I hope these are words you never have to utter in labor but if you’re giving birth in a hospital you may want to practice saying this phrase confidently.

This post may be upsetting if you’ve had previous perineal injury or if tearing is something you’re really worried about for your upcoming first baby. I’ve included lots of tips at the end and a video - please get sympathetic support from a mental health professional if you’re struggling with a difficult recovery or experiencing prenatal anxiety.

There is a LOT to unpack in this post.  You may need to read it more than once and please ask your partner to read it too.

 Recently a Cosmo Australian blogger Zoe George graphically described how her vagina was ‘broken’ in labor.  This Mom of 2 experienced a difficult forceps birth during her first baby’s birth.  The words ‘broken’ and ‘vagina’ should never be in the same sentence but it’s a case of what you don’t know can hurt you and your vagina.

Tearing is not a given in childbirth (but most women will experience some kind of tear). But there are things you can do to stack the odds in your favor of emerging from labor healthy and well and in most cases without a broken vagina (or at least only temporarily so). Most of the time your body will heal wonderfully but wouldn’t you like to avoid a tear if possible?

Perineal trauma has become so commonplace that moms almost expect that they will need some ‘help’ in this last very important part of birth. Hollywood has us convinced that all that purple faced pushing is normal. The 2nd stage of labor (pushing) becomes a frantic race to get the baby out as quickly as possible – suggesting to mothers that their own body is a danger to her baby. Your body has grown your baby from 2 cells to a perfect baby…knowing exactly where each fingernail should be placed….where your baby’s tiny ears should be placed….down to the perfect number of hair follicles on your baby’s head…with no conscious input from you…..no 'fetus growing’ classes…just the intelligence and wisdom of your body. When baby is in a good position and you’re mobile your body knows how to finish the process.

Most women who have experienced ongoing complications from a broken vagina have had traumatic births - in many cases it involves an assisted delivery with forceps or vacuum. As perineal injury becomes 'normalised’ we are losing sight of how physically and psychologically debilitating a damaged pelvic floor can be in day to day life and in a woman’s relationships with her partner.

Often mom simply receives a referral to a physiotherapist to help her with the physical recovery but the emotional recovery and mental health issues (including depression) are not seen as being equally important. Day to day living can be a nightmare for these moms especially if they are experiencing fecal as well as urinary incontinence. These professional, healthy, young women have no control over their bowels and end up prisoners of their own homes and nobody is talking about it.

 Sadly some women feel it was their fault because they couldn’t 'push’ properly or were too uptight and couldn’t 'let go’. So let me start off by stating that your body works. Your body knew exactly what to do. You weren’t too 'uptight’ or had issues with letting go. Your body did not fail you - but there’s a good chance that routine maternity practices most certainly did. 

Even the most skilled yoga moms and the most laid back relaxed hypnomums are faced with the most harmful intervention in current obstetrics - the clock. What many moms don’t realise is that the clock is ticking. There is no evidence to support these arbitrary time limits especially for the 2nd (pushing) stage.

Here’s a typical scenario that plays out in our hospitals every day. Mom is managing well - baby is healthy and coping well with labor. 

Mom has frequent VE (vaginal exams) to ensure she is dilating to the hospital’s timeline. 

Sometimes your pattern of contractions slows down as your body rests and your baby rotates into the optimal position.   But for some careproviders you’re now ‘diagnosed’ with failure to progress and are deemed to have inefficient uterine action. Pitocin is recommended and your waters are broken.  You’re also now on continuous electronic fetal monitoring due to the administration of Pitocin. You’re finding it more difficult to cope with the chemically driven contractions that give you and your baby little or no rest between. An epidural seems to be a good idea. Your baby finds it harder to recover from the intense, longer contractions and is now showing signs of distress on the monitor. Is the distress due to the Pitocin, due to you being on your back in stirrups or cord compression due to the waters being broken artificially.  Remember the vast majority of healthy babies complete the labor process healthy and well (look at how humans continue to overpopulate the planet).

Additional staff enter the room and you’re instructed to pull your knees up to your chest as a nurse loudly tells you to and push into her backside like you’re having the biggest poop of your life.  Sometimes staff will tell you to 'get angry with your baby’. Prolonged breath holding further restricts oxygen to your baby which makes labor more challenging for your baby so a decision is made for an assisted delivery. An episiotomy may be performed depending on your careprovider and vacuum applied to pull your baby out.  In some places if the vacuum fails then the next step is forceps or a cesarean. Baby is born limp and has low APGARS due to hypoxia (lack of oxygen). You are in a state of shock but thankful that your baby was 'saved’ your notes read - 'FTP’ - failure to progress and you reluctantly accept that this was your fault – your body just couldn’t do it, baby was too big, you don’t have childbearing hips.

I call BS on this – let’s move that blame to where it belongs – your careprovider’s practice.  Here’s why.

Nobody told you that holding your breath for long periods of time might not be good for your baby.

Nobody told you that 'purple pushing’ could damage not only your baby, but your bladder, your pelvic floor and perineum. In fact the birth classes encouraged it and other women told you to 'listen to your nurse - she’ll show you how to push’.  

Nobody told you that if all is well that there is no hurry (even up to 3 hours is reasonable for a 1st time mom and longer with an epidural).

Current evidence and international best practice would suggest that this was a case of 'failure to wait’ rather than failure to progress. In my experience there are several factors that increase the risk of perineal/pelvic floor damage.  

1 - Arbitrary time limits (time limits mean more intervention to ‘beat the clock’).

2 – Cheerleading style coached pushing (like you see on TV).

3 – Careprovider stretching of the perineum in an attempt to give baby more room (more bs).  The best way to make space for baby is to get mom off her back…even side lying would help if you have an epidural.  You do NOT need mineral oil or Johnsons Baby Shampoo to ‘lubricate’ the perineum.  Both can impact that precious microbiome your baby needs to be exposed to for his long term health and they can also impact the vaginal wall cell structure and make infections more common.  There is no need for your careproviders fingers to be in your vagina while you’re bearing down.

3 - Overuse of episiotomies 

4 - Induction of labor

There are a number of studies comparing coached vs spontaneous pushing In 2003 the WHO recommended removing coached pushing from practice. Research from 1957 describes the damage to the muscles of the vagina and support ligaments after coached pushing so the new research is reaffirming what we already knew to be the case - that 'purple pushing’ is harmful for women and their babies and the more Moms can educate themselves about Irish maternity practices the better. I often hear Mums say not to focus on the birth as it’s 'just one day’…..but that’s not the case for those women who are living with incontinence for the rest of their lives. Information is power. My recommendations are the same to all women whether they have had previous trauma to the pelvic floor or are first time Moms. It’s so important that you understand how the 2nd stage (pushing) actually works.

How Do Babies Get Out?

The pushing stage is a reflex.   When your baby’s head triggers Fergusons reflex (also known as the Fetal Ejection Reflex). Your body automatically starts to nudge your baby down. The top of the uterus gets thicker and thicker and moves down around your baby - like a tube of toothpaste. When you think of how our body works when we feel sick and vomit. Your body throws up….so in labor it’s like your body is throwing 'down’. You’d never say ‘oh I had a dodgy curry last night and was pushing up vomit all night’….you’d say you were throwing up….it’s the same with the 2nd stage….your body does all the work for you but it feels sooo good to go with it. The sensation is irresistible.

It’s an urge that you can’t ignore. Think of how the bowel works - pushing when you don’t have the urge to push is like me instructing you now to go and have a bowel movement immediately when you don’t feel the need to go! Think of a time when you really really needed to go….did you need someone to coach you? Did you need to do anything else other than sit down and relax? Whether you sit on the toilet and practice Olympic pushing or bring a book (men are great at this) the poop still comes out!!! When you think of it how did humans get out of the uterus for the thousands of years before Midwives and Doctors came on the scene? Who is coaching the cows and sheep in the fields or the women who have accidental homebirths or give birth in the car?  I guarantee you those women pushing in the car are sucking their baby in to try to keep the baby there until they get to the hospital.

Mother led pushing is protective for your baby. When you hold your breath for sustained periods of time the oxygen to your baby is turned off (as well as oxygen to the uterus, pelvic floor and perineum).  For most healthy well moms your body does an amazing job at ‘ejecting’ your baby.

What Can You Do to Reduce the Chances of Having a ‘Broken’ Vagina?

• Avoid induction unless medically necessary.

• Practice perineal massage in the 3rd trimester (especially for a first baby).

• Talk to your careprovider about not stretching your vagina and perineum during the 2nd stage with or without an epidural.

• Hire a doula to help you avoid needing an epidural or if you’re planning an epidural a doula can help you change positions.

• No application of mineral oil or Johnsons Baby Shampoo to ‘lubricate’ the vagina (have you SEEN how much fluid and mucous comes out of a vagina in labor?

• Practice saying the words – “please remove your fingers from my vagina”.

• Write your birth preferences down and discuss Prenatally e.g. “I prefer not to have coached pushing but will push with my own urges”

• Have your birth partner advocate for you in labor if a staff member starts instructing you to hold you breath or your careprovider keeps stretching your vagina.

• Ask for more time if you and baby are well.

• Choose an upright birth position or side lying even with an epidural.

• Focus on slow comfortable breathing - let your body do the work.

• If you have an epidural request additional time for 'passive descent’ especially if you and baby are well.  If you have no urge to push let baby come way down to at least +2 station in the pelvis – that way you and your baby are conserving energy while your body keeps nudging baby down.

• Labor in a bath or pool if possible – if not have your doula/nurse/partner use a warm compress on the perineum.  The heat brings more blood flow to the tissues making them even stretchier and it can be a wonderfully soothing. It does NOT cause the tissues to swell (something I hear from some OBs) and there is really great evidence to support this care option.

• Ask your careprovider not to pull on your baby’s head as he is being born. This is a recipe for disaster and very common hospital practice.

Consider a homebirth or birth in a birth center (in 2008 a Swedish study showed a lower frequency of perineal injury associated with homebirths between 1992 & 2004). The risk of perineal/pelvic floor damage was 5 times higher in hospital. Or if possible choose a maternity unit or careprovider with a low rate of episiotomies for healthy moms. 

Of course there will always be exceptions -  sometimes babies come into the world with a hand up by their face or come very quickly and there’s little your careprovider can do in that case. 

Make a point of having a conversation with your careprovider about how they plan to help you to avoid unnecessary perineal injury – because at the end of the day – that’s their job not yours. 

(No matter how your baby arrives – see a women’s pelvic health specialist around 6-8 weeks postpartum for an assessment on your pelvic floor).

Phew - that was a lot. I hope it was helpful. My intention is not to frighten you but to help learn about the reality in many hospitals. But you may have an amazing careprovider who will look at you in shock when you ask them about these practices. I really really hope that that’s the case for you! Remember information is not power - applied information is. Start the discussion - you do potentially HAVE a lot to lose.

I want to hear from you and so do other moms. Does some/all of it sound familiar?

Make sure you read this blog too!