How to avoid perineal damage in the final stage of labour

When you are in the final stage of your labour, you will have an overpowering urge to push your baby out. This may happen suddenly, in the middle of a contraction, and you will start pushing without having any control over it. It is best to wait to push until you have that urge, as it shows your baby’s head has moved right down into your pelvis.

The good thing about this stage is that your contractions are not as painful, so long as you are pushing with them. When a contraction comes, just push when you feel like it, breathe, and then push again. Rest in between contractions. If you have had an epidural you may not feel this urge and the midwife will assist you by telling you how and when to push.

Staying upright will allow gravity to help your baby move down through your pelvis. If this pushing phase seems a little slow, walking may help, or standing with one knee resting on a chair, so that you are leaning slightly to the left or right. Change knees every second contraction.

Limiting damage to your perineum

As part of a study, we interviewed expert midwives in Ireland and New Zealand who were able to assist first-time mothers to birth their babies with very little damage to their perineums (Smith et al 2017 and Begley et al 2019).

Six out of every ten women did not need to have stitches in their perineum. The midwives only needed to do an episiotomy (a cut made in the perineum) for four women in every hundred they helped to birth.

The key things these midwives did was:

• Teach women how to do perineal massage in pregnancy
• Use upright positions for the pushing phase and less upright ones for the actual birth (all fours, or resting back against their partner after being on the birthing stool)
• Use hot pads on the perineum during the pushing stage of labour
• Birth the head very, very slowly over a number of contractions
• Help women to ‘breathe’ the head out without pushing strongly

How can I avoid an episiotomy?

Ask your midwife not to do an episiotomy unless your baby’s heartbeat is causing concern. Use all the tips below to help your perineum to stretch.

1. Once your baby’s head is visible, your partner or midwife can put a pad soaked in hot water on your perineum (the area between your vagina and back passage) to help this area to stretch. The pad should be very warm, not enough to burn but hot enough to be noticeable (they can test it on the inside of their wrist to check). The pad needs to be re-heated for every contraction, so that your perineum is always kept warm.
2. You will feel the baby coming down very slowly, a little more each time you push, and soon you will feel the head stretching your perineum – a burning, stretching sensation, which may frighten you. Remember, it will be OK.
3. Breathe, and consciously relax all your perineal muscles, just like you practised if you did perineal massages.
4. Open your mouth wide, as it is hard to tighten your perineum if your mouth is open. If it is very sore, maybe breathe through the next few contractions without pushing, to give your body time to get used to the feeling. You can breathe Entonox (gas and air, laughing gas) if you like.

Local anaesthetic

If the midwife suggests or recommends doing an episiotomy because they think your perineum is a bit tight, they will give you an injection of local anaesthetic in your perineum. If your baby’s heartbeat is not causing a concern, ask if they will then wait a few more contractions before doing the episiotomy.

Usually, because you no longer feel the burning sensation, you are able to relax your muscles and let the baby’s head out without needing the episiotomy. You want the baby’s head to come out as slowly as possible, to let your skin stretch very slowly and gently, with the hot, wet pads helping. The breathing you will use now is: ‘pant, pant, blow’ or ‘hee, hee, who’.

This breathing is important for you to reduce any chance of a tear to your perineum, and you may need to do it for 5-7 contractions before your baby’s head is born. Listen carefully to your midwife; they will guide you when to push gently, and when and how to just breathe.