Episiotomy during childbirth is one of the biggest traumas for expectant mothers. However, it’s important to know that perineal care begins even before pregnancy.
What can we do for a supple and elastic perineum?
– some of it is genetic predisposition, which we cannot influence
– a healthy and balanced diet for the pregnant woman (if possible, food should be organically processed, rich in proteins and vitamins – vitamins E, B12, C, and D, as well as minerals and foods rich in omega-3 and omega-6 fatty acids, particularly affect tissue elasticity)
– early detection and timely treatment of vaginal inflammation (by wearing breathable cotton underwear and not overly tight clothing that causes inflammation + appropriate diet again)
– appropriate hygiene of the anogenital area (do not use alkaline soaps!)
– performing pelvic floor strengthening exercises
– using complementary methods (perineal massage, preferably with cold-pressed organic oils in combination with essential oils or oils rich in vitamin E. Perineal massage is recommended from the 26th week of pregnancy onwards, or at the latest after the 35th week; most authors suggest approximately 6 weeks before the estimated due date).
– steam or herbal sitz bath from hay flowers from the completed 38th week of pregnancy
– drinking raspberry leaf tea from the 36th week of pregnancy onwards, or from the 34th week for multiparous women
– consulting with a midwife already during pregnancy.
In the delivery room, we can care for the perineum by:
– using warm compresses on the perineal area, or a warm shower or bath where water birth is possible. Compresses can be made from ginger or comfrey, but even warm water alone helps
– having the midwife lubricate the perineum with appropriate oils just before the crowning of the head or with a water-based lubricant
– an appropriate position in the second stage of labor (legs spread at the knees and feet approximately 30-40 cm apart, regardless of whether the woman is squatting, sitting, lying, kneeling; for a high perineum, old midwifery textbooks advise giving birth lying on the side; a side-lying position for pushing is an excellent choice)
– constant presence of a midwife – one-on-one model
– proper management of the second stage of labor
– if we decide on perineal massage during labor, it should be performed gently, as otherwise it can cause perineal edema and tissue fragility, and vaginal spasm may occur if the woman does not like massage in this area; if perineal massage is chosen during labor, some authors recommend using vernix from the fetal head instead of oil. Generally, NICE advises against perineal massage in the second stage of labor
– and of course, trust between the midwife and the birthing woman/couple, leading to relaxation and cooperation. (Franc, 2014)
–we encourage the mother to touch the baby’s head as it crowns
What are the degrees of perineal rupture and why are we afraid that an episiotomy will progress to a III or IV degree rupture?
I. degree – damaged perineal skin
II. degree – damaged perineal skin and pelvic floor muscles
III. degree – damaged perineal skin, pelvic floor muscles, damage to the anal sphincter
IV. degree – in addition to everything else, the anal epithelium is also torn
Burns (2011), in her manual on antenatal perineal massage, provides instructions for performing the massage.
INSTRUCTIONS FOR PERFORMING PERINEAL MASSAGE (Burns, 2011):
- perineal massage can be performed by the pregnant woman or her partner,
- massage is best performed after bathing or showering, as warm water softens and relaxes the perineum,
- it is recommended to use unscented oil (olive, almond, vegetable, sunflower) for perineal lubrication,
- a comfortable position for massage should be chosen (sitting or semi-sitting position on the bed with bent knees, lying position during a bath with one leg raised, etc.),
- it is important that the pregnant woman is relaxed, in an environment where she feels safe and where no one interrupts her,
- the pregnant woman or partner should wash their hands, lubricate their thumbs or index fingers of both hands with oil, place them in the vagina, and press downwards towards the anus and outwards,
- this is followed by semicircular, rhythmic U-shaped movements with gentle stretching of the vagina and surrounding tissue,
- the pregnant woman should focus on relaxing the perineum during the massage,
- the massage should last approximately five minutes or as long as the pregnant woman finds comfortable,
- over time, as the perineum becomes more elastic, the pregnant woman or partner can increase pressure towards the rectum during the massage,
- the massage should be performed daily or every other day,
- perineal massage should not be performed by women with genital herpes or vaginal inflammation. Most women who massage the perineum during pregnancy report that the massage is acceptable to them and believe it helps them better prepare for childbirth (Labrecque, 2001). Pregnant women report that in the first weeks, the massage causes discomfort and a burning sensation, is unpleasant, and can even be painful. However, most say that the burning sensation and pain disappear after one or two weeks of performing the massage. Most (79%) report that they would use massage in subsequent pregnancies, and as many as 87% of women would recommend it to other pregnant women (Beckmann and Garrett, 2009).Given that perineal massage with fingers from 35 weeks onwards reduces the incidence of birth injuries (especially episiotomies) and perineal pain three months postpartum, and is well-accepted by women, all pregnant women should be informed about the benefits of perineal massage and the technique of its performance (Beckmann and Garrett, 2009).(Teppey, 2012).
Factors Associated with Perineal Injuries
Literature lists the following factors that contribute to perineal injuries during childbirth:
- primiparity,
- baby’s birth weight over 4 kg,
- second stage of labor longer than one hour,
- epidural analgesia,
- occipitoposterior presentation,
- induction of labor (RCOG, 2007),
- directed pushing (Valsalva) during fetal expulsion (Sampselle and Hines, 1999),
- episiotomy (Renfrew et al., 1998),
- sutured birth injury from a previous birth (Alberts et al., 2006),
- giving birth in the lithotomy position (Soong and Barnes, 2005),
- giving birth squatting (Shorten et al., 2002),
- birth managed by an obstetrician (Meyvis et al., 2012, Shorten et al., 2002),
- birth completed with an instrumental delivery (forceps delivery and vacuum extraction) (Labrecque et al., 1997),
- Asian race of the birthing woman (Dahlen and Homer, 2008).
The authors mentioned above reached these conclusions in their research, in which they, among other things, studied factors influencing perineal injuries.
Consequences of Perineal Injuries
Many women suffer perineal injuries during childbirth, which cause them pain and discomfort in the postpartum period. The injury leaves short- and long-term consequences on their health and well-being (Steen, 2010).
Short-term consequences include blood loss and infections (Renfrew et al., 1998), pain and discomfort while sitting, urinating, and defecating, limited mobility, reduced ability to care for the baby, poorer lactation, and insomnia (Steen, 2010). Long-term consequences include weaker pelvic floor muscle tone (Renfrew et al., 1998), depression, exhaustion, stress incontinence, dyspareunia, and altered relationship between partners (Steen, 2010). In the first three months postpartum, approximately 23% of women experience dyspareunia, 19% urinary incontinence, and 3-10% fecal incontinence (Steen, 2010).
Thanks to Ana Teppey, author of the diploma thesis “Perineal Care during Pregnancy and Childbirth (2012); under the mentorship of mag. Teja Škodič Zakšek, dipl. ing. rad., dipl. bab., MSc (UK)
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