When we discuss the clitoris and the perineum – the holy grail of womanhood comes to mind.
We know episiotomy can impact on the function and healing of these two sacred parts of the female anatomy, so it is important for women to be educated on what you can do during labour and birth to reduce or eliminate the risk of tearing and decline routine episiotomy.
Having recently spent time at workshops with both Debra Pascali-Bonaro from Orgasmic Birth who shared her 3D clitoris and knitted “pussy puppet” with us and Dr Rachel Reed from Midwife Thinking where we had lots of discussion and shared resources about the clitoris, but it was clear that the clitoris is still a mystical part of the female body so it was valuable learning mixed with knowing smiles.
Do you know what the clitoris looks like?
When I ask my clients most of them say something like “the little G-Spot in the vagina.”
So let’s delve a little deeper – it is not just that little pea like button of the mons pubis.
This is in fact the clitoral glans – which is the visible part of the whole clitoris that is very sensitive to touch.
The whole clitoris looks like (for lack of a better description) an exotic tulip.
The clitoris is a multi-part system and includes two shafts (called crura), which are around 10cm long that encircle the vagina.
Dr Robert King wrote: “it has at least eighteen distinct interacting functional parts including muscular, erectile, and sensitive tissues.”
MRI studies revealed that most of these structures expand significantly during arousal and the bulbs can effectively wrap about the vagina.
The clitoris is only used for pleasure and there are approximately 8000 nerve endings in the clitoris, whereas men only have 3000 nerve endings in the penis.
We are taught from a young age to disconnect from the pleasure of clitoral stimulation but many women experience orgasm during birth and this is something that should be explored more – how amazing would it feel to experience an orgasmic birth?
Unfortunately, many women who have experienced orgasm during birth keep this to themselves for fear of being shamed or laughed at.
What a long way we have to go in giving women the freedom to express their pleasurable experiences.
The perineum is the area between the vagina and anus, made up of skin, muscle and nerves that stretches incredibly as the baby’s head emerges.
Many women become fearful about the perineum tearing or needing an episiotomy and wonder how their baby is going to fit through their vagina.
The good news is that a woman is less likely to experience tearing if she is breathing deeply and allowing her body to feel calm and relaxed without tension, relaxing her pelvic floor and going with her own urge to push rather than holding her breathe and being told when to push.
During labour the perineum is amazing and stretches and thins as far as it needs to because it is saturated with the hormone relaxin being released by the receptors in that area.
That is one of the amazing things about being a woman is that our body has been designed to do what it does so beautifully during an undisturbed labour and birth – stretch and open.
If a woman is given the opportunity to birth naturally without being induced or augmented, then her perineum will stretch gradually, slowly and gently the way it has been designed to do and is less likely to experience any trauma.
When the head is crowning the woman may feel a burning type of sensation, but if they are practicing their breathing techniques, then many times that burning is not felt – all women are unique and wont always have the same experiences.
This burning sensation is like what you would feel if you stretch the corner of your mouth with your fingers – the tissue of the corner of the mouth is similar to that of the perineum.
Try that now – stretch the corner of your mouth until you feel it stretching and “burning” and that is what a woman may experience during childbirth.
Midwives may also reduce the risk of tearing by using warm compresses on the perineum when the head is presenting.
Here is a video by Professor Hannah Dahlen from University of Western Sydney demonstrating how midwives can prepare and use a warm compress.
Episiotomy versus tearing
An episiotomy is a surgical cut through the perineum to make the opening larger.
It is done on stretching tissue and muscle and this is very different to an incision that you would have during general surgery.
When a woman has a medio-lateral episiotomy (so diagonally across rather than down towards the anus), the midwife or obstetrician will cut through not only the nerves, tissue and muscles of the vulva but also the clitoris shaft, which is known to cause sexual dysfunction after birth.
During birth the perineum is flooded with relaxin and is designed to stretch and with the right position and breathing this reduces the risk of tearing or need for an episiotomy.
There are also oxytocin receptors in the perineum and during an episiotomy these are cut through, which leads to five times increase in a postpartum haemorrhage and could also interfere with breastfeeding.
An episiotomy leads to more pain, longer recover and more sexual dysfunction.
Tears heal better because they are along the muscle lines and not a straight edge.
Not all women will tear – but if she is routinely cut, then she is cut.
Ask your Obstetrician what they consider to be a reason for an episiotomy.
A highly skilled Obstetrician is one who can do an instrumental birth without the necessity for an episiotomy – there are good Obstetricians out there – you just have to ask the right questions.
As mentioned previously, positioning and breathing reduces the risk of tearing.
As Dr Sarah Buckley mentions in her Gentle Birth Gentle Mothering book “nature has a plan” so we should not be interfering with the process.
Research has shown that episiotomies cause more pain, trauma, blood loss, sexual dysfunction and takes longer to heal compared to a natural tear and unless there is a medical need to do an episiotomy then there were no benefits and more harm associated with it.
Yet even though we now have many health bodies advocating for episiotomies to only be conducted when absolutely necessary the episiotomy rate is still high, even in Australia.
Professor Hannah Dahlen from the University of Western Sydney states that:
An episiotomy is more likely when:
- Having your first baby
- Having a forceps or vacuum birth
- Having a long second stage
- Having an epidural
- Giving birth lying on your back, especially with legs in stirrups
- The baby’s head is in an abnormal position
- The baby is very big
- You have a private obstetrician as your care provider
An episiotomy is less likely when:
- Having your second or subsequent baby
- Giving birth in a side lying or upright position
- Perineal massage has been done in the late stages of pregnancy
- Your pelvic floor is relaxed
- You birth the baby’s head slowly or between contractions
- You have a baby in a birth centre or at home
- You are cared for by midwives you know and have good support
Rachel Reed from Midwife Thinking says:
“An episiotomy does not prevent a tear from occurring, instead it increases the chance of a third- or fourth-degree tear (involving the anal sphincter). A Cochrane Review has summarised the research in this area. Even in obstetric guidelines an episiotomy is not recommended as a way to protect the perineum during birth. Although an episiotomy is easier to suture, a natural tear is less painful and heals quicker. The only excuse for cutting an episiotomy is for an instrumental birth (and not in all cases) or for a baby who needs to be born quickly.
What does the Cochrane Review say?
“In women where no instrumental delivery is intended, selective episiotomy policies result in fewer women with severe perineal/vaginal trauma. Other findings, both in the short or long term, provide no clear evidence that selective episiotomy policies results in harm to mother or baby.
The review thus demonstrates that believing that routine episiotomy reduces perineal/vaginal trauma is not justified by current evidence. Further research in women where instrumental delivery is intended may help clarify if routine episiotomy is useful in this particular group. These trials should use better, standardised outcome assessment methods.”
My name is Vicki Hobbs and I am a Childbirth Educator (Back to Basics Birthing), Hypnobirthing Australia Practitioner, Certified VBAC Educator, Remedial Massage Therapist specialising in Pregnancy & Postpartum Massage, Birth & Postpartum Doula, Certified Placenta Encapsulator, Hypnotherapist, Aromatherapist, Reiki Practitioner and Life Coach. I am a serial workshopper and learner, so that I keep up to date with new research and information so that I can provide you with up to date resources. My focus has always been on the mind, the body and the emotions and how they all need to be in balance for harmony. You can subscribe to my newsletter by adding your details in the box on the right-hand side and when you do I will send you a free relaxation meditation to help you feel calm and relaxed. I am based in the northern suburbs of Perth and can be contacted by email at [email protected] or phone (08) 9303 9111 or click here to go back to my Blog Page for more great articles and information.