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To Cut, Delay or Tear~ that is the ?

Fetal Heimlich Manuever | Intact Perineum | Episiotomy Free Birth

I present to you, the Fetal Heimlich maneuver! I was fortunate to capture this amazing photo and even more thankful my clients agreed to allow it to be shared. It's a natural phenomena in which the intact mother's perineum pressing inward on the baby's ribcage, naturally expelling any mucous/fluids in baby's mouth and nose. Even today, few are aware of the Fetal Heimlich maneuver, its benefits and reason to help prevent medically unnecessary episiotomies or extensive tearing whenever possible.

We can not prevent all tears or necessity of episiotomy, but we can support mom's perineum during crowning with use of oil, perineal massage and hot compress. We can also help mom slow those last few pushes down. We can allow mom to choose a more favorable pushing position for her body and comfort level. And no doubt, with the expertise of a fabulous midwife, increase the success rates of protecting more women from what could possibly have been preventable damage to their perineum.

Tina Moreno, CNM works her magic helping keep perineum intact

I have had the pleasure in now three states, to witness some of the finest midwife work. Allow me to brag on a few... above the amazing Tina Moreno, CNM with her awesome work and support. I have had numerous first time moms have a completely intact perineum with their first baby! Some of my new favorites, here in Athens, Ga, Hillary Midler, CNM & Hannah Turner, CNM they both have remarkably has assisted several of my GA birth family in avoiding damage to perineum... thank you Hillary & Hannah for your dedication to support baby & bottoms! The "until you witness it first hand, you wouldn't believe it" work of Tina Hayes, CNM... I dubbed her the Leonardo da Vinci of birthing. I compare her skillset of protecting the perineum to that of painting the Mona Lisa down below. It's a process full of patience and coaching that works for skilled midwives for many years.

Tina Hayes, CNM catches and relieves two loops of nuchal cord

Another, controversial topic is the difference in how a skilled midwife handles a nuchal cord as shown below. Some OBGYN's will immediately clamp and cut to free nuchal cords, where as many skilled midwives & OB's will birth baby, if all possible and simply unwrap the cord after birth. The cord is full of what is known as Wharton's jelly, a substance which insulates and provides protection within the umbilical cord. Remember, as long as your placenta has not detached, your baby is receiving oxygen from the cord (not mouth and nose) until the cord is cut. At that time, baby must take its first breath. Ready or not.

Did you know, even to current date, we sometimes shockingly witness OBGYN's and even on a rare occasion a nurse midwife, who flat out refuses to perform preventative work? We have heard everything from "No", to "No that's what the baby does", to "you are going to tear into your rectum if you don't let me cut you" (while still forcing the mom to remain flat on her back and refusing to do the work which could prevent damage)?? And, we are not just referring to epidural clients who have little to no use of their legs for other positioning. I've even experienced an OBGYN who spoke the words (when my client reaffirmed she was told she could choose her position), "of course, you can choose your pushing position". What followed was my being bumped from the bedside so, that the nurse could step in and assist the doctor in his way of birthing. Then, as a helpless doula, I had the unfortunate pleasure of watching as he physically pulled the pee pad underneath her, until he had her exactly where he wanted her and all while the head was emerging. He had physically pulled off her side to flat on her back. I was shocked as he continued zero support to baby's head, even after birth of head completely took both hands off allowing the baby to rest solely on her perineum as he clamped & cut while Dad said we wanted delayed cord clamping. We entered the hospital at 9cm, walked to the room, she had a beautiful experience up until this point. The OBGYN maybe spent 10 minutes in the room prior to birth and sadly, my client had to be taken back minutes after giving birth drug free to the operating room to undergo extensive repair under general anesthesia. If you are a provider, don't misconstrue this message, we are not expecting you to work miracles, nor are informed clients unrealistic, we simply are asking, Please just PERFORM THE WORK that is within your power to help prevent damage. In other wards, be open to change and supporting the perineum. Your clients will rave about you, even if a tear happens if you can encourage and be mindful of the wishes of those who are paying you for a service. And, refer their friends!

Readers, these extreme examples do not reflect all practitioners, nor a specific title, there are still very good OBGYN's who will do all they can to help prevent damage. I even literally coached a Charlotte OBGYN (like a cheerleader) into protecting my clients bottom. He was such a team player and couldn't believe she had labored drug free and had a successful vaginal birth of what an ultrasound considered too large to birth vaginally. In fact, with the use of oil, compress and support Dr. Lucas was able to birth her 10lb baby boy, with her perineum in tact and just two stitches! Now, that's an awesome OBGYN!

Be mindful of the following:

- You are paying your providers for a service~ choose wisely.

- Tailor sit often, practice deep squats/ natural stretching of the area, avoid soap and other drying agents which can destroy your body's natural PH and oil glands.

- Consider including your preference of perineal support/massage on your birth plan.

- Laboring down and pushing in a position utilizing gravity can help.

- Oil and massage with controlled breathing/positive pushing techniques can help.

- Your midwife or doctor does not typically remain bedside throughout hard labor.

In many hospital births, we may not see a provider until toward the end of push phase closer to crowning.

- An episiotomy can potentially shorten push phase, however, we typically tear in addition to, or as head emerges extend the original episiotomy.

- We typically tear around blood vessels.

- If ever there is a fear of upward damage into the clitoral area, choose wisely, with the episiotomy, at least one of the benefits is to try to direct in which way the tear goes.

- If mechanical assistance is necessary, most common is vacuum extraction or forceps. In the past, episiotomy was most commonly performed in combination with use of forceps due to the size of forceps blades entering the birth canal.

- In unique circumstances, an episiotomy could potentially spare a mother a C-section (if baby in trouble) and/ or shorten push phase.

Remember, we can't prevent all tearing or necessity for avoiding episiotomy with good positioning and proper push techniques, but even in unusual situations we can attempt to limit excessive damage. In the best case scenario, prevent tearing all together, provided your baby does not enter the world with a hand under its chin or an unusually large head size, of course. It is imperative you choose a practitioner who will honor your preferences, do what is medically best for you and your body and not simply choose a position that's easier for them. Make no mistake, if your definition of a happy "birth" day includes some personal preferences, IT MATTERS WHERE and WITH WHOM YOU BIRTH. There are no re-do's. There is a difference in a provider who says they will support your wishes, who goes along with your birth plan and those providers who actually go above and beyond to encourage their clients to achieve their birthing goals. Education matters, Preparing your body and training matters. Once you know your birthing options, you can best determine where to birth. For example, you desire use of tub or water birth, that will narrow your choices of where. Once you determine where you desire to birth, ask around for supportive provider referrals online, in various mom groups, LLL mtgs., call your local Doula's and Childbirth Educators and ask any nursing friends who they might recommend that aligns with your preferences. Find the provider that's right for you- everyone benefits from a little homework!

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