UK Midwifery Archives
These archives contain extracts from discussions held on the UK Midwives and Consumers email list, a discussion group for people interested in midwifery in the UK. Open to midwives, students, mothers, and anyone interested in improving maternity services in UK. Posts in these archives express the views of the individual authors, and not those of the Association of Radical Midwives.
The Perineum and Perineal Tears
- Tears and how to avoid them
- Hands off the perineum, or hands poised?
- Suturing versus leaving tears unstitched
- Elective caesarean to avoid perineal damage?
- Links to other sources of information
I have recently had three births all with women ending up with 2nd degree tears, and I use hands off. Two women were standing when they birthed and one was in water. I am very disappointed by the tears. Two were quite big but the client and I opted not to suture. One of the women actually had a misalign healed perineum, although I am quietly confident the cosmetic appearance will improve over the next months. It has caused this individual some distress, not discomfort, just fear, and the introitus is slightly larger than it was. I was surprised because the perineum stretched up so beautifully with restitution occurring etc etc, and I did not pull the baby out either. I am not concerned about leaving tears, but sometimes wonder how these women will be in 20-30years time???? It is discussed beforehand and during of course. Sigh! comments?
I’m not convinced that there is much you can do as a midwife to stop this type of trauma, bar letting women birth themselves rather than giving directions.
Good idea Cate, if more womyn caught their own babies I think the tearing would reduce, as they know the control that is best from inside and out, they are more in tune with the balance, when to counter and when to ease back.
Actually, I do think that there is sometimes a need for some hands-on. Just something may happen in a physiological 3rd stage that necessitates some action, even if it is not the whole hog with pitocin etc, so too there are reasons to put hands on. I am talking about perineal support, not flexing the head or putting slight upward traction on the head to release shoulders. 1) WEIRD DECELS…tight cord , may want to check 2) perineum gets that blanched stretched look and is about to tear-especially over old episiotomies 3) baby coming really fast, may be better off with support.
One of the reasons it took me a long time to get comfortable with catching babies in hands and knees or standing positions is that I found it harder to see what was going on and whether I needed to support the area or not.
Most times I do not think my support helps much, nor hinders, but there have been some births where I felt that I was holding the perineum together, or I was easing the labia around the head to avoid grazes.
This also may answer Deb’s question about 2nd degree tears in standing position.
My own daughter was born with hands-off by accident really as I hopped into the pool and she was born with 4 pushes. My midwife could not reach my perineum and I was in no mood to remember that she needed to support it!
We knew the birth was going fast (4-complete in less than 3 hrs transition was 10mins) and we knew there was a likelihood of nuchal hand. I did however somehow have the wherewithall to remember to ask which shoulder came out first (posterior!).
I got quite a bad labial tear when the nuchal hand came out, just above her brow line, clutching placental membranes. I have the picture sequence to prove this. You can see the head beginig to crown, then the water around me reddens as the labia splits with the diameter of the head and hand being too much, then the head is out and then the arm with the membranes being clutched.
The tear/split was the size of 10p (a quarter for the USA readership) and it took 3 weeks to stop hurting and 10 days of agony. I really wish that my midwife could have put her hands up near the area where my daughter’s hand was and held it off with pressure until the head was out.
There is a school of thought amongst some midwives that the event that you are most anxious about is the thing that keeps on happening to you most until you somehow resolve your fears and anxieties about it. Does anybody have any knowledge of this?
For me I’m sure I have heightened anxieties about perineal tears and good healing afterwards and so it is an area where I find myself constantly searching for information that will help to ensure 100% intact perineums. Yet the wisest of midwives keep telling me some perineums tear and many don’t and its mostly to do with maternal and baby aspects and not much to do with what the midwife does or doesn’t do. So I keep trying to be cautiously expectant and maintaining suturing skills for those times when I need them but seem to continue to feel terribly responsible if a tear occurs even if it’s not very often.
I was recently attending a woman giving birth when during the second stage the perineum opened and then stretched forward over the baby’s head as it crowned, giving the appearance of a head coming through a polo-necked jumper. I’m sure other midwives have seen this occur in some women as I have, and though I have in the past feared that the women would suffer much bruising, I can’t recall any adverse effects, though the baby’s head can sometimes seem to be crowning for ages.
However on this occasion perineum was intact, but on further examination there was a deep vaginal wall tear which appeared to extend deeply so that it was very close to the wall of the bowel (though not the anal sphincter as it wasn’t as low down as that).
I requested examination by a midwife more experienced than me and she felt it necessary to refer to a registrar. After close exam in theatre(!) the consultant also had a look and in the end decided they should perform an episiotomy in order to better repair the vaginal wall, though the anal sphincter was not involved. I visited the woman later and she seemed well, as I hope she continued to.
I discussed this with a couple of midwives at work who asked if I would do an episiotomy in the same situation again. I have always believed that I would not do an epis. unless for severe fetal distress as research as far as I was aware showed that this was the only indication. I must admit though that, since qualifying 5 years ago, I have never found a case where any compromise to the baby occured with the head on the perineum when delivery without episiotomy wasn’t imminent anyway! So perhaps this only applies to those who would perform one on an unstretched perineum. No I don’t think I would, was this a one off, has anyone any comments, ideas? I would be grateful as I’ve pondered this long and hard.
After pondering on this one I can’t see what good doing an episiotomy would have done. The damage to the vaginal wall was still classifiable what sounds like a large 2nd degree tear…..So, an episiotomy would only have resulted in a similar amount of damage to the vaginal wall. It is also possible that even if an episiotomy had resulted in a smaller amount of vaginal wall damage initially it may have extended. You could also look at it that an episiotomy may have meant a quicker delivery of the head and therefore less chance for the tissues to stretch up & the potential for greater damage…..
In a squat I have seen worse tears and i think that is because gravity is helping too much
This is interesting. Jean Sutton (Optimum Foetal Positioning) says a similar thing, that squatting causes more tears, I think due to gravity and hard on pressure from the head. Also euro women squat differently from Asian women – when we squat our pelvises actually close up a bit as our coccyx dips under.
Re the “ring of fire”—-I often hold a cool soaking wet pad against the perineum. Or trickle water over the tissues as they stretch. This seems to ease the “burning” sensation and can enable the woman to “breathe” the head out slowly—-hopefullly reducing the risk of tears and grazes. Can be done in most positions—though standing is fun!!
From a midwife who had just attended three births:
The third lady with whom I was ‘hands on’, rather than just observing, at the point of crowning, had come in with a really short, sharp labour, 2nd baby, contractions barely 30 secs apart (history taking not easy!!, some urge to push as soon as in the delivery room. She was on all fours for the moment of birth, using entonox, but pushing quite uncontrollably.
Despite best practical and verbal efforts, I could not control the force and speed with which she popped the head out. I could feel the perinuem tear like paper under my hand (eurgh!). The previous two had had an intact perineum, so I am not beating myself up too much, neverthless I would like to know if there was anything I could have done differently.
We are taught to be ‘hands on’ for delivery, 1 hand supporting (? guarding) the perinuem and holding a sterile pad over the anus, the other hand controlling the rate/force of delivery of the head.
I honestly don’t think there is anything you could realistically have done differently. Sometimes these things just happen! You did your best in challenging circumstances.
The only thing I *may* have tried would be to ask her to put the Entonox down (but, from your description of events, this would probably not have been a welcomed suggestion!) Without the Entonex, she *may* have been more responsive, both to your verbal guidance, and to the sensations of her own body.
I think we do blame ourselves too often. But we are really not that powerful.
I see this as a fundamental difference between the obstetrical mind set and midwifery mind set. When outcome is not optimal the medical mind says ” What did I not do.” ,but the midwife mind says “what did I do”.
Let me give an example. Yesterday I was doulaing at a hospital birth. The mother had a tear in the posterior vaginal wall. The perineum was intact. The doctors decided that it happened because they were not permitted by the woman to cut an episiotomy.They were clearly angry at the mother.
However it was clear as day to me that her tissues had swollen and were already traumatised by the OB nurse ironing that area for nearly two hours solid. I shall discuss it with the doctor and nurse but I do not think they will understand my point much less agree.
Midwives think of themselves as facilitators in a healthy process. The medical model sees birth as pathology. It believes poor outcomes happen as a result of a lack of some intervention. The lawsuit mind set only feeds this tendency to believe that the more interventions the better, since they are almost always punished for not interfering sooner.
Hands Off – Hands Poised – Hands On – what does it all mean?
The Hands On Technique – in which the midwife’s hands are used to flex the baby’s head, guard the perineum and use lateral flexion to deliver the shoulders.
The Hands Poised Technique – in which the midwife keeps her hands poised, prepared to put light pressure on the babies head in case of rapid expulsion, but not to touch the head or the perineum, or the shoulders otherwise.
Taken from the HOOP study protocol – The randomized Controlled Trial of Care of the Perineum at Delivery.
I would be interested in your thoughts on the ‘management’ of 2nd stage, in particular flexing the baby’s head at crowning, guarding the perineum and whether you think that guarding can prevent a woman from tearing.
I have recently had a discussion with a few midwives who feel that the technique of flexing the head as it crowns and guarding the perineum can substantially reduce the trauma suffered. From the research and the reading round I have done this seems to be unsubstantiated. I have always practised a hands-poised technique, observing the advancement of the head and acting accordingly. However a midwife who came in as a second midwife was very concerned that I was not obviously guarding the perineum. She believed that in if I had the woman would not have sustained a tear.
A personal audit of my practice reveals a large number of intact perineums and therefore I am reluctant to radically change my practice without good evidence. I am coming up to qualifying which in itself is making me question my knowledge and ability so I would welcome any input the list has to offer.
I feel that in the majority of births whether you support the perineum or not makes little difference.The trials that were done recently in britain shed some light on this.
Perhaps someone on the list can shed some light as to the interpretation of “Hands on or hands poised” policies.
I was taught to do hands on but ended up positioning my hands in a way that I have never seen anyone else do (hard to explain too, so I won’t). My tear rate was as low as the others doing the regular support.
The mere 40 births where I have been catching the baby have ended up with only 6 tears, two of which needed stiches as second degree tears, and three (two first-degree and one second) where the senior midwife decided not to suture. Of the 250 births I have attended in some capacity other than primary midwife my stats show roughly the same percentage of tears.
I have only ever seen one episiotomy done and never seen a third degree tear. Granted, I do not have vast experience but the collective experience of all the midwives who were training with me (total of 1500 births amongst us!) shows very similar statistics.
The Midwives Alliance of North America has been keeping stats on this for a few years now and amongst its members, who are mainly home birth or birth center midwives, the figure is also similar. I think an episiotomy rate of about 2-4% is the norm for this type of midwifery (this includes primips and multips)
However, there are some births where I feel I would do support and these include ones where women are galloping along and head coming down fast, like my own daughter’s birth.
In a squat I have seen worse tears and I think that is because gravity is helping too much, but that’s not to say that this is so for all squating births, particularly those births where the squat is being suggested or adopted voluntarily because of a long slow second stage.
There are also the babies that come out with nuchal hands or arms, and that often requires a poised hand to move fast to try and protect the area, although my personal opinion is that often these nuchal parts cause tears and there is not a darn thing you can do about it.
Some women tear along old episiotomy scars so I’d be more inclined to want to support their perineums.
Some women have what is termed bad skin integrity…you can just see that the tissue will shred and tear, and again, I was taught to support their perineums.
Other women have really rigid perineums and they stretch really slowly . I have only seen one woman where it was so excrutatingly unyielding that an episiotomy was cut (and just a small one), so perhaps in these cases it is midwife/Ob anxiety that feels a need to cut rather than wait it out.
I have no experience of this but I am betting that women who have a pitocin drip going (with or without epidural) will have a higher tear rate, as will women with epidurals because they can’t feel when to slow themselves down.
Overall my personal experience has been that when the woman pushes and is not told to push the tear rate is low and the type of tears heal perfectly well without suturing. I have not seen many women ‘escape’ without a few scratches or skid marks though!
The Hands Poised Technique – in which the midwife keeps her hands poised, prepared to put light pressure on the babies head in case of rapid expulsion
I think it would be good if the mum could perform the light pressure as she would know how much pressure is needed to stop the head wizzing out. I did this with one of mine – to push back the head a little with my hand as my body bore down really helped the head ease out and supprisingly took away that ring of fire. It must of had something to do with the halt put on the bulging perenium – instead the skin just got to ease back.
The HOOP study found that hands-on resulted in less perineal pain as an outcome:
Choosing perineal pain as a measurable outcome seems to me to be fraught with difficulty. Perineal pain in my experience is hugely subjective, and to say the least, multifactorial!
I have looked after a woman with a small straightforward second degree tear (unsutured) who complained of great pain for several days; I have looked after a woman with a small straightforward second degree tear (sutured) who complained of great pain for several days; I have looked after a woman with an intact perineum who was in pain for two days; I have looked after a woman with a (sutured) second degree tear and a lot of bruising who was moving and sitting quite normally from day two, and not complaining of pain at all (a bit achey was how she described it…)
In addition to the women’s own perceptions, I think you also have to take into account such factors as postnatal perineal hygiene – to put it bluntly, how often do they wash, and change their pads? Are they using something like calendula tincture or homeopathic arnica to help? Are they taking plenty of vitamin C? Are they anaemic? Are they eating and drinking properly? Are they taking care to sit with knees together as much as possible, and keeping their weight off the perineum by resting lying down? Are they doing plenty of pelvic floor exercises?
And so on.
So, I view the HOOP Trial findings with a great deal of scepticism – for me, perineal pain is not associated clearly enough (if at all) with hands on or hands off delivery, and the findings will not cause me to change my own practice. Although talking to other midwives about their practice might.
The HOOP trial, I had hoped, would reveal that hands off is the ideal. Applying pressure to the head to control the delivery seems well like one could flex the head too much and increase the diameter of the presenting part. One of my mentors posed the question to me that well….
“could any pressure on the babes head slow/stop the surge of a powerful contraction?”
I believe that the answer is no, so I practice hands off. Then the HOOP trial did not support my practice so I felt that I was back at square one.
Also wasn’t it strange that the study revealed that hands off lead to a higher rate of retained placentas! I can not begin to see the conection there.
Mostly I leave tears unsutured at mother’s choice, but sometimes on healing there is some raggedy skin and awareness for this is indeed wise.
One 2nd degree tear I left unsutured at request didn’t heal well – there was some granulomas that had the silver nitrate tx but all okay then. The woman had had a lot of generalised oedema prior to birth and did a lot of travelling soon after birth. Other 2nd degree tears have healed so neatly and can’t see where it happened and function reported back to normal.
However, there is a school of thought that believes that muscle should be sutured to muscle otherwise retraction and dysfunction/weakness occurs.
There has been an argument put forward by one registrar for two deep vaginal muscle sutures only and the rest left to heal naturally. This minimal activity doesn’t get around my experience that most home birth women prefer not to have any suturing done as it interferes with the initial early together feelings of the family but anyway mostly they don’t tear.
Overall if there seems like there is a real need to suture- haemostasis, mother’s request or a very irregular tear that just does’t align at all e.g. spirals (“hangy down” is another image that fits,) then I think fewer sutures are better than more. Tears which may cause continence dysfunction need specialist midwife or doctor attention with mother’s consent. And I supppose one day research may tell us something useful….
This woman was advised to have a caesarean for subsequent births, after perineal surgery. Her message was forwarded to the UK Midwifery list for discussion, with her permission, as ever:
I didn’t feel the birth was well managed by the hospital in various respects. The end result was that I was told to push harder before the baby’s head was out, so I did, and he came out completely in one push. Presumably this was the cause of the damage. However I think I only had a 2nd degree tear, which seemed normal enough to begin with, but 3 weeks after the birth it became incredibly painful. A friend who’s a health visitor said it didn’t look right and I should see a GP, but he removed some stitches and said it was fine. I could hardly walk out of the surgery after his efforts at ‘helping’!
Eventually, after resistance from me, I saw the consultant who advised surgery. By this time (10 months) I was in quite a lot of (increasing) pain so had to go for the op which he described as ‘major perineal surgery’. Contrary to expectations this wasn’t too bad (though psychologically a bit upsetting) and I’m now really glad I had it. Therefore although in principle I don’t want a caesarean if the baby is OK, I have to look at my long term well-being which is not easy as mums want to put their babies first.
If the consultant definitely advises a caesarean, I would feel worried about going against his advice, as I’m sure you can appreciate. I may be worrying unnecessarily as everyone seems full of praise for caesareans, so I need to find out more.
What a dilemma for this woman.
My advice to her would be to discuss thoroughly with the surgeon AND obstetrician as to the EXACT nature of surgery performed. How long ago was surgery performed? Is everything well healed now? If all is healed and strong again, I think it would be an over-reaction to advise having a Caesarean section. This is MAJOR abdominal surgery.
From personal experience, the chances of tearing with a subsequent birth would be reduced – I have no research to back up this statement. Anyone on the list help??
I do know that I have ignored instructions to perform “elective” episiotomy for previous third degree tears – and have had the joy of seeing the women’s joy at having intact perineums.
It’s a tricky one – I think it really depends on the degree of healing & also your woman’s gut feelings about what she would really like to happen. Her mind as well as her body has to cope with her decision.
- She could have a vaginal birth with no perineal trauma.
- She could have a vaginal birth with perineal trauma which may or may not require sutures.
- Elective Caesarean section with abdominal wound but no perineal trauma.
I did look after a labouring woman one night who had undergone a “re-fashioning of the perineum” (if I remember correctly, about 18 months prior to THIS labour). Her perineum had broken down after her previous (1st) baby and she had had a miserable time. On her notes in RED BLOCK CAPITALS was, “For elective Episiotomy in 2nd stage”. She had been seeing this all the way through her pregnancy and in had put the fear of hell into her. She stated to me quite clearly that she did NOT want this – I smiled, oh so sweetly. PHEW! We got away with a tiny nick at the fourchette which was not sutured. We were all very ecstatic and extremely silly about the whole thing – and who could blame us?
If only we had hindsight ….. I don’t know what to advise, really. It seems to me to be a bit iffy to undergo major abdo. surgery without a VERY good reason.
Bad midwifery, bad suturing bad aftercare is not really an indication for elective CS. Maybe they are more skilled at CS than they are at repairing perineii but do you know that?? Badly done CS and bad CS suturing can be just as bad in its way as bad perineal surgery.
It sounds like this woman had quite an ordeal, but… let’s get this straight. Her consultant is advising her to go for caesarean to avoid the risk of having another perineal tear and botched repair. This sounds like a rather extreme take on the old line about “Better to have a nice neat episiotomy than a nasty jagged tear”!
So he’s saying that, rather than take the risk of a perineal tear, she should have an incision through the skin and muscles of her abdomen, cut open her uterus, increase the risks for all her future children of complications such as abrupted placenta, uterine rupture etc,, increase her risk of dying in childbirth by four to sixteen times, increase her risk of having a hysterectomy in childbirth by a factor of between nine and twenty seven, increase her chances of needing re-admission to hospital, etc.., etc.. !! For references to support these statistics please see archive page on risks of caesareans(www.radmid.demon.co.uk/csrisks.htm)
And not to mention the vastly increased risk of placenta praevia, placenta accreta, or even placenta percreta extending to the bladder. Oh, and isn’t bladder damage more common in caesareans too? Not to mention wound infections which are sometimes recurrent and may also require repairs in hospital later.
Or perhaps this consultant has some amazing technique which means that his caesarean patients do not get infections, healing problems, and sequelae in their subsequent pregnancies..
In a situation like this, it sounds like the consultant is presenting the option of a well-handled caesarean as an alternative to a badly-managed vaginal birth and subsequent repair. But this is not a fair comparison – we have to compare apples with apples and pears with pears. This means comparing the reality of each birth option – ie factoring in the full spectrum of risks with each.
Caesareans seem to give doctors the illusion of control in the unpredictable birth process, but it seems from the data that this is just an illusion – the unpredictability may disappear from the time and duration of labour, but it appears in other areas – such as how the mother’s body will respond to surgery, and how the baby’s lungs will respond to the absence of a vaginal birth, and of course how the mother’s subsequent children will fare.
Does this mother want many more children? Sometimes doctors may assume that a mother will only want two children, and if this is indeed the case then recommending a caesarean for her second is less risky than it would be if she wanted a larger family.
Sorry this is a bit of a rant, but honestly – I thought there was supposed to be a national audit of caesareans in progress.
Is this mother really being given all the information she needs to make an informed choice?
I have a friend who had a botched labour, extremely bad tear and repair with first baby. When she had her second she begged for a section but was refused. Had second baby, another tear and now has some awful condition where she is in constant pain around the perineum – something to do with the nerves permanently being switched on. She goes bananas every time anyone campaigns against c-section as she is now living a life of permanent pain with her marriage going rapidly down the pan.
I do agree with all that people have said, but I look at my friend sometimes and just wish someone had listened to her (or radically improved their maternity services!!)
I unfortunately have personal experience of problematic perineal tears. (I’m not a midwife – this is just what happened to me).
I had a 2nd degree tear with my first birth (combination of hopeless student midwife ‘delivering’ and baby’s hand up by head I believe). This was sutured after birth by the least sympathetic midwife I have ever met – she informed me that it didn’t hurt and I should stop making a fuss! Anyway, the result of her handiwork was a misaligned join, leaving an obvious ‘flap’. As I had no experience of these things, I didn’t know it should have healed by 2 weeks, and my GP at the postnatal check told me it had been stitched ‘beautifully’ and therefore couldn’t still be hurting.
After 5 months of constant pain I was sent to hospital for a spot of granulation tissue to be treated with silver nitrate. This still didn’t resolve the problem that I was stitched up ‘wrong’, causing intermittant pain and emotional distress. I thought they might take me more seriously if I said that it hurt too much to have sex. Hah! The consultant sent me for psycho-sexual counselling – apparently the problem was all in my head! Eventually some time after my baby’s first birthday I saw the consultant again, she called my bluff by offering to resuture there and then, I gladly accepted, and healed within a couple of weeks.
The upshot of this is that I have had 2nd degree tears and stitches for both of my subsequent (home)births, probably due in part to the babies shooting out within a couple of pushes, but no doubt also due to weakened perineal tissue. In fact in my last pregnancy the scar had split open in the middle by 30 weeks, so a tear was inevitable. I have had adequate suturing which has healed in a couple of weeks both times (I never knew until I started reading this list that 2nd degree tears don’t *have* to be sutured).
It seems incredible to me that a woman would be advised to have major surgery to avoid another perineal tear; *if* my experience is anything to go by future tears are more likely but won’t necessarily lead to the same problem recurring.
I understand the rationale behind your E-mail and there are many issues surrounding the care you recieved that make me sad and angry on your behalf. However, if this lady did have a third degree tear then the tissue damage is far more extensive and includes the anal sphincter. This can on occasion lead to very young women being incontinent of faeces which as you can imagine is extremely distressing. There is a liklihood of the tear recurring if there is extensive scarring.
I also feel we can discuss this lady’s case at length and all its ramifications but the main issue here is lack of communication between professional staff and the woman. Only they know the full facts of the case and can jointly discuss the rationale behind options. This lady can then make an informed decsion which best suits her. It is sad that this appears not to have been done from the outset.
My first child was born very fast (under 3hrs) and it was a mad rush to get to the hospital so as a result I guess I was pretty uptight and certainly not relaxed! He was posterior and rotated to anterior at the last corkscrewing his way out pretty explosively! (plus I was squatting) As a result I ended up with a nasty tear that was just off 3rd degree.
I was offered transfer to a nearby large hospital for obstetiric repair but not realising exactly what was involved I elected for my midwife to do the repair – and it took ages! I asked afterwards how many stitches and her reply was “you dont want to know” 🙂 I think she did a pretty good job but it was *very* sore for weeks after and even up to a year or two after the birth my perineum still felt bruised and there was this small spare flap of skin …
For my second (3hr labour) I decided to have a homebirth and my birth plan read simply “no stitches” !! I avoided pushing in the last stage and used a hands and knees position to take the pressure off my perinium – this time the baby was anterior and came out oh so nice and gently – no tear – not even a graze!! What a difference!!! But even better all the pain I’d felt previously disappered and I was like a new woman! My conclusion was that his slow gentle birth was the best internal massage Id ever had and helped resolve all the old scar tissue.
My third child (1hr active labour) was again posterior and did the last minute corkscrew thing but once again I avoided pushing and used hands and knees and once again remained intact!
Personally if I had been given the option of a c-section to avoid further trauma to my perineum I would have declined – to me it seems bad enough to be scarred in one area without adding another on my belly!
See separate archive pages on these subjects:-
- Third Degree Tears and management of the next birth after a third-degree tear
- Does horse-riding affect the pelvic floor?
Web page all about pelvic floor exercises:
AH updated 5 February 2002