Will I tear pushing my baby out?

This is one of the most common anxieties surrounding vaginal birth that I come across as a midwife. As soon as I start talking about this topic in antenatal class I see a roomful of people wince and cross their legs, and I totally get it, I do. But, what if we reframed the question? How about: will my perineum and tissues stretch to allow my baby to be born? The answer to that is a big fat YES!

Just a reminder: the perineum is the area between the vaginal opening and the anus. This is the area that stretches as your baby is born. The baby’s head descends into the vagina and sits behind the perineum as it gradually thins and stretches. Try to remember: your body is designed to birth a baby, it has primed itself throughout pregnancy to be ready to do the job. The hormone relaxin will enable the perineum to soften and stretch before and during labour. And there are lots of other factors at play that influence the occurrence of injury to the perineum.

Photographs showing the perineum stretching.

But, I am going to be real here. For the majority of births (80%) there will be some degree of ‘trauma’ to the vagina and/or perineum. This is a completely normal part of birth and does not mean your vagina will be left unrecognisable to you. Trauma sounds scary and extreme, but can simply be superficial grazes to the skin around the labia, which heal easily with no intervention needed. Commonly, you may have a first or second-degree tear. A first-degree tear involves just the skin of the perineum, and a second-degree tear involves some of the vaginal and perineal muscle. This will often require some stitches, but sometimes can be left to heal by itself. ‘Suturing’ as it is called can be performed by a midwife or doctor. Usually this is done shortly after the birth, in the room where you had your baby and with effective local anaesthetic.

Rarely, more severe tearing can occur that extend into the anal sphincter (around 1-4% of births). This is known as a third or fourth degree tear. I often feel conflicted about whether to share this information as know it can cause further anxiety. But I also don’t feel that I can just leave it out. My main takeaway messages are: it is very rare, and there are things you can do to prevent it.

I think we can fall into tricky waters if we claim that an ‘intact’ perineum (no tears) is a badge of honour to hold. You have not failed or done anything ‘wrong’ if you tear or need some stitches. However, research shows that women with an intact perineum:

• Experience less pain after having a baby
• Are less likely to have problems passing urine
• Are more likely to resume sexual intercourse earlier
• Report less pain with first and subsequent sexual intercourse after giving birth
• Report greater satisfaction with sexual experience
• Report greater sexual sensation and likelihood of orgasm at six months postpartum

So, aiming to reduce the degree of trauma as much as possible is hugely important for your ongoing physical and sexual health, and psychological wellbeing. You are more likely to experience symptoms described above with 3^rd or 4^th degree tears, which as I mentioned before are very rare.

Top tips for letting your perineum do its job:

• Communication – Having good communication with those present at your birth can really help you to focus on the job of pushing your baby out. You will most likely have an uncontrollable urge to push when your baby is low down and ready to come (this can vary depending on if you are using pain relief and what type). For most people, this is experienced intensely as an urge to poo, as the baby is pressing on your bowel and rectum. Trusting your body and going with these natural sensations and urges is important, but there will come a point when it is preferable to breathe and slow down as much as possible as the baby’s head is being born, known as ‘crowning’. The sensation at this moment is referred to as the ‘ring of fire’, as the skin and tissues are stretching to their maximum. But remember that relaxin is working to help the skin stretch, and the body is also clever enough to release endorphins which are natural painkillers. It may feel like you want to push with all your might at this point to put an end to this intense sensation, but keeping as calm as possible and breathing with the support of your birth partner/midwife will help your baby come gently and give your perineum time to stretch as nature intended.
• Position – the position you are in when you birth your baby is also really important. Kneeling, all-fours, lying on your left side or resting in a semi-recumbent position are all fantastic for helping your baby as much as possible to navigate their way out. Deep squats, standing and ‘lithotomy’ (legs up in stirrups) are associated with greater degrees of tearing, as these positions can put intense pressure on the perineum as the baby is being born. This doesn’t mean that these positions are ruled out if they are what you find comfortable. Your own comfort is the most important factor. Every labour and birth is different and it is about finding what works for you. I have observed that women will instinctively adopt positions that help their baby descend through the birth canal as they push, and then move into a ‘preferred’ position such as kneeling when they feel the baby’s head crowning. This is because the body intuitively knows what to do when birth is as undisturbed as possible and physiological processes are nurtured.
• Warm compresses and immersion in water – Research has shown that one of the few interventions that really make a difference is applying warm compresses to the perineum as it stretches when the baby is being born. Giving birth to your baby in a birthing pool or bath has been shown to have similar outcomes to birthing on land and reduce overall perineal trauma. This is thought to be due to the warm water helping the skin to stretch and the counter-pressure of water against the perineum as support.

I hope this post has given some practical and useful information rather than causing further anxiety or fear. In my next blog post I will be talking about perineal massage and how this can be done in pregnancy to help increase the perineum’s ability to stretch.

 

 

Researchy bits:

http://www.cochrane.org/CD006672/PREG_perineal-techniques-during-second-stage-labour-reducing-perineal-trauma

Stats (UK based):

https://patient.info/doctor/episiotomy-and-tears

Water birth:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3982045/

https://www.ncbi.nlm.nih.gov/pubmed/12708093

 

Oxytocin – breastfeeding, birth & sex

Oxytocin is a powerful hormone that plays a significant role in birth, breastfeeding and sex amongst other human behaviours. It is often referred to as the ‘love hormone’, as human touch and affection raises the levels of oxytocin in our blood stream. You know that tingly sensation you get that feels like warmth spreading around your body? That’s associated with oxytocin! Higher levels of oxytocin are linked with feeling calm, safe, secure and comfortable. It is also responsible for attachment between infants and their parents.

Birth

Oxytocin has the power to ‘expel’ things from the body. It acts on the uterus, making it contract in order to push the baby out. During labour, oxytocin is released in pulses from the hypothalamus, deep in the centre of the brain. These pulses of the hormone are what stimulate contractions throughout labour that come and go every few minutes in a rhythmic pattern.

Oxytocin is easily influenced by anxiety, tension and fear, as these are associated with a surge in stress hormones, which halt the release of oxytocin. Stress hormones, predominantly adrenaline, are what trigger the ‘fight or flight’ response in humans. This dates back thousands of years and is a primitive response to a perceived threat (eg. imagine the caveman out hunting who comes face to face with a sabre toothed tiger). For this reason, it is important to create an environment during labour that helps the labouring individual to feel as calm, relaxed and safe as possible to prevent stimulating the release of stress hormones that might slow down or completely stall the natural progress of labour.

Breastfeeding

Oxytocin acts on the breasts to allow milk to be released when a baby is feeding.

Baby suckles → nerve impulses travel from breast to brain → oxytocin released into bloodstream → oxytocin reaches muscle cells that lie next to milk-producing cells → cells contract and squeeze out milk

As the baby continues to feed the feedback loop is completed. Immediately after birth, when a baby is skin-to-skin with its mother and starts to breastfeed, this increases oxytocin levels further and helps to expel the placenta.

The body learns this reflex action, and that is why sometimes a mother will leak milk when she sees her baby or hears them cry. Breastfeeding releases oxytocin in both you and the baby.

Orgasm, Sex and Labour

When we orgasm a flood of oxytocin is released into the bloodstream. It is possible that oxytocin is responsible for the muscle activity related to orgasm in both women and men. Studies have shown that women release higher levels of oxytocin than men during orgasm. If you think about the fact that these bodily functions are controlled by the same hormone (oxytocin) you start to see the similarities between birth and sex. Imagine a scenario of sexual intimacy: it is unlikely that you would be able to orgasm in front of a room full of people, in an environment you are unfamiliar, with bright lights shining on you (it would appear I have just described the set of a shit porno…) Birth follows the same rules. Women generally have uncomplicated labours when disturbed as little as possible. Support is important, but support from people who are trusted and have faith in the woman’s ability to birth her baby.

As I have discussed before, the release of oxytocin at orgasm can also stimulate uterine contractions. To be clear: it is not dangerous to orgasm when pregnant! No studies have found that orgasm will cause a baby to come prematurely. But if your body is already in the process of preparing to go into labour it may help to stimulate the process. The other reason you may hear that sex (specifically penetration with a penis) can bring on labour is because male ejaculate contains prostaglandins. These are natural hormones, which are also released by the cervix and help it to soften and open at the beginning of labour. (Again, this will only get things going if you are ‘term’ i.e. 37+ weeks pregnant). And one more thing to bring this full circle… a fantastic way of stimulating contractions in labour is nipple stimulation. And why might this be? For those at the back, RELEASE OF OXYTOCIN! Just as the baby stimulates oxytocin when they breastfeed.

“When we realise that pregnancy and birth are not primarily medical conditions, but part of a woman’s psychosexual experience, we discover the relations between different aspects of our sexuality and gain new understanding, in touch with our bodies and our feelings.” Sheila Kitzinger

Effects and benefits of Oxytocin:

• Anxiety reducing
• Lowers blood pressure and pulse
• Reduces levels of stress hormones
• Increases tolerance to pain
• Promotes learning and feeling calm
• Improves digestion and nutrition storage

These are the effects of oxytocin that can be experienced when enjoying food, being massaged, having sex or intimacy such as kissing and cuddling, but also IN LABOUR! We can directly see how the facilitation of oxytocin to work its magic can help with the intensity of labour. So how can we help oxytocin out?

How to aid release of oxytocin in labour

There are two key ways to help oxytocin do its job:

• By developing an understanding of the process of labour: through knowledge comes power. If you haven’t had a baby before (and even if you have) you cannot know exactly how you will feel in labour and the ways it may affect you, but if you have an awareness of how labour progresses you will hopefully feel less fearful. Less fear -> more oxytocin!
• Creating an environment that fosters safety, security and comfort. This includes the people you have with you and your physical surroundings. I always think of a cat going off to find a quiet, dark, warm and undisturbed corner to have her kittens. We are mammals too after all!

 

I could talk all day about the wonders of oxytocin, and I have merely planted the seed for how you might go about creating the right birthing environment… to be continued.

 

 

Further reading:

The Oxytocin Factor – Kerstin Uvnäs-Moberg

Birth & Sex – Sheila Kitzinger

 

Hormones in Pregnancy

We all know that changing hormonal levels can make you feel, quite frankly, like you are LOSING YOUR SHIT sometimes…. But why is this? What hormones are being produced? And how are they actually affecting our bodies and mood?

Hormones are the chemical messengers produced and secreted by glands, which maintain the body’s internal environment. During pregnancy there are huge changes to the levels of different hormones that the body produces. It can feel like, and you literally are in, a state of constant hormonal overload…

Here are the key players in the hormones produced in pregnancy:

HCG (Human Chorionic Gonadatopin) – this is the hormone that is produced shortly after an egg is fertilised by a sperm, and is the hormone detected in the urine by pregnancy tests. It basically is the hormone that signals to your body that you are pregnant and needs to build a nest for the growing embryo. It tells your ovaries to stop maturing an egg each month and stops ovulation. HCG can affect appetite and is associated with nausea and vomiting in the first trimester. It is also partly responsible for the frequent need to pee in the first trimester as there is greater blood flow to the kidneys so they eliminate waste quicker.

Progesterone – the hormone that prepares the lining of the uterus to be invitingly rich and squishy for when a fertilised egg implants. If an egg is not fertilised then the lining sheds away (otherwise known as a period). In pregnancy, progesterone maintains the environment of the uterus and prevents uterine contractions until the baby is ready to be born. It also prevents the production of milk in the breasts until birth. At birth there is a dramatic fall in progesterone and an increase in prolactin, stimulating milk production within a few days. Some women will have leaking from their breasts in pregnancy, but this is generally in small amounts and not the level of lactation that occurs once the baby is born. High levels of progesterone can have a sedative effect and contribute to an altered sleep pattern. It can also increase hair growth, hello luscious locks!

One of the main effects of progesterone is that it relaxes smooth muscle in the body (not just the uterine muscle to prevent it uterus contracting). This can lead to lots of common pregnancy symptoms:

• Constipation/ gas – the intestine is a muscle so digestion is slower due to the relaxing effect of progesterone on the gut’s movement
• Acid reflux/ heartburn/ burping/ bloating – the muscles that normally prevent stomach acid coming up are relaxed
• Dizziness as a result of lowered blood pressure (blood vessels ‘relaxed’ and dilated)

 

Oestrogen – Plays a major role in preparing the body for lactation (the production of milk in the breasts). It also helps the uterus grow and become more ‘vascular’, which means there can be increased blood flow to this organ that is doing a lot of hardwork. Oestrogen also triggers the development of key organs in the baby such as the lungs, liver and kidneys. At the end of pregnancy, the start of labour is triggered by a cascade of hormones, and oestrogen is responsible for preparing the uterus to respond to another hormone called ocytocin. Oxytocin is the hormone that causes contractions and is truly amazing, so much so that I am saving a whole post on this gem!

Side effects of increased oestrogen:

• Nausea
• Increased appetite
• Skin changes, such as pigmentation
• The much talked about ‘pregnancy glow’ is attributed to oestrogen
• Mood swings – by the sixth week of pregnancy the level of oestrogen is around three times that of the highest point in the menstrual cycle
• Breast tenderness

No need to be a mathematician to see that your hormones rise significantly in pregnancy!

Relaxin – this hormone (you guessed it!) relaxes the muscles, joints and ligaments to allow for the growth that occurs in pregnancy and to make room for the baby. This can lead to some discomfort and pain in the lower back and pelvis as the ligaments almost soften too much and there is less stability in the joints. The pubic bone, called the ‘symphysis pubis’, is actually two edges of bone connected by cartilage binding the pelvis together. As the pelvis relaxes this bit of cartilage gets tugged apart and can cause quite severe pain for some women in pregnancy, known as ‘Pelvic Girdle Pain’. Physiotherapy and gentle exercise such as yoga and swimming can help relieve this or prevent it worsening. Due to the potential hypermobility of your joints in pregnancy it is important to be careful when exercising and being active to reduce the risk of injury.

Progesterone and Oestrogen are the two key players for mood swings, irritability, anxiety and low mood, which is also why we experience Pre-menstrual Syndrome (PMS). The body has to adjust in the first trimester of pregnancy to these hormones significantly rising. However, many women will report that once the body has come through this period of adjustment they feel a renewed sense of energy and vigour! This can be a huge relief from the sheer exhaustion of the first trimester, as this is a time when SO much is happening in the body, but little can be seen externally and most people don’t know you are pregnant yet. Having to cope with this physical, emotional, and psychological upheaval and not feeling able to scream and shout about it can be quite isolating. Try to be kind to yourself, rest when you can and look after your body as best able to. All symptoms associated with pregnancy vary so much person to person, you may find that pregnancy makes you feel great and full of energy, but for a friend they may be suffering and struggling to find the joy in growing a tiny human. Furthermore, there are remedies and things to help with a lot of the issues discussed above, so ask your midwife or doctor for advice as needed.

The Placenta

The placenta is the organ that the body grows in pregnancy in order to supply the baby(ies) with the necessary nutrients, oxygen and removal of waste products throughout pregnancy. It is attached to the lining of the womb and will usually embed at the top or side of the uterus, away from the cervix. The placenta provides protection to your baby by passing antibodies that you have developed to help with their immunity for the first few months after birth. Your blood and your baby’s blood do not actually mix during pregnancy, the placenta prevents this from happening. Think of it as a barrier that communicates between the mother and baby. Or if you are wanting the sciencey stuff: it is an exchange surface that nutrients and gases cross by diffusion.

The placenta does its best to protect the baby, but it cannot prevent all harmful substances from crossing the barrier such as alcohol, drugs and certain prescribed medications. Infectious diseases can also cross over.

So to put it all in context, the placenta is attached to the uterus and the amniotic sac is attached to the placenta.The amniotic sac is made up of two membranes which contain the baby, the cord and amniotic fluid inside. The umbilical cord connects the placenta to your baby. Blood vessels run through the cord delivering the nutrients to the baby and removing the waste products.  The first two pictures below show the side of the placenta that the baby is in contact with.

The cord is white because it has been drained of blood, but when still attached to the baby immediately after birth it is thick, juicy and the vessels are filled with blood! The two membranes can be seen on the surface.

This is the side of the placenta that is stuck to the uterus. The membranes surround the edge of the placenta in this picture.

 

When the baby is born, the cord will usually be clamped and cut to separate the baby from the placenta. Research has shown that delayed cord clamping – where the baby stays attached to the placenta until the cord has stopped pulsating or the placenta is delivered -is extremely beneficial for the baby. This is because when the baby is born one third of their blood is contained in the cord and placenta, so if the cord is cut immediately they will not receive their full blood volume.

There are two ways for the placenta to be delivered:

1. Nature’s Way (physiological management) – After the birth of the baby there is a huge peak of oxytocin, the hormone that acts on the uterus causing it to contract. This causes the placenta to detach from the wall of the uterus and then the placenta can be pushed out with your effort. It does not feel the same as pushing out your baby as it is soft and squishy. Sometimes, if the placenta has detached already it is simple enough as just moving to a more upright position and it slides out easily. Having skin-to-skin with your baby during this time and helping them to breastfeed for the first time aids the flow of oxytocin (the love hormone) too, which further helps the uterus do it’s job of expelling the placenta.

 

2. ‘Active Management’ – This involves giving a drug containing oxytocin by injection into your leg soon after the baby is born. It causes a big contraction which acts in the same way to expel the placenta. The midwife will then help to deliver the placenta by pulling on the umbilical cord and may ask you to push at the same time. Active management is generally recommended if there is added risk of you bleeding more than is normal after birth. For example, if the birth has been complicated or there have been other interventions.

 

I hope you’ll agree that the placenta is a truly fascinating part of pregnancy. I have tried to focus on the basics here, and haven’t delved into some of the abnormal things that placentas can get up to… that’s for another time I think!

The cervix in labour

Most people are aware that for a baby to get out the cervix has to open. One of the ways of monitoring progress in labour in most maternity systems is through performing vaginal examinations (VE). These are offered to see how open the cervix is, also referred to as dilation. These examinations also give other information such as how low the baby is in the pelvis and the position the presenting part of the baby is in (usually head, sometimes bottom!) The concept of the cervix opening is somewhat misleading, and results in a lot of confusion. Especially when told that the cervix opens to 10cm… don’t worry no one is going near your cervix with a ruler.

So, let’s break this down.

The cervix is 3-4cm long and ‘closed’ before labour. The os is the small hole that runs through the centre of the cervix. During pregnancy there is a mucous plug in the cervix to protect the inside of the uterus and the baby from anything that could travel up inside (for eg. bacteria that could cause an infection). The cervix is literally what keeps the baby in during the pregnancy – it is mighty strong!

When your body begins to prepare for going into labour the cervix will begin a process of changing, referred to as ‘ripening’ – as if like fruit. The cervix will become shorter and softer (known as effacement), and begin to open (dilate). It will also start to move round from a posterior position, pointing towards your tailbone, towards a more central and eventually forward facing position. The cervix begins to open as a result of hormonal changes and also with the weight of the baby as they enter the pelvis (referred to as ‘engagement’), applying direct pressure to the softening cervix.

Cervix: long, posterior

Cervix shortening

The cervix opens further when contractions start. Contractions are the tightening of the uterine muscles that help to draw the cervix up into the body of the uterus and help move the baby downwards. So when it is said that a woman is ‘10cm dilated’ or ‘fully dilated’ it really just means that the cervix can no longer be felt as it has been drawn completely up around the side of the baby’s head. Imagine a roll-neck jumper: before you pull it on the neck is a smaller hole and the material is thicker, as it stretches over your head the material becomes thinner and the hole opens. This is what the cervix does! Below are some pictures to help visualise this… use you imagination a bit as the ‘uterus’ is knitted and technically upside down! But hopefully what happens to the cervix makes sense.

Cervix is long

Cervix is shortening

‘fully effaced’, 4-5cm dilated

Small amount of cervix remains

No cervix left – ‘fully dilated’

And with a pelvis involved…

Note: For the purposes of showing the ‘cervix’ in these pictures the pelvis is resting flat, which would actually mean the woman would be lying on her back. This is not a helpful position for labour.

I hope that this has stripped away some of the mystery from what the cervix does in labour and how it opens. The million pound question is: ‘how long does labour take?’ and that will have to wait for another blog post!