Reality TV fans (not me) and readers of the Celebrity Baby Blog (OK, that's me) may have heard that Kendra Wilkinson of The Girls Next Door "fame" is expecting her first baby this winter. In addition to the news that Kendra's ex, Hugh Hefner, will be the baby's Godfather (ick!), CBB readers were treated to some early news on Kendra's wishes for her labor and birth.

"I'm getting an epidural, everything they can give me, "she reports. "That's the one thing I'm nervous about the most. Everything else is so fun, but I have visions of my vagina tearing, and that sucks."

A red flag popped up when I read this. An epidural is about the last thing I would recommend to someone who was nervous about her vagina tearing. Why? Because if there is one thing that no one disputes about epidurals, it is that they increase the need for forceps- or vacuum-assisted delivery. And instrumental vaginal birth is not good for vaginas.

It seems to me Kendra wants her cake and to eat it to. Either that, or she has very unrealistic expectations of what an epidural can and cannot achieve. But Kendra shares a concern with many women (albeit, whose careers may be less wrapped up in their sexual and reproductive organs) who want to preserve their genital integrity in birth. With this in mind, I thought I'd take this opportunity to share some tips, supported by scientific research and a little common sense, on how to protect against genital tract injury in childbirth.

1. Choose a provider with a low episiotomy rate - under 5%. Research confirms that your provider's episiotomy rate is the single strongest predictor of whether you will have one. Episiotomies, by definition, cause injury to the tissue of the vagina and perineum. They also predispose women to severe injuries that involve the anal sphincter. A large body of research tells us that midwives use episiotomy less than doctors do, but there is much variation in episiotomy use across midwives, too, so it's best to ask.
2. Choose a provider who rarely uses a vacuum or forceps. In studies of first-time mothers, the rate of instrumental vaginal delivery in women without epidurals has been reported to range from 4-60%. This huge variation can only be explained by factors that have nothing to do with women and babies (arbitrary time limits, the provider's attitudes, etc.). If instrumental assistance is needed to get the baby born safely, choose a vacuum rather than forceps.
3. Give birth off your back and follow your own pushing urges. Studies show that giving birth on your back and "purple pushing" can increase the chance of an instrumental vaginal birth, an episiotomy, or both. Letting someone push on your abdomen while you give birth (fundal pressure) increases the chance that a tear will extend into the anal sphincter muscle.
4. Avoid continuous electronic fetal monitoring unless there is a good medical reason for it. It increases the chance of instrumental vaginal birth.
5. And again, plan to give birth without an epidural because of the much higher risk of instrumental vaginal delivery that comes along with an epidural. If you do have an epidural, wait for an hour or longer after you are fully dilated to begin pushing, unless a strong urge develops sooner. This practice of "laboring down" decreases the chance of instrumental vaginal delivery and reduces the likelihood and severity of lacerations. It's also safer for babies.

I've said it before and I'll say it again: epidurals may make coping with labor pain easier, but they often make labor itself much more difficult. The urge to push may be decreased, delayed, or absent. And epidurals increase the chance that a baby will settle into the pelvis facing toward the mother's front or side (occiput posterior or transverse), which makes it much harder to push the baby out. If a baby gets stuck in this position, a vaginal birth is very difficult to achieve and if the baby does come out vaginally, a severe laceration is likely. Women who want epidurals must be told of these trade-offs, and women who want to optimize their chance of a safe vaginal birth with minimal or no tearing must be given the full range of pain relief options and care that maximizes comfort to reduce the need for epidurals.

As for what women or providers can do proactively to avoid genital tract trauma, the research here has come up rather short. Whether the provider has her hands on the perineum or not, whether lubricants or warm compresses are used, and whether the woman performs perineal massage prenatally all have minimal if any effect. One approach that was found to be statistically associated with a reduction in trauma is birthing the baby's head between contractions. A team of midwifery researchers in New Mexico reported this finding and concluded the following:

To deliver the fetal head between uterine contractions requires a joint effort by the mother and her clinician to achieve a slow and controlled expulsion of the baby, requiring patience and effective communication from the clinician. In these data, a calm and unrushed approach to vaginal birth improved the health of new mothers by lowering overall trauma rates and reducing the need for suturing. (Albers 2006, p. 99)

This reinforces points #1 and #2 above: Choose your provider wisely.

Still not convinced? Or think that a c-section is the answer? Childbirth educator, Mamarama, gives the straight talk on that myth. Hat-tip to A Much Better Blog for passing on the link.

Click on the extended post to see a bibliography.

Bibliography

Albers, L. L., Sedler, K. D., Bedrick, E. J., Teaf, D., & Peralta, P. (2006). Factors related to genital tract trauma in normal spontaneous vaginal births. Birth, 33(2), 94-100.

Alfirevic, Z., Devane, D., & Gyte, G. M. (2006). Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews (Online), 3, CD006066.

Lawrence, A., Lewis, L., Hofmeyr, G. J., Dowswell, T., & Styles, C. (2009). Maternal positions and mobility during first stage labour. Cochrane Database of Systematic Reviews (Online), (2)(2), CD003934.

Lieberman, E., Davidson, K., Lee-Parritz, A., & Shearer, E. (2005). Changes in fetal position during labor and their association with epidural analgesia. Obstetrics and Gynecology, 105(5 Pt 1), 974-982.

Lieberman, E., & O'donoghue, C. (2002). Unintended effects of epidural analgesia during labor: A systematic review. American Journal of Obstetrics and Gynecology, 186(5 Suppl Nature), S31-68.

Roberts, C. L., Torvaldsen, S., Cameron, C. A., & Olive, E. (2004). Delayed versus early pushing in women with epidural analgesia: A systematic review and meta-analysis. BJOG : An International Journal of Obstetrics and Gynaecology, 111(12), 1333-1340.

Simpson, K. R., & James, D. C. (2005). Effects of immediate versus delayed pushing during second-stage labor on fetal well-being: A randomized clinical trial. Nursing Research, 54(3), 149-157.

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