth canal and begins to distend the perineium). The biological, physiological and psychological aspects of second stage change quite dramatically, depending on where the baby is in relation to the pelvic inlet, mid-plane or outlet. The role of gravity in relations to maternal posture and the mother’s reaction to perineal sensations and psychological response to the impending birth changes as the baby’s head progresses down through the stations of fetal descent. Obstetrical textbooks usually do not distinguish between the first phase of maternal pushing (moving fetal head through cervix and down to a +3, +4 station) and the last half which includes rocking the baby under the pubic arch, distending the perineum, extraverting the anus and eventually the crowning of the baby’s head and subsequent delivery of the shoulders. However, midwives have historically made this distinction in the course of managing the expulsive stage labor.

It is important to avoid all maternal postures that result in the childbearing mother bearing her body weight on her sacrum -- this closes the bony aperture of the pelvis by 20-35% and increase soft tissue resistance resulting in "mattress" dystocia.

Conservation of Maternal Effort through right use of Gravity -- During the second stage (all stations above +3 or 4) the best progress and the least maternal effort is achieved when the mother is in a vertical posture. The most favorable accommodation of the irregularly shaped fetal head to the irregularly shaped maternal pelvis is achieved via a combination of maternal mobility (changes of position) and the pelvic enlarging effects of a squatting position, in which abduction of the thighs to the side and slightly back against the abdomen increases the intra-abdominal pressure while increasing the pelvic diameter.

Psycho-social/sexual aspects of expulsive labor -- creates maternal needs for privacy and a feeling of security which shares many of the same characteristics as the social norm for using the bathroom. These are brought into play by the strong expulsive sensation of 2nd stage in which many childbearing women are, quite naturally enough, convinced that they needs to have a bowel movement. Fear of soiling often means that the mother is triggered to use the muscle of her buttocks to hold back in the rectal area while simultaneously using her abdominal muscle in an attempt to push the baby down through the birth canal. This creates a push-pull war of sorts that works against the goal of expulsive labor.

Facilitating the mother to push fully while simultaneously relaxing the gluteal muscles of the buttocks is best addressed by suggesting she sit on the toilet for a minimum of 3-6 pushes when she first begins to feel "pushy". Sitting produces a body posture sharing many of the same characteristics of squatting. Supplying the mother with 3 or 4 inch prop under each foot helps her maintain good flexion and abduction of the thighs. This comfort measure also reduces the pressure on the under side of her thighs which if prolonged will interfer with circulation and contribute to vulvular edema.

Providing the mother with privacy in the bathroom except for the presence of her spouse or intimate family member and/or the midwife/L&D nurse addresses the intimacy needs of the situation. If there is justifiable concern about precipitous birth (a multip), the caregiver can monitor progress by placing a small mirror between the mother’s legs. By shining a flash light at the mirror while angling the mirror appropriately the perineum can be visualized to be certain that she does not inadvertently deliver while on the toilet.

The creative use of gravity to shorten the 2nd stage reduces the stress on the baby and associated risk of fetal distress. In addition, physiological postures and acknowledgements of the psyco-social/sexual aspects of the mother’s experience also reduce the number of times she must push and the actual quantify of body energy the mother must expend. When a mother pushes while lying in bed on her back she is bearing body weight on the maternal sacrum. This means she must overcome the deleterious forces of gravity which now work against her as the birth canal is a relaxed right angle aiming up towards the ceiling in this position. This closes the pelvic aperture down by 1/5 to one 1/3 (equal to 1 to 3 cms). The aggregate of these forces means at the very least 1/2 hour, often an hour or more of extra pushing and increased time with expendature of incalculable amounts of finite maternal energy for very little gain. This additional time and increased pressure may also have detrimental effects on the baby and result in fetal distress.

Practitioners should keep in mind that the pushing stage comes at the end of labor, when the mother had lost sleep and not eaten for many hours, suffers from fatigue and often is discouraged. It is unkind to ask her to do the hardest physical work ever required by our normal biology (especially if it is a first vaginal birth) under these sub-optimal conditions. The normal amount of psi (pounds pressure per square inch) required to give birth to a first baby is approximately 120 psi. The uterus on its own produces only about 80 psi, which means that either the mother must use abdominal muscles and gravity to provide the missing 40 psi or the caregiver must pull with forceps or a vacuum device with 40 psi of downward torque. When every drop of maternal energy is expended on pushing to baby down to the perineum, there is nothing left for her to use for the perineal stage -- that is to push the baby’s head and shoulders out and across the perineum. This sets up the situation for the otherwise unnecessary surgical intervention of episoiotomy and its risks of bleeding, infection, prolonged postpartum pain, the need for narcotic medications and the disruption of bonding and breastfeeding that pain and drug use entails.

On those occasion when mothers are unable to be upright or out of bed due to a medical condition, side-lying is the physiologically appropriate position as the curve of Carus is neutral to gravity when the mother is on her side. While not as effective as upright positions, at the very least side-lying does not require the mother to work uphill against the forces of gravity.

Management of Perineal Stage: The concept of a "perineal stage" is a functional definition of the latter part of 2nd stage used by many midwives to describe the biological and psychological events from a +four station to the actual crowning of the baby’s head and delivery of shoulders. It is during this period of time that a biological event often occurs that French obstetrician Michael O’Dont described as the "fetal ejection reflex".

The idea of a fetal ejection mechanism is that after the cervix is fully dilated the mother experiences a dramatic event in which the body simultaneous opens up (relaxes normal muscle resistance) while forcefully propelling her fetus downward. The fetal ejection reflex efficiently overcomes the usual soft tissue resistance and takes advantage of momentum to press the baby down and out. While the example of gastric emptying (emesis) makes for an unpleasant analogy, in truth it shares the same biological chain of events, except going in the other direction. This reflex usually is triggered when the baby’s presenting part is quite low and the pressure of the advancing head triggers the same expulsive receptors as used to move the bowels. To the observer it reminds one of the reflex commonly referred to as the "dry heaves" in which a sudden powerful contraction of the abdominal muscles causes a dramatic bodily event to occur -- often to the surprise of the mother herself.

In some multips the fetal ejection reflex is initiated long before the baby’s head presses on the perineum (perhaps as soon as the cervix is fully dilated) and the baby almost "free falls" through the birth canal and across the perineium in the matter of 1 - 3 pushes. However for most mothers there is more to this reflex that just the physical trigger of cervical dilation and pelvic floor pressure. Of equally or even greater importance is the psychological component. While it is impossible to predict which mothers will experience this "labor-saving" biological event, many birth attendants have observed that a confident mother is more likely to do so than a fearful, anxious one. While no caregiver can program mothers under her care to experience this beneficial reflex, acknowledgement of the pyscho-social /sexual nature of childbirth greatly helps.

It should be noted that the following principles are relative to healthy mothers with an established ability to push effectively (normal length of 2nd stage up to this point). However, epidural anesthesia is not a contra-indicator to many of these techniques if the mother is moving the baby with each successive expulsive effort.

The position of choice is usually the mother’s choice. This includes being seated on the toilet or a birth stool such as one designed by the Dutch midwives, kneeling, side-lying in bed or some version of a full or supported squat or standing crouch with knees slightly bent or bowed outward. This last maternal posture has been immortalized in statute of the Hindu goddess Kali whose bent and splayed knees reflect the position of giving birth in the ancient world.

Physiological management of the perineal phase up to and including the crowning of the baby’s head and delivery of its shoulders often occurs without any practitioner/medical intervention whatsoever, except for the intense gaze of the practitioner. However, it is usually multiparas who are able to progress and deliver completely unaided. Primiparas or those with much larger baby usually benefit from active (hands-on) management of the perineal stage.

Favorable positions for the perineal stage: Helping the first-time mother to remain upright until the perineal cleft (that part of the mother’s perineal anatomy including the anus that is normally tucked up inside of the cleft of her buttocks) has flattened out and caput is visable at the vaginal introits is very useful. Squatting is an excellent choice to bring this about, or pushing on a birth stool or the toilet may be helpful. However it is better for the birth stool to be removed before the baby crowns and the mother to either squat (associated with increased rate and severity of perineal lacerations in primipara) kneel or lie on her side (the least likely to cause perineal tears) for the actual birth of the baby.

According to historical and contemporary sources (Dr. Joseph DeLee, L&D nurse and professional midwives) who have had experience with a large number of spontaneous labors and physiological births, side-lying reduces the rate of perineal trauma and minimizes shoulder dystocia. It permits better control of the emerging fetus and of the delivery of the shoulders over an intact perineium. In addition, the weight of the upper leg can be assumed to bow the pelvis (increasing the A-P diameter). The elimination of "mattress dystocia" and this added front-to-back space may account for the observed reduction in shoulder dsytocia and serious perineal trauma for mothers delivering on a side-lying position.

This may be particularly important in for VBAC mothers as it reduces the amount of force the mother and her uterus must expend to get her baby out safely. When the pelvic outlet is reduced by 30% and the perineium is pressed into the bed, the mother must muscle the baby past these significant impediments. In the process of overcoming this abnormal resistance, the pressure on the incised uterui is increased, which could contribute in some cases to uterine rupture in post-cesarean labors.

Active management of crowning and delivery of shoulders in a side-lying posture ~

In a side-lying position, the mother’s upper leg can be held up by a family member or assistant or it can be placed on a large pillow. partially inflated birth ball or a 20 inch toy beach ball. However stabilizing support is achieved, the idea is to cradle the mother's upper leg at an increased (acute) angle with the knee of her top leg closer to her chin than the lower leg. The goal is a stable and well-supported lateral position, both knees bent, upper leg more acutely flexed with maternal knees about 20 inches apart. Do not force her legs into a “spread-eagle” position as this reduces the stretchness of the perineum. The person assisting should hold her upper foot in their hand so she can press against it as a source of leverage to help her push more effectively. This position also allows the parents to be able to see the baby emerge and for the practitioner to immediately bring the baby up into the mother’s arms after its birth as she returns her upper leg to a normal position on the bed, leaving the mother resting on her back, with the head of the bed slightly raised or pillow provided.

Practitioner Position in relation to the mother: When this maternal position is used, the caregiver can either sit on the bed next to the mother's back (in contact with the small of the mother’s back and hips -- see photo in DeLee Obstetrical Textbook) or can sit on a stool at the bedside. Unlike the position used when the bed has been "broken" down into an obstetrical operating table (i.e., bottom 1/3 of bed removed, mother's perineum at the bottom edge of the bed, mother's feet in stirrups or foot supports) the bed is not "broken" and the caregiver sits at same level as the mother and to her back (rather than the foot of the bed).

Maternal Participation: If the mother wants to be active in her birth she can be encouraged to place her own hand (finger flat) on the front of her pubic region/back of the baby’s emerging occiput as the head begins to crown, as this is a naturally protective act on the part of women functions to keep the baby’s head well flexed. If the mother elects not to do this, the practitioner would place one hand on the slowly emerging baby’s head and the other over the perineum, with the web of skin between fingers and thumb approximating the web of the perineum in size and position. This small measure of passive support retards (and one hopes prevents!) the “explosive” egress of the head and/or shoulders.

Practitioner Participation: If the caregiver is sitting on the bed to the right of the mother, the top (or left) hand of the birth attendant reaches across and to the side of the mother’s lower abdomen and down to the top of the baby’s crowning head to maintain flexion of the fetal head with light pressure by one or two fingers. The lower (or right) gloved hand is placed palm down on the perineum to lightly support it during the birth of the head and more firmly supporting it during the delivery of the shoulders.

If the birth attendant is sitting on a stool at the bed side, the hands are reversed, with the right hand reaching up between the mother's flexed legs, using one or two fingers to maintain flexion on the fetal head. For the practitioner, the other (or left) gloved hand is placed on the perineum (ether directly or on a disposable diaper or other type of warm water compress), with the web of the thumb approximating the web of the perineum, lightly guarding the perineum. This provides an excellent view (do not cover the baby's emerging head with the warm compress, only the isthmus of perineal skin) and excellent control of the whole situation.

Often the baby's head is born without causing a perineal laceration only to have the shoulders and arms delivers a karate-chop to the perineum. The DeLee side-lying method is superb for managing the delivery of the shoulders, compound arms and the remainder of the body as the practitioner can actually feel the arms up in front of the baby's chest or shoulders and therefore can exert moderate counter-pressure to keep the arm from rupturing the perineum with a karate chop on its way out.

Vocal Coaching through out crowning and birth of the head: The ideal is to help the mother push slowly over the course of a few minutes so as to provide time for the perineum to slightly stretch with each uterine contraction. To that end you want to encourage her to "press" or lean into the pain, to "push through the pain", to "get tired of it, get rid of it" and any other form of direction and encouragement that is germane but avoid urging her to override or "over-push" her natural inclinations. Haste should have no part in the natural unfolding of these sequential events. It is useful to the mother to get positive feedback when progress can be observed so she can tell when her efforts are effective. The same is true of efforts that are not successful -- in order to preserve her energy reserves, she needs to be repositioned or redirected if what she is doing is not moving the baby at all.

The principle of physiological or spontaneous birth is similar to a form of reverse peristalsis -- not unlike the gastric phenomenon of throwing up, only in this case "throwing up >> down". As a physiological process, the mother is best served by moderation in all things -- just as it is not helpful to rush things (excited instructions to "push, push, really really hard"), it is also not useful to verbally instruct the mother to hold back, to pant, blow or stop pushing at the point where the mother expresses the need to "get it out". This seems to occur at about 5 or 6 cms of caput/perineal dilation. If you stop this natural "reverse peristalsis" or opening up and relaxation of the perineal muscle, the resulting stop and start motion actually increases the likelihood of perineal lacerations (usually several small ones). Its like trying to stop someone who was right in the middle of throwing up or having a bowel movement. It would seem that a natural characteristic of sphincters and sphincter-like tissue is an affinity for constant motion in which these tissues do well by being on the move outward to the nadir of their orbit and then, without stopping, they begin the return journey.

It may be helpful to consider how one would converse to someone who was slightly nauseated -- that is to encourage them to breath slowly and calmly resist the gastric contractions -- versus someone who was really nauseated and best served by just going ahead and getting their stomachs to empty. To begin with the mother is best served by the "slow but steady" instruction until "critical mass" has occurred (a process somewhat like the orgasmic phase of sexual intercourse in which sexual organism become inevitable). At that point, it is best to direct the mother to let go and let the baby just come out on that (or the next) uterine contraction. The head (still flexed by the practitioner's fingers) is permitted to fully emerge through the continued pushing efforts of the mother. The head naturally crowns fully and begins to slide free while the mother is instructed to continue pushing (or not) depending on whether or not continued progress is occurring.

Physiological management of the shoulders: The fetal head is not grasped between the hand and downward traction exerted by the attendant. Instead the normal cardinal movements of birth are permitted take place. In completely spontaneous or physiological birth of the shoulders, it is the posterior shoulder that delivers first in most instances (at least for term sized fetuses). This is consistent with the Curve of Carus, in which the baby’s posterior shoulder is distal or inferior to the pubic bone (therefore not restrained) while the anterior shoulder is anterior or above the pubs (i.e. restrained). When the mother reaches down to pick up the baby as it emerges, the anterior shoulder spins around the pubis and is freed with any special maneuvering or forceful extraction by the caregiver. This frees up the practitioner to continue to support and guard the perineum as the shoulders emerge. Continue to verbally coach the mother to push and expect the delivery to be effected by the pushing efforts of the mother (rather than pulling by the caregiver).

Typically the shoulders are born after 30 to 90 seconds of internal rotation. The practitioner’s perineal hand remains firmly over the mother’s perineum as the shoulders slowly emerge. Some mothers will push the baby out in one long effective push but most complete the delivery on the next contraction following the birth of the head. With the hand of the caregiver firmly over the perineum, one can easily feel the baby’s arm/elbow when it is drawn in front of the baby. The caregiver’s hand helps keep the baby’s outstretched elbow from landing a karate chop to the maternal perineum as it passes.

As for the concern about shoulder dystocia, this situation has several aspects which reduce this risk. The first is the voluntary efforts of the mother are already well established (otherwise the delivery would not have proceeded). Because the mother is in a position that does not require her to bear her weight on her sacrum the pelvic outlet is enlarged 1-3 cms. The weight of the upper leg on the physiologically unstable pelvis (due to pregnancy hormones) can be anticipated to slightly bow the AP diameter of the pelvis as well, reducing the likelihood of the shoulder getting hung up on the superior side of the public bone.

However, if it appears obvious that shoulder dystocia is developing (purple head, turtle sign) the practitioner can immediately employ the standard maneuvers to overcome shoulder dystocia, such as steady traction or change of maternal position (McRoberts or Gaskin). In a physiologically managed labor with no oxytocin stimulation, no narcotics, no anesthesia, no forceps, mother not in lithotomy position and with the added postural benefits of sidelying, shoulder dystocia is quite rate and usually successfully managed.