perineal massage vs. "ironing"

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    hello friends and neighbors,

    a question: can anyone describe for me the basics of perineal massage to reduce the chances of laceration or "need" for episiotomy?

    in reading another thread regarding "dense" epidurals, someone described a technique that was referred to as "ironing out the vagina" and i am afraid that in trying to do perineal massage for one of my recent pushing primips, i ended up inadverdently ironing. :uhoh21: i was gloved and lubed (of course), had my index and middle fingers just inside the introitus and my thumb on the outside of the perineum, and was gently trying to relax/massage the area in between contractions, almost like i would massage someone's hand only more gently. while doing this i began to notice a trickle of bright red blood that seemed to originate in the posterior vaginal wall, and i stopped what i was doing. the pt eventually ended up with a midline episiotomy but the doctor did not need to repair any vaginal lacerations, so evidently if i did cause a laceration by massaging incorrectly it didn't require sutures... anywho.

    any advice or tips? i am going to start using warm compresses more often i think, but would like to know whether i was taught perineal massage correctly, or simply need more practice.

    thanks much!

    kori
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    Sometimes as the tissue stretches, tiny blood vessels pop; not a laceration but they can bleed. If the tissue is healthy you may just get a "skid mark", if it is not a spontaneous lac is very possible. Good maternal nutrition and the absence of vaginal HPV can contribute to the absence of perineal lacerations.

    There are two schools of thought on perineal massage: Do it because it can be helpful and don't do it because in the end it probably doesn't make any difference. There is some evidence that too vigourous of a massage can contribute to periurethral lacs.

    My natural patients who have read the advantages and disadvantages are split about 50/50 do it/don't do it; but the ones who do it start a week or so before labor begins.

    I wish there was a way to go back and say "yes, it was helpful" but I've seen enough "hands off" births with no lacs to say it may just be our wanting to be helpful and stimulate that pushing reflex.

    If the vagina is a clock, I will massage from the 4 oclock to the 8 oclock area ONLY, and only if the patient requests it, and I use a down-and out sort of stretch vs. going side to side. I let the head do the side-to side stretching. My two fingers are spread out to the 4 and 8 oclock areas. I've seen some docs who get pretty vigorous and stretch from 3/4 of the vagina or more and there are lacs in the upper part of the vagina/clitoris/periurethral areas.

    It works for me. I'm not a surgeon and I don't really want to sew if I don't have to.
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    A study just came out on this very subject, which you can download in .pdf format at [url]http://www.medscape.com/viewarticle/513202

    Leah L Albers, CNM, DrPH; Kay D Sedler, CNM, MN; Edward J Bedrick, PhD; Dusty Teaf, MA; Patricia Peralta
    "Midwifery Care Measures in the Second Stage of Labor and Reduction of Genital Tract Trauma at Birth: A Randomized Trial"
    J Midwifery Womens Health. 2005; 50(5): 365-372.

    I learned a lot of great things while working in Berkeley, CA, which was epicenter for much of the natural labor movement in the 1970s-1990s. Among them was if some sort of perineal pressure was needed for a denser epidural, just press downward with fingers just far enough so mom could feel where to push, but don't "iron" out the perineum -- this increased trauma. Small rivulets of blood you may see are normal, probably small tears or such, and don't worry about them. They can be easily stitched up if need be. When the baby's head made the turn up and under the symphysis pubis, we'd have her push less forcefully, esp. if the head was coming quickly -- slower expulsion dramatically decreased perineal trauma. If it was coming fast we'd have her not push but pant with UCs, and baby's head would be eased out more easily and slowly with much less risk of tearing. We'd use mineral oil also for lube -- I'm not sure how effective this was, but it didn't seem to hurt. Few providers did episiotomies there -- very very nice. Many lacerations were first or second degrees only. Can't quote 3rd and 4th degree stats, but those were dramatically decreased with the new protocols.

    Check out Penny Simkin and Ruth Ancheta's book, The Labor Progress Handbook. The advice given here blows my mind. They also talk about pushing. I think Penny Simkin also has a book on second stage of labor that may discuss this (too tired to look it up now ...)
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    Check out Penny Simkin and Ruth Ancheta's book, The Labor Progress Handbook. The advice given here blows my mind. They also talk about pushing. I think Penny Simkin also has a book on second stage of labor that may discuss this (too tired to look it up now ...)[/QUOTE]

    I agree that "The Labor Progress Handbook" is awesome! It reinforced a lot of things I already believed based on years of observing laboring women and trying to get those little darlings repositioned!


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