is prevention always the best cure?
sara wickham
This article was originally published in
Midwifery Today. Republished with permission.
Without having seen the other articles in this issue of Midwifery Today {which was a compilation of articles about tear prevention}, I feel fairly confident that a number of my midwife friends will have written brilliant articles sharing tips, tricks and ideas for preventing perineal tears. And I am very glad they have; it is always good to learn new ways of helping women through birth.
Yet I'm wondering whether 'tear prevention' is as important a goal as we think? Given that I believe we should always be ready to question even the most sacredly held of our practices, I've been giving some thought to what lies behind the ideal of tear prevention. Is a high intact perineum rate an unequivocally noble goal and the mark of a 'good' midwife (as we have generally come to believe), or does tear prevention constitute another set of interventions which may be beneficial to individual women, but whose routine use should be carefully reflected upon and questioned with the aim of improving our practice?
The perineum in nature and culture
We hear and read a lot these days about the need to focus on physiology and 'normal birth'. Yet how 'physiological' is it to routinely squirt oil onto a woman's perineum during labour, to place (or move) our hands in strategic positions or to apply packs to raise or lower the temperature of body tissue? I have had the privilege of watching a number of animals giving birth, but I have never seen a cow instructing another cow to pant, or a rabbit carefully lining her paws up on her friend's bottom while she pushed her bunnies out. I understand that babies of different species are birthed differently, but are the practices we use to attempt to prevent tears really necessary on a physiological level, or are they cultural rituals which we have developed over the years which may or may not be helpful to the women we attend?
As far as the perineum is concerned, perhaps it would be better to let nature and the woman's body choose. I wrote a paper a couple of years ago (Wickham 2000) where I discussed Midwife Jane Evans' suggestion that the labia are designed to guide the baby out as it is born. We both suggested that midwives might consider a hands-off approach at birth, unless there is a reason for our hands to become involved, and I remember stating at a study day where I presented this paper that, “if nature had intended hands to routinely guide the baby out, women would be born with an extra pair attached to their inner thighs”. I feel much the same way about tear prevention; if nature needed all woman to routinely have a hot pack on their perineum, I am fairly confident that a self-warming one would be provided in a handy zip-up flap just inside the labia majora. (If I just haven't managed to locate mine yet, instructions on how to do this would be very much appreciated!)
Let's not forget that the perineum was not normally in view until men forced women to lie on their backs to give birth. Where women are upright it can be difficult, if not impossible, to put anything near the perineum, including our hands. On occasion, I have had enough trouble getting my body into a position to 'catch' under a woman where I wasn't in danger of overbalancing, or rolling on the three-year old sitting next to me. In that situation, it is hard enough to try to keep your gloved hands reasonably clean, let alone using them to anoint or support the perineum which is swaying to and fro above your head.
The positive side of tears?
One of the other questions we need to ask ourselves is whether perineal tears are always a bad / negative / harmful thing for women, or whether they could be neutral in their effects. Maybe they could even have advantages? Having a tear does help women to slow down after they give birth; they are not physically capable of moving too quickly, which might make some women take better care of their bodies and get more rest. A tear also offers the woman (and her midwife) an easy 'marker' by which to gauge healing. If a woman tries to do more than her body wants her to, her tear will usually let her know about this.
A healing perineum helps remind women that they have had a baby. (Which might initially sound like a stupid thing to say, but I don't believe there can be many midwives who haven't occasionally met a woman who needed reminding of this.) Having a tear might enable some women to learn more about their bodies, their pelvic muscles, how they can work with these. It might also be a way for the midwife to introduce women to herbs or other ways of healing that the woman might not have previously encountered. For at least one woman that I worked with, having a tear meant she had a valid reason to not engage in unwanted sexual activity after the birth. More generally, helping a woman to deal with a tear can open up discussion of a woman's sexuality, and issues which she has never before been able to talk about.
Birth is a rite of passage, which takes women's bodies on a journey. We become marked with the symbols of our passage into motherhood and retain the cellular memories of the experience. Whether we judge these marks as “good”, “bad” or “neutral”, we hold them as women whose bodies tell the stories of our lives. To what extent does the fact that we midwives often judge all tears to be “bad” impact on the way that women perceive their bodies, their tears and scars?
What do we need to know?
For the record, I can think of a number of good reasons not to question the noble and ancient art of tear prevention. I understand that a deep tear can be traumatic, painful and debilitating to a woman. I understand that some tears can need stitches to promote haemostasis (or for other good reasons), and it is because of my understanding of these things that I am not suggesting that we should never attempt to prevent a tear. Instead, I believe that we should attempt to develop our knowledge about when it might be appropriate to use particular substances, manoeuvres or 'tricks' for individual women, rather than doing things routinely to everyone whose perineum ever appears before us.
Unfortunately, the research studies on the long term effects of perineal tears are, unfortunately, often too confounded by the impact of medical birth, semi-recumbent positioning and directed pushing on the woman's body to tell us anything really useful about the effects of tears in environments where midwives support women to work with their bodies. We are going to need more midwifery debate on this; more sharing of ideas, experiences and intuitions. More unravelling of those practices which are truly helpful and those which we only perceive to be so. In our quest for authentic midwifery knowledge, we need to continue to unravel the tension between knowing when to simply 'be' beside a woman as she embarks on her journey of childbirth and when to step in and 'do' something that may change the course of events, and the journey of her body.
S Wickham (2000)
Perineal Pampering- before, during and after birth.
MIDIRS Midwifery Digest, Vol 11, suppl 1, March 2001, p S23-S27.