labor nurse has been reborn and shares her experiences as a new nurse-midwife, woman, and blogger

Saturday, February 23, 2008

Stem to Stern and Back Again

This post holds new meaning to me now that I am actively involved at the perineum. For each birth I have done, only one had an intact perineum. I feel horribly when the woman ends up with a tear of some sort, and fortunately nothing has been bigger than a second degree laceration. But I end up questioning my hand maneuvers, or if I should have done something different to prevent the tear that does appear. One of my preceptors told me to not put the blame on myself, some women are just going to tear no matter what. But still....

Stem to Stern

There is one thing that bothers me in my line of work: 4th degree perineal tears.
One word: OUCH.
Fortunately, it's unusual. But it's just awful. It looks awful prior to repair, it looks awful after repair, it's awfully uncomfortable to say the least, and my heart (and perineum) goes out to those who end up with one.
Some of the nurse's I work with have said that some tears actually have a sound. Like a pop or a ripping noise. I can't say that I have heard it, and I am so glad that I haven't. I don't go listening for it either.
I've just had a marvelous idea for my research project (if I make it that far): looking at the correlation of the women's diet and perineal trauma. I'm going to see what research has already been done with this. It comes to mind because I have noticed that women with vegetarian diets seem to have larger perineal tears and longer healing time. Hmm...
But the worst has got to be the risks that are associated with 4th degree lacerations. Like fistulas. Imagine every time you poop or fart that some leaks into your vagina. Ya, that's a fistula. It happens.
Take for instance the phone call I received from a woman who delivered 2 years prior. She was still dealing with the sequela of the 4th degree laceration she suffered during a vacuum extraction. She had surgery on the fistula, but it didn't end up correcting it completely, and so she was facing yet another surgery. And she was angry.
Apparently she was trying to obtain her medical records for the birth. She felt like she was being lied to by the delivering physician. I'm not sure exactly why but she felt that he was hiding something. Either way, her medical record happened to be missing some vital components (which is probably why she was suspicious). I asked her, "Are the nurses notes from the delivery in your record?"
She didn't know. I told her to get them. If her nurse at delivery was prudent, then everything that happened would be documented there.
Not only was she angry about the records and whatnot, she was angry because it ruined her marriage. It caused a great strain on the relationship because she was in pain for so long, requiring surgery, trying to care for an infant, and her marriage began to dissolve. I can see why. She said she couldn't blame her husband for feeling like he didn't have his "original" wife. Because he didn't. He had a women who was dealing with chronic pain that took away an intimacy; it took away any future children. She said it was frustrating because people she spoke with couldn't understand why it would affect a marriage the way it did. They thought that he should be more understanding. He was trying, she said. But how could she expect him to love an angry, depressed woman?
On an aside, this was the one and only time I recommended looking into an elective c-section. I worked with one physician that did them for prior severe perineal trauma and she would be a candidate. But then she reminded me in order to have a c-section she'd have to have sex. Oh...ya... I knew that....
Her case is probably extreme. But either way it sucks. I pray for perineums at every birth.
"May the perineum remain supple and intact. Amen!"


Sheridan said...

I had 3rd degree tears with my 2 VBACs. Not fun recovery, I can't imagine a 4th degree tear.

If I have another baby I will try perineal massage a few weeks before my due date. I figure it can't hurt. Also I want to try birthing in a different position.

What positions are the moms in you are attending? Are they upright or traditional (in stirrups, etc) That is how I was with my 2 VBACs and I wonder if a different position may have helped.

Labor Nurse said...

Perineal massage might help, but its one of those things that research is inconclusive about. I want to say that if it is going to work, it works best in a woman who has never had a vaginal delivery before. I personally like warm soaks to the perineum during the second stage (pushing).

All of the mom's I have attended are in some sort of semi-upright/supported or side position. Never any stirrups involved.

Real said...

One question I am wondering, too, is how many kids they have had. I had a 2nd degree tear with my first two babies. The first one was pretty awful and I was in pain and it took a while to heal and make me feel normal. The second time, I hardly noticed it at all. For babies 3-7, not only have I not torn, I haven't even been swolen. It's awesome. It makes me wonder if vaginal tears happen more frequently for first time moms and maybe we don't notice it diminishing the more babies we have because frankly there aren't many people that have tons of babies these days...

Just my thoughts.

razorbackmama said...

I've had 6 babies.

1st - 2nd degree episiotomy (oh the things we allow when we don't know any better)
2nd - 2nd degree tear (guess where)
3rd - 2nd degree tear
4th - NADA (I'll come back to that)
5th - 1st degree tear (she was in a weird position, and I pretty much blasted her out of there LOL)
6th - 1st degree tear, but it didn't need a repair

With my 4th baby, I give all the credit for my no tear to my midwife. I was in a horrible position - flat on my back, but that was because I couldn't move LOL. My midwife felt soooooooooo horrible about the position I was in. For some reason once I feel the urge to push, I just cannot move anywhere. So I was sort of stuck where I was, and she just had me lie back.

Anyway, so that was the position I was in, which is just asking for a tear, especially since I've had multiple scars form over multiple scars. She took a warm compress and PUSHED on my perineum. I mean major counter pressure. I think that did two things. It supported the perineum and sort of "held it together." But also, it pushed the baby's forehead down so that his crown would come out first. She totally guided his head so that the skinniest part would come out first.

She rocks, and I miss her!!!

Megan said...

I had a 2nd degree episiotomy w/my first baby (8lbs 15oz lbs, vacuum extraction due to failure to wait, semi-sitting w/stirrups) that took FOREVER to feel normal again, as in almost a year until sex had no pain. I agree with the previous commenter - the things we allow when we're young!

The second baby was 10 lbs, 6 oz, I was side-lying with a CPM attending. She basically olive-oiled the baby out, and there was no tearing!

Also, for the second baby, I was a vegetarian.

Nine Texans and friends.... said...

Since the grand multips are chiming in:
#1 C-section
#2 2nd degree tear (I think)
#3 1st/2nd degree tear (I think)
#4 2 stitches
#5 1 stitch
#6 no stitches
#7 no stitches

The first two VBAC"s I never asked what degree my tear was I'm going by how long the repair took. That first one may have even been third degree, it took him a while to repair and I was in a lot of pain. With the third baby I only had 7 or 8 stitches, it wasn't that bad.

Rixa said...

You might want to talk with SageFemme and Navelgazing Midwife. They both take a very hands-off approach. SageFemme says it's very common for her to never even see the woman's vulva, let alone touch it or do exams, until they check her for tears an hour or so after the birth.

Also an article by Sara Wickham that you might like:

As I understand it, semi-upright still puts more pressure on the perineum than a true upright, such as kneeling/H&K/standing.

That said, I don't think that a tear is a sign of the midwife's failure. Nor does a truly upright position guarantee no tears either. Thankfully most tears are fairly superficial and heal quickly.

Anonymous said...

I've had two babies, both home births, both hands and knees. W/my first baby, I did the perineal massage fairly regularly, and had him in water; plus he was 7 lb. 5 oz, and I pushed for 40 minutes. I had a 2nd degree labial tear. My second was 9 lb. 2 oz, and I pushed just a couple of pushes; his was a land birth and I did no prenatal massages. I guess I broke all the rules, because I only had "skid marks" w/him. Supposedly being in water, doing antepartum perineal massages, and giving birth slowly all help to keep you from tearing, but it didn't. Oh, and my first birth was CNM-attended, and I think she was trying to keep me from tearing (can't remember feeling her applying pressure or anything); but my second was born before the midwife was there, so my personal experience is that another person's hands didn't really help keep from tearing.

Fwiw, I've read that regular perineal massage done prior to labor may show some benefits, but when it's done during labor doesn't show anything.

My friend just had a baby, and her first was 9.5lb, born at home, w/5 hours of pushing; and her second was at the hospital w/less than 2 hours of pushing, weighing about 8 lb. She didn't tear at all w/her first, and tore horribly (anterior) w/her second. I figure she was in a standard hospital position since she'd had an epidural, but am not totally sure about that.


Labor Nurse said...

Megan, thanks for sharing your vegetarian/perineum outcome. I can't find anything in the literature that addresses this; I might not be using the right search words...who knows.

Off the top of my head, Varney's text mentions that some upright positions are higher risk for tearing anteriorly (like periurethral, for example). I'm saying this without having the text in front of me, so I can't remember which positions specifically.

I forgot to mention that I am at the mercy of my preceptors, and so far all of them have a hands on approach. All of them provide perineal support, and all of them do it slightly differently. My inkling is to leave well enough alone; only one of my preceptors said that if you notice the perineum start to turn white then start providing support by pulling towards the perineum with your fingers in the groin (this allows a little extra tissue give while not really touching the perineum) which seems reasonable. I've also found that good control of the head helps as well.

Working Girl said...

I think every labor nurse prays for the perineum. I know I do.

Christy. said...

I just found your blog and I was so excited to see your sympathy for a fourth degree tear. 7 years ago I had my first baby, 6 lbs 9 oz, and had a fourth degree tear. I was not prepared for all the pain and trouble. I suffered postpartum depression after the birth requiring medication. Who knows if I would have had the depression without the tear...
I had fecal incontinence but never told my OB. When she was stitching me up from my second birth, 6 lbs 14 oz only needing 3 stitches, she asked me if I was having problems and I reluctantly told her I was. When my second daughter was 5 months old I had a sphincteroplasty and perenialplasty (spelling?). It was the most painful thing I have ever gone through. Thankfully my husband was supportive because we couldn't have sex for 6 months. When discussing with my surgeon about having baby #3 he told me yes, but only with a c-section. So, I had our little boy by c. I still do not have the control I did before my first birthing experience but it is much better than pre-surgery.
All this to say, thanks for making us 4th degreers feel like we were worthy in our pain!!! :0)

SPalmerston said...

With my second I had no tearing. I am convinced it was because I was encouraged to push in whatever fashion I felt I needed to, spent the first few pushes on my knees and flipped onto my butt/semi reclining in my own bed for crowning and was coached through crowning so that I allowed the perineum to stretch.

I had a significant tear with my first where I was coached to purple push for hours in a semi upright position and then pushed like hell to get the head out when I crowned as the sensation scared me senseless! I am pretty sure it was the trauma to the vagina from prolonged purple pushing and the hard push at crowning that ripped me silly.

RN2CNM said...

Hey labor nurse, how about familial links and torn perineums? I had a 4th with my first son (slightly asynclitic, forcep delivery) No epidural until after pushing for two hours it was decided to use the forceps. Second son, 2nd degree perineal. Third son, skid mark :) BTW, all my boys were over 8# and I am not vegetarian.

My sister has only had one child, so far, but had a 4th with her. Baby was only 6#3oz, no epidural, very short labor. Now, she did have PIH and the swelling that goes along with it makes the perineum more edematous and prone to tearing. It will be interesting to see what happens with subsequent children.
Hmmm, now I'm thinking I need to ask my mom what she knows about her three births.

Jack and Lexi's Mom said...

I have found genetics and infection to be the biggest factors in tearing. My Hispanic patients just don't tear like caucasians and Asians.

Anonymous said...

I've had six births.
1. episiotomy...very minor, one stitch. Baby was OP but turned by the OB.
2. I had a labial sunburst tear. I was semi-reclined, legs up, and they told me to push with all my might and had me bend forward. It took forever for me to be stitched. I had a hematoma on the left side (big and bad swollen labia and all that), and still have a hole in my labia on my right side big enough to put my pinkie tip into. At the six week check up I had to have silver nitrate put on something on the left side because the OB said I didn't heal completely.

Babies 3-6 came out with no tears and only "skid marks" mentioned with #4. I know this last time I had the baby on my side, she had been OP and turned after I changed positions several times. She came out with an intact bag of waters. I didn't even swell or feel pain in the vaginal/perinial area at all.

I read that if your labia tears, and mine did terribly, it heals well and was the fault of the attendants likely. I would say they were having me push way too hard and my husband was trying to get me to calm down but they told him to get back. Curling up and pushing with all my might really hurt me!


Labor Nurse said...

Dawn, I'm curious to know where you read that labial tears were the fault of the birth attendant. I've never heard that, either as an RN or a student midwife. I can't see how it would be anyone's fault, but I'm open to hearing what's out there.

Anthea said...

I had a c/s with #1 who was 9lb12oz. VBAC with #2 who as 8lb9oz. In less that 2 hours she went from not even engaged, to out the other side! I ended up with a 3rd degree tear. She was born with her hand on her head and the midwife thought the cord was around her neck so reached in (for want of a better word!) to help that. I can't imagine all that extra activity made it easier. Lots of stiches and bruises!
As for the vegetarian thing, I would say its perhaps due to protein. If wounds aren't healing well, a high protein diet is needed. If a vegetarian doesn't have a well balanced diet, they are probably missing protein.
I've also heard that people with red hair tear more due to less elastin in their skin...

Anonymous said...

I wish I could was 9 years ago when she was born. I am sutr if they were having me not push so hard and were slowing me down it wouldn't have been so bad...but not sure how to avoid labial tears.


Just Janice said...

I gave birth to a 5lb 0oz preemie and still had a tear - actually that tear was bigger than my 2nd 6lb 10oz baby. I guess some of us tear no matter what (like you said). My best friend had a 4th degree tear and somehow managed to get pregnant with #2 - she had an elective c-section two months ago.

Angi said...

If you do choose the correlation of the women's diet and perineal trauma for your research project, please share your findings.