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Nitrous Oxide – the “other” pain relief option

by Dr. EeVon Ling, ND

** At the time of this writing, COVID-19 policies have restricted the use of nitrous oxide in some birth settings. Inquire with your birth location if this option is available to you. 

What is it? 

Laughing Gas for pain relief?

Nitrous oxide (N2O). Aka “Laughing Gas”, “Gas”, “Nitrous”, “Entonox” (Brand name). 

It is a colourless and nearly odourless gas that is a chemical compound and mixture of nitrogen and oxygen. It has both analgesic and anesthetic properties – meaning it can reduce or alter pain sensation and pain perception.  You may know about nitrous oxide because of its wide use in dentistry. It is the same gas, but the concentration used during labour is much less. 

I haven’t heard much about Nitrous Oxide. Is it common in labour? 

You may be surprised to learn that N2O is the most commonly used form of analgesia in childbirth around the world. 

Historically, N2O has been in use for more than a hundred years! It was widely used in US hospitals for childbirth in the 1930’s – 1950’s. By the 1960’s, epidural use sharply overtook as the primary choice for pain relief and N20 use would pretty much disappear from labour and delivery in the US. But more recently in Canada, its popularity has increased as a pain relief option.  A survey in 2006 found that about 1 in 5, or 20%, of women who gave birth in Ontario used N2O for pain relief. In comparison, the rate of epidural use is about 50-60%. 

Is it as good as using an epidural for pain relief?  

The short answer is “no”. 

It does not replace getting an epidural in terms of pain relief. An epidural is meant to completely take away pain to the point where you usually don’t even know when you are having a contraction or not. Because N2O doesn’t take away pain like an epidural, I have noticed that OB’s and nurses don’t mention it as an option to clients, even to clients that express that they want to labour without an epidural. They don’t consider the value it may offer and in fact, I’ve heard OB’s tell my clients that nitrous oxide “does nothing”. This thinking is a result of comparing N2O with an epidural, but it is a great disservice to completely dismiss it as a useful coping tool.

The more thoughtful answer is that nitrous oxide is a “good enough pain relief”. The following are quotes from my own clients who used nitrous oxide as their main pain relief: 

“It helped take the edge off”

“It helped take the edge off” 

“It made me care less about the pain”

“Breathing through the tube helped distract me” 

“It helped me relax more and focus” 

“It helped me birth without an epidural”

“Without it, I would not have been able to have my homebirth”

“I think it made me a little giddy”**

In some cases, clients have used N2O while waiting to get an epidural or when they are receiving stitches on their perineum post birth. 

What can I expect if I use N2O? 

Begin use at the beginning of a contraction

Where available, it is used in a hospital or birth centre setting, and occasionally some midwife groups have it available for home births (check with your midwife or birth location for availability). It is administered through a tube with a face mask attached. When you are in labour, you hold the mask to your face and deeply breathe in the N2O at the very beginning of or in anticipation of a contraction. The maximum concentration is reached within 60 seconds so you continue to breathe the N2O gas until the contraction ends. Once the contraction is over you take the mask off of your face. Repeat this for each contraction if you continue to use it. If you’ve learned breathing exercises for labour (which I highly recommend that you do, either through a comprehensive prenatal program, HypnoBirthing or through our own Confident Birth Prenatal program), the deep breathing that you’ve been practicing is perfect for using with N2O. 

It is quick acting with the effects felt almost immediately. As described above, N2O does have the ability to alter the way you perceive and feel pain. It doesn’t take away pain like an epidural, but it can help increase your ability to cope with it. 

At the biochemical level, N2O alters levels of certain brain chemicals. It reduces those neurochemicals that activate pain (N-methyl-D-aspartate, NMDA for short) and increases neurochemicals that increase endorphins and make us feel good (dopamine, norepinephrine, endogenous opioids). It has the ability to produce a sense of euphoria and occasionally psychedelic effects. (**Yes, I’ve observed a couple clients get a little “high” while using N2O, all to their benefit)

You are able to remain alert and have full control of your body (no numbing effects). You don’t need an IV or continuous fetal monitoring, you can move freely and use the washroom, and you can eat and drink as normal. 

If you don’t think the N2O is helpful, or if you start to feel drowsy or dizzy, you simply stop using it and it leaves the body within 30 seconds.  Being able to fully control how and when you use N2O is seen as a big benefit to using this option. 

Studies of thousands of people who used N2O during labour (compared to placebo) report 

N2O helps by increasing endorphins
  • Decrease in pain perception
  • Decreased anxiety
  • Increased sense of control
  • Increased satisfaction

That said, when compared to epidural use, women were much less likely to rate N2O as effective pain management compared to those who used an epidural. But when compared with no pain relief or placebo, there was better pain relief reported with N2O use. Reported levels of satisfaction were about the same among epidural users and N2O users. And most N2O users said they would have used it again. Again, highlighting that N2O doesn’t replace using an epidural, but it may still be a very useful measure for those who want to birth without an epidural. 

Is it safe for my baby? What are the side effects? 

Some nitrous oxide does cross the placenta, however, it is safe for both you and baby when used in labour in a full-term pregnancy. It is not recommended in preterm labour as there is increased risk of brain hemorrhage for the preemie baby. Care providers may recommend using N2O only when you are in active labour (cervix is dilated 6cm or more) to reduce excess exposure to the gas. 

N2O is safe for baby when used in active labour

Otherwise, the use of N2O has not been found to affect APGAR scores in babies (the initial assessment of well-being for the newborn) and does not slow down labour or increase risks (such as interventions or c-sections) for the pregnant parent. That said, no long term studies of nitrous oxide on both the parent or baby have been conducted (in fact, no long term studies of many interventions in birth exist). From a biochemical point of view, N2O exposure can decrease levels of vitamin B12. Vitamin B12 is an essential nutrient for blood, nervous system and metabolic functions. It is found in animal-based foods such as meat, eggs and usually included in prenatal vitamins. If levels of vitamin B12 is a concern, this is something that can be addressed post birth with your naturopathic doctor. 

Potential side effects (from most common): 

  • Nausea 
  • Vomiting
  • Dizziness
  • Drowsy
  • Reduced sense of awareness
  • Reduce feelings of being present; Increases feeling detached from situation 
  • “Mask phobia” from using the mask on their face

Bottom-line: 

Nitrous oxide, if available, can be helpful during labour. It can be used as your main coping strategy (along with massage, relaxation exercises and breathing techniques) or be a helpful tool as you wait for an epidural or even be used immediately post birth if you need to receive stitches for your perineum. 

We at Your Downtown Doula are fully supportive of your choices in birth. We act as your source of information so that you are fully aware of the options so that you can make good decisions for yourself and your baby in labour. We have attended births where parents chose N2O, epidurals or other means to cope and in the end, positive births can happen no matter how you decide to journey towards parenthood. 

Want to learn more about how a doula can be a valuable support to you during pregnancy, labour, childbirth and beyond? Book a free 15 min meet and greet with one of our Naturopathic doctors and doulas today! 

Dr. EeVon Ling, ND

Resources: 

https://www.contemporaryobgyn.net/view/nitrous-oxides-revival-childbirth

https://evidencebasedbirth.com/nitrous-oxide-during-labor/

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Considering a VBAC*? You Need to Read This!

Dr. Ee Von Ling, ND

*There is a shift towards using the term TOLAC (Trial of labour after C-section) instead of VBAC (Vaginal Birth after C-section). In many ways this term is preferred, less emotionally loaded and less cumbersome than using VBAC. Thus, I will be using both VBAC and TOLAC interchangeably in this post. 

One of the very first births I attended as a new doula was a home VBAC. The parents had taken my HypnoBirthing classes and requested me to be their doula. At the time I was just so excited to be going to a home birth that I didn’t even think about the significance of this being a TOLAC.

The mother told me her birth history and the events that had led up to her c-section – “failure to progress at 9cm”. I took all her info and simply reassured her, “every pregnancy is different and so this will be a different experience than your first one”. And it was different. Amazingly different. The labour and birth progressed just like any other normal labour and birth and the mother had her successful home VBAC!

This VBAC homebirth imprinted on me that VBACs were no big deal and they were just like any other birth.

It wasn’t until I started having more conversations with pregnant clients and doctors and reading comments in mommy forums and news articles that I would realize that VBAC’s were seen as A. BIG. DEAL. Words like “highly risky”, “uterine rupture”, “endangering baby”, “dangerous for mom”, “irresponsible” almost always accompanied the VBAC discussion. It was bad enough that women had fear of normal labour and birth itself, but having a past c-section somehow put a whole other layer of fear and worry on top of that.

So I double checked the evidence and the statistics around VBAC and risks and benefits.  Contrary to the conversations, the numbers showed that a vaginal birth after a previous c-section was a reasonably safe and healthy choice for most women. The absolute risks were very low and the success rates for attempted VBACs were actually quite high. In fact, the risks for a planned repeat c-section were worse. If you’d like to learn more about the pros, cons and risks around attempting a VBAC, you can read this very excellent handout created by the Ontario Association of Midwives here.

Over the last several decades VBAC rates have gone up and down. According to US statistics, In the 1990’s about 30% of those who had a previous C-section attempted a VBAC. Today that number is about 13%. These numbers have fluctuated because of changes in the practice guidelines of obstetricians. VBAC births themselves did not become more dangerous, but practice guideline updates recommended more medical requirements in order to offer them. These changes influenced the perception and accessibility of attempting VBACs – OB’s became less supportive of them and the public developed a bigger fear of them. Understand that the risks and outcomes for those who attempt VBACs did not change in the last 40 years. 

Being able to go through a trial of labour after C-section might be a very significant and impactful choice. For some, being able to vaginally birth helps them to heal a previous birth trauma and reclaim the birth experience for themselves. As a medical industry, we should not take the personal decision to try for a VBAC lightly and we should provide unbiased information and support for that person. 


If you had a previous C-section and are now considering a VBAC for your next childbirth, here are 6 things you can do to help improve your chances of birthing your baby vaginally: 

  1. Choose a supportive provider: This might be the most important factor of all. Having a midwife improves your chances of giving birth vaginally and with fewer restrictions around VBAC. If you are not able to get a midwife, make sure your OB is VBAC supportive. How will you know if they are VBAC supportive, ask them outright: 

  • Are you supportive of VBAC?
  • What is this hospital’s TOLAC rate? How many of your own patients chose TOLAC and how many of those result in VBAC?
  • What would be your advice around increasing my chances of achieving a VBAC?

You will get a sense of their own attitudes and biases based on how they respond to these questions. 

  1. Learn techniques so you can labour at home for as long as possible: Choose a program that includes learning and practicing breathing exercises, visualizing, releasing past fears. Our clients who have been able to VBAC took HypnoBirthing classes, listened to positive birth podcasts, read books about empowered birth by Ina May Gaskin and Penny Simkin. From our own collective experience supporting our own VBAC clients, we teach a special condensed version of our  Confident Birth Prenatal Program that focuses just on the relaxation exercises and techniques to help you be calm and confident during labour.  

  1. Ensure the baby is in a good position: Head down is not enough!  Baby’s position with their back on the left side so you feel kicks or the big movements on the right (referred to as LOT) or baby’s back is in the front so you don’t feel a lot of kicks or movement elsewhere (referred to as OA) are the ideal starting positions for baby. A baby in the posterior position (or OP or “sunny side up”) may have a harder time being born vaginally. Perhaps during your previous birthing the baby was in this posterior position, which can lead to slow or arrested labour. 

There are ways to help encourage a baby to get into the ideal starting position for birth. Daily positional awareness, acupuncture, massage, chiropractic, osteopath and physiotherapy treatments may help. 

  1. Get your labour to start naturally: If you labour starts naturally, this will help you avoid further interventions that might increase the risks of a TOLAC. Speak with your midwife or doula about ways to start labour that are safe for those who’ve had a previous c-section.

  1. Try to avoid an epidural: An epidural can limit movement and slow down labour (if started early in labour). If labour slows down, then artificial oxytocin will be needed to help progress the labour. But using artificial oxytocin in someone who had a C-section increases the risk of having a VBAC (ie. scar separation). This is why learning good coping techniques and having a doula can be very helpful. That said, if you need an epidural to help you have a positive birth experience, then by all means, choose that for yourself! 

  1. If you have an epidural, use a peanut ball: Even if someone has an epidural, there are tips and tricks to help increase your chance of a vaginal birth. A peanut-ball is a peanut shaped exercise ball that can be used in a variety of positions to help open up the pelvis and positively influence the positioning of the baby as it’s being born. 


Beware the “VBAC calculator”! Recently, I have been hearing about care providers using a “VBAC calculator”. Different factors about the pregnant person are inputted into an algorithm that is supposed to predict the percent chance of having a vaginal birth. The use of this is a HUGE RED FLAG to me, and if this becomes part of routine OB and midwifery practice I fear that VBAC rates will decrease even further. 

What is wrong with these calculators? 

First, the database of information that these calculators use is from observational data of a specific patient population. The one that care providers in Toronto have been known to use is from a patient population in the United States. American birthing patients and American birth management practices are very different from the birthing patients and birth management practices in Canada. VBAC rates in the US are much lower than VBAC rates in Canada. A hospital with low VBAC rates will produce patients with low VBAC rates and vice versa. So you can already see a discrepancy in applying such a calculator on a random patient. 

These calculators are not evidence based, meaning no study has been done to test the impact of using these calculators to accurately predict actual VBAC success, we also need to study how these calculators impact decision making in both the OB and the patient. 

We are well aware that there is bias in the practice of obstetric medicine, meaning, if a care provider is personally biased in the management of a particular patient, it greatly influences the outcome for that patient. For example, if this VBAC calculator happens to calculate a low success rate, then that can influence the OB to assume that the patient’s attempted VBAC will end up in a c-section. 

Here is a link to an article that explains the research that critiques the use of VBAC calculators.

In any case, the American College of Obstetricians and Gynecologists had this to say about VBAC calculators: “… population-based statistics cannot accurately predict an individual’s VBAC success odds….It is ill-advised to use statistics as a primary indicator when making VBAC decisions.

The role of a doula in your plan to have a TOLAC: The good news is, a doula can navigate at least 5 out of 6 of the positive factors listed. Having the presence of continuous and on-going support from a doula is supported by research to help you avoid a c-section (whether it’s your first childbirth or an attempt at a VBAC). If you are interested in learning more about how a doula could be an integral part of your VBAC team, book a free meet and greet with us today!   

Dr. Ee Von Ling, ND

Want to get prepared for pregnancy, birth and postpartum? Grab our free Bump to Baby Checklist! This clear and thorough guide walks you through everything to expect from your first trimester to past your 6 week postpartum check up.

  • What tests and screenings will be offered and when
  • When to sign up for prenatal education and what types to consider
  • Things you should think about that your care provider may not mention
  • Links to helpful resources

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Things Your Care Provider Can’t Predict

by Dr. Ee Von Ling, ND

Care providers of pregnant people (OB, midwife, nurse and MD) seem to take pride in somehow being able to predict the future of your labour and childbirth. Do they have a special sense or skill set to be able to do this? 

No.  

They are regular humans just like you and me and they are NOT able to predict very much, if anything at all. But they will have you believe that they can. 

Here is a list of the most common things that your pregnancy care provider may try to predict but they cannot possibly know the absolute future: 

  1. When your labour will start. There is no way to know when your labour will start. Not by the size of your pregnant belly. Not if this is your first or second or 5th pregnancy. Not even if they check your cervix at 40 weeks (if you are still pregnant). And yet, we will hear of care providers telling clients that they will have their baby early or go past their due date purely on a personal hunch. 

Did you know that medicine and science don’t really understand how labour spontaneously starts? This always blows my mind because we certainly have many methods of artificially starting labour. We just don’t know the exact mechanism that causes your body to start its own labour. We do have some understanding that the baby influences the start of labour, and this makes sense. When your baby is mature enough to survive and thrive outside, their body secretes proteins from their lungs and brain that can eventually make their way into your blood circulatory system and to your brain. In the brain these signals received from the baby trigger the production of different hormones that prepare and perhaps trigger the body to start labour.  

Around your due date, your care provider may offer to check your cervix. This check is optional and only gives us a snapshot of what is going on with your pregnancy at that moment. Even if your cervix has changed and is showing signs of getting ready (getting soft, moving from posterior to anterior position, starting to dilate by 1 or 2 cm), we can’t tell when labour will start. Even if your baby is low in your pelvis, there is no way to predict when labour will start. 

There is no way to predict when labour will start if this is your first pregnancy or subsequent. Many people hear that first babies come late, and statistically this is somewhat true. According to the US childbirth data available, by 5 days after the due date, 50% of babies of first time parents will be born, and the other 50% are born after this time. What about subsequent babies? By 3 days after the due date, 50% of subsequent babies are born and the rest are born after this time. 

What does this mean? We are born procrastinators (you may groan now). 

There is no way to predict when labour will start according to family history or within the birthin history of the same person. Each pregnancy is different, and this includes when labour will start. That said, research has been able to find some factors that may increase the chance of preterm labour. Some of those factors are genetic and some of those factors are environmental (for example nutrient deficiencies, illnesses, smoking, drinking alcohol or doing drugs while pregnant). 

It may seem harmless to tell a pregnant person that their baby will come early or late. But for that person, such baseless comments can cause unnecessary stress or even cause that person to make pregnancy or childbirth-based decisions that may not be healthy and are certainly not warranted. 

  1. The size of your baby. The only way to get an accurate assessment of your baby’s weight is to weigh the baby after they are born. There is no accurate way to know the exact size of your baby before that. Not by the size of your belly. Not by the amount of weight you have gained. Not by ultrasound assessment.

It is pretty common, although not actually considered a standard part of prenatal care, to be told to get a 3rd trimester ultrasound. The main reasons are to assess the growth of the baby (read: size), amniotic fluid levels and general health of the placenta. Parents will be told, “Your baby is 1234 g”. The care provider might run with this info and say “based on this, your baby will be 4567g at birth. That will be a big baby! You will likely need a c-section”. Then they turn around and leave the room, leaving the pregnant person VERY DISTRAUGHT. 

There is a lot to undo here. First, ultrasound weight measurements are very inaccurate, with at least a 15% margin of error. The inaccuracy of ultrasound to measure weight WORSENS as you get closer to the due date, by at least 20% margin of error. There is no other professional industry that would accept such a high margin of error. Could you imagine if an engineer used tools with such a high margin of error? “I think this bridge will be 50 metres long, give or take 10 metres”. Or if your pharmacist said, “The dose of this medication is 100mg give or take 20 mg”.  Even with acknowledging the margin of error, it is very hard for parents to “unhear” that they may have a large baby. Thinking that a baby is going to be a certain size most definitely influences medical decisions around early induction and choosing c-section.I have had clients choose a c-section based on “big baby” predictions, only to find out the baby was a very average 7-8 pounds. 

Growth in pregnancy is not linear. This means that a snapshot of what is happening now cannot predict what will happen in the future. Weight gain often happens unevenly throughout pregnancy. You or the baby might gain most of your weight during 1 trimester and not as much the next trimester. As long as the placenta is healthy, some babies might be 80 or 90 percentile for weight during much of the pregnancy (according to ultrasounds) and then end up being 50% for their birth weight (real life weight).  

Let’s also not underestimate the amazingness that is your body. I have attended births where the parent vaginally birthed (and often without an epidural), 9, 10 and almost 11 pound babies. We just had no idea of the baby’s weight and just focused on her being able to birth her baby. 

Don’t get me wrong, ultrasounds can be a useful tool to track trends in a pregnancy. We can track over a series of ultrasounds that a baby is growing well, or not well, or is trending on the upper end of the weight charts. We cannot make such a guess based on just one ultrasound picture. Even so, there will still be surprises at birth. No technology that currently exists is perfect. 

Ultrasounds aside, any other comments on a person’s weight related to baby’s size should stop as there is no relationship between the two. In fact, let’s just stop comments on the size of people’s pregnant bodies altogether.  

  1. How long labour will last or how it will progress. When labour starts, your miraculous body is working to eventually accomplish a few things: a) Softening and thinning out the cervix from the firmness of your nose to the stretchiness of a piece of very thin spandex material; b) Drawing open the cervix so that it is fully dilated and “gone; c) shifting the muscles towards the top of the uterus so that they can better move the baby down into the vagina; d) Moving the baby around the pubic born to e) emerge and be born out the opening of the vagina.

There is absolutely no way to accurately predict how long any of these stages will take. Checking the cervix and the station of the baby (how far down they are in relation to a specific point in the pelvis) are a couple of the ways to assess how the labour is progressing. The softening of the cervix (step a) is expressed as a percent with 100% being completely soft and stretchy like a piece of spandex. It takes a lot of work for this to happen and it needs to happen in order for the cervix to open fully. Sometimes the cervix effaces completely first and then the cervix starts to dilate. So if the cervix is only minimally dilated (say only 1 or 2 cm) but it is 100% effaced, that is still a very good sign because the cervix can easily and sometimes quickly dilate to 10cm. 

Other times, the cervix softens a little then dilates a little, then softens a little more and so on. So when checked, the cervix may be 4cm (yay!) dilated but 50% effaced (still good, but more work and time may be needed for the cervix to become completely effaced and dilated). 

There are also those times when me and the birthing team are completely surprised when all of a sudden the parent goes from 5 cm to fully dilated within an hour. 

And while the cervix is changing, the baby is moving downward. The system of assessing this movement is called “stations”. Zero stations means the baby’s head is aligned with a bony landmark within the pelvic called the ischial spines (or simply “spines”). If the baby is higher than this, a negative number is used, like -1 or -2. If the baby is lower than this, it means the baby is descending into the vagina and positive numbers are used + 1, +2 and so on to +5 being the baby’s head is about to be born. In a textbook labour, when the cervix is fully dilated, the baby is at zero station. In real life the cervix can be dilated and the baby is at -2 station (still high), or the cervix can be just 5 cm dilated and the baby is at zero station (quite low). 

All this information just illustrates that there are too many factors in play to be able to predict or dictate how fast a labour should progress. Unfortunately a long held “formula” (called Friedman’s curve) is often quoted: “We expect your cervix to dilate 1 cm every hour.” This rate was created by a Dr. Friedman based on his observation of 500 births in first time labouring women aged 20 – 30 years old in the 1950’s. He was the first to put a timeline on labour and his observed rate of dilation in his limited population of study has been used as a guideline ever since. As you can imagine things have greatly changed since the 1950’s and this very limited view of labour can no longer be applied. To read a full and thorough critique of using Friedman’s curve you can read this article by Evidence Based Birth.

The main point here is that there is a huge range of how long a labour may last. As long as the birthing parent and baby are doing OK and as long as there are signs of labour progressing (cervix is changing, baby is descending), then we just need to afford you the time to allow your body work and make childbirth happen. 

Dr. Ee Von Ling, ND
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Perineum Discussion Part 2: Besting Your Chances for Minimal Injury

Dr. Ee Von Ling, ND

Dr. Ee Von Ling, ND

Trigger warning: Discussion about vaginal birth and perineum. Discussion about perineal injury and tears. 

This post will go right into the discussion of how to reduce perineal tears and injury. To learn about the 4 different types of perineal injury and read my personal account of having a 2nd degree perineal injury, first read My Childbirth Experience

Is there anything you can do to help reduce perineal injury? 

YES!

The most important factor that influences your risk of a perineal injury will surprise you. 

Your care provider is one of the strongest factors of having an intact perineum: 

Having a homebirth with a midwife is the best way to help avoid a perineal injury. Second to this is having a birth centre birth with a midwife. The main reason is episiotomies and repairing a 3rd or 4th degree perineal tear are not within a midwives’ scope of practice, so they are skilled in helping birthing people avoid or minimize these injuries. 

Having an OB with a high 3rd or 4th degree perineal injury rate or has a high rate of episiotomy use will have the highest risk of developing a perineal injury. 

If you want to give birth in a hospital, get a midwife to help reduce your chance of a perineal injury. 

If you don’t have access to a midwife, ask your OB what their 3rd and 4th degree rate is (it should be 3% or less, if it is much more, it means they are not taking preventative measures). Ask  your OB how often they are doing episiotomy, or under what circumstance they are doing this. Fortunately, hospitals in the GTA have a no routine episiotomy policy, meaning, the OB should not be doing them as just a matter of routine.  Ask your care provider if they obtain consent from the client first if they are considering to do an episiotomy

Other tips to help reduce severe (3rd and 4th degree) perineal tearing: 

  • Be in an upright birth position (If you have no epidural)
  • Be in a side lying birth position with delayed pushing (If you have an epidural)
  • Warm compress against the perineum (Done by your care provider – this helps reduce severe tears and reduce pain)
  • Perineal massage by the care provider might help lower your risk of a severe perineal  trauma, increase your chance of having an intact perineum, or it might make no difference (They need your consent first!)

These other factors that can increase your risk: (Unfortunately, these factors are less under your control)

  • Size of baby (the bigger the baby, the bigger the risk)
  • Position of baby at birth (if baby is “sunny side up”, OP or face up at birth)
  • Very long or very short 2nd stage (pushing time)
  • Shoulder dystocia (difficulty with birthing the shoulders)
  • Use of forceps or vacuum
  • Family history of severe perineal tears

Among the research, there was a particular group of midwives with an amazing 73% intact rate! What did these expert midwives do differently?  

  • They performed slow, calm and controlled delivery of the baby’s head
  • They guided with non-valsalva pushing
  • They delivered the baby’s head between contractions

Additional tips from these expert midwives: 

  • When the baby is crowning, they warn clients to blow instead of push
  • Avoid coaching to push
  • Avoid pushing during crowning
  • Encourage hands and knees position
  • Allow the baby’s head to remain on the perineum for a number of contractions
  • Wait until baby has rotated before trying to birth shoulders

What about doing perineal massage? 

Studies conducted have shown that doing a minimal amount of perineal massage (1-2 times/week, 10 minutes each time, starting from 34 weeks of pregnancy) can help reduce the chance of perineal injury for people birthing for the first time. People who are birthing after the first time generally have a lower chance of perineal injury, and doing perineal massage has not shown to reduce the rate further. However, doing perineal massage has been shown to help reduce perineal pain from childbirth. Interestingly, there is no added benefit in doing more than the minimum amount. 

Also, no study showed that perineal massage made it worse for perineal health. Thus, I always recommend that you do some perineal massage to help prepare physically as well as mentally for childbirth (learn to relax and practice breathing exercises while doing it). 

Injury to the perineum is cited as one of the most common fears that people have about giving birth. The fear is strong enough to influence people to not have children. It is the unseen and unspoken part of birth.  We don’t properly educate the public on the ways that help reduce perineal trauma, leaving the power and decision making to the care provider. I hope that in sharing these evidence-based tips and my own personal experience that you feel more empowered to gain control of this part of the birthing experience. 

Links: 

Perineal massage video

Evidence Based Birth: Perineal Massage

Evidence Based Birth: top 5 tips on protecting the perineum

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My Childbirth Experience (Perineum Discussion Part 1)

Dr. EeVon Ling, ND

Dr. EeVon Ling, ND

*Trigger warning*: Discussion about vaginal birth and perineum. Discussion about perineal injury and tears. 

Injury to the perineum is cited as one of the most common fears that people have about giving birth. (I prefer to use the word “injury” rather than tear, as I feel “tear” in the context of childbirth can produce such a visceral response that can be disturbing for many people)

Ask any group of people of child-bearing capability “How many of you have felt frightened at the thought of tearing during childbirth for yourself or someone else?” Almost all will say yes. This fear is so impactful that it can influence the decision to not become pregnant at all.

So what is it really like to give birth vaginally?  What happens if you have a perineal injury? 

This is my account of what it’s like to vaginally birth and have a 2nd degree perineal injury. 

To give some background info, perineal injuries due to childbirth are divided into 4 categories, based on severity and tissue and organs that may be involved (It is not based on the number of stitches needed as many people believe): 

  • Intact perineum – no injury occurred
  • 1st degree – least severe, involves only the skin around the opening of the vagina. Depending on the nature of this, stitches may or may not be needed
  • 2nd degree – involves the muscles between the vagina and anus – usually needs stitches
  • 3rd degree – affects the muscles around the anus
  • 4th degree – the most severe, reaching the tissue lining of the rectum

3rd and 4th degree injuries require an OB to repair in the OR of a hospital (for example, if you have a midwife and a homebirth and a 3rd or 4th degree injury occurred, you would be transferred to the hospital and an OB would  be assigned to help you). 

Generally speaking, up to 80% of people birthing for the first time experience perineal injury. Of that number of people: 

1st and 2nd degree perineal injuries are most common

3rd and 4th degree occur in less than 10% of that number – when no preventative measures are taken. 

Upon digging into the research on this topic, I learned that there are a few factors and preventative measures that can help you significantly reduce your chance of having a perineal injury! If you want to go straight to the evidence, read Perineum Discussion Part 2: Besting Your Chances for Minimal Injury.

Back to my experiences. I had 2 wonderful home water births, about 2 years apart, with 2 very different perineal outcomes. 

First birth: “She flew out of me”

I woke up that morning with a sore back, causing me to curse the really long walk I did the day before. As the morning progressed, I realized it was labour starting. I had learned HypnoBirthing (YDD HypnoBirthing) in preparation for our planned home birth and the techniques helped me cope with the progressing labour. As we got into the evening, our midwife arrived, checked me and my baby and everything was healthy and going well. At some point I got into the birth pool and continued labouring there.  

As my labour really ramped up, the midwife asked me “Did your water break?”  I had been in the pool for a few hours at least and so I had no idea. The midwife suggested that she check my cervix, which I agreed to.  I got out of the pool and during the check it was discovered I was 8cm dilated but my water had not broken yet. Labour was really intense at this point and after having a short conversation, weighing my options (yes, you can still have a logical conversation weighing the pros and cons of an intervention in the thick of labour!), I agreed to have my water broken by the midwife (also referred to as “rupture of membranes”).  

Once that happened, things progressed extremely fast. My baby quickly descended and was crowning within just a few minutes. One moment I could just feel the tip of her head. The next moment I heard a “Floomph ” and I saw my husband and midwife fish our daughter out of the water and put her on my chest.  Our daughter literally flew out of me in 1 contraction. 

As a result I had a 2nd degree perineal injury. 

Because she was born so fast, I did not feel the commonly described “ring of fire” that many birthing parents report. Because she was born unexpectedly fast, my midwife didn’t have a chance to do anything to support my perineum. Would it have made a difference to my perineum had I not had my water broken (I believe that really sped up what was already a fairly fast labour)? Would it have made a difference if the midwife were able to actively support my perineum during crowning? I did perineal massage (link to perineal massage video), did that help reduce the severity of my injury? I’m not sure, but later I will discuss what can help in reducing perineal injury. 

My labour and birth were a great experience that I owe to having the birth pool and using the HypnoBirthing techniques. The repairing of my perineum? That SUCKED. 

For me, getting the stitches was the worst part of my birth experience. Why? During labour and birth I sort of knew what to expect based on what I learned in my naturopathic medical training and from the HypnoBirthing prenatal classes. I was sitting in a padded pool filled with warm water and listening to relaxation music and affirmations and breathing like a real pro. 

Getting the stitches, on the other hand, was quite the opposite of zen. I had to lay on my back on a bed. I was wet and cold (despite my husband’s best efforts to dry me off and our condo was an un-air conditioned 28 degrees in the middle of July). Before doing any stitches, the midwife injected local anesthetic. My perineum felt very raw and vulnerable and all the poking and sharpness of the repair process was harder for me to handle than the labour and birth. Luckily that part was very short, only a few minutes. I used my breathing exercises during that time. In hindsight, more distractions like music playing, having my husband close by (he was tending to the baby in a different room as the bedroom we used was very small) and having other coping measures available would have been very useful to reduce the intensity of that experience.  Would it have been helpful if someone disclosed the details of what it really feels like to get your perineum repaired (without an epidural)? I’m not sure, and I still grapple with this question when I teach HypnoBirthing Classes and our Confident Birth Prenatal Program to my parents. 

Recovering from a vaginal birth and 2nd degree perineal injury:  It took me about 2 weeks before I felt normal down there. It is very normal, and very alien-feeling, to have all that swelling and tenderness. A girlfriend, who gave birth a few months later and who has a very crass sense of humour, called it her “hamburger”.  

I didn’t pay much attention to my perineum before, but for the 2 weeks after birth I had 2 all-consuming jobs 1) feed the baby 2) look after my perineum.  I was quite diligent with the ice packs and sitz baths. I used 2 peri bottles filled with hot and cold water so I could do a mini hydrotherapy session each time I used the toilet. (I always remind my new parents to take the extra time to care for their perineum.) I think I spent those first couple of weeks horizontal as standing, walking and sitting made me really tired and caused my pelvis to feel heavy and dragging. It was helpful that I was sort of observing the Chinese tradition of “confinement”  – resting and staying indoors for 1 month after the baby is born. Meaning no going out to run errands or doing things that would further exhaust or deplete me. 

The stitches get itchy making you want to, but also don’t want to, scratch them. 

When your perineum starts to feel better, and you know you’ve rounded the corner on your recovery, it’s like the fog has lifted and you start to feel more like yourself. That said, please still take it slow as doing too much too fast can regress your recovery. After my perineum fully recovered, I did experience a bit of a lingering sensation. It wasn’t pain exactly, but a bit like a ‘pulling” sensation with sex and sometimes with peeing. I didn’t know much about pelvic floor physiotherapy at the time, although I wished I did and it’s something I recommend to my clients postpartum to help address any issues that remain after recovery from childbirth. 

Second Birth Experience: Much better

The birth of my second daughter about 2 years later was almost a rinse and repeat of my first experience. I say almost because I came away from it with an intact perineum (that and the labour was much faster).  What was different this time around? Experienced birthing parents do have a decreased risk of perineal injury  to begin with (almost 50% less chance), so the odds were in my favour. My second child was almost the same weight and size as my first, but the difference was the speed of her entry into the world. My midwives (different than the first) were very hands off and it wasn’t until my baby was crowning that they realized my water hadn’t broken yet! With the water intact maybe that helped slow down the crowning a bit.  Once they realized she was about to be born, they were able to guide me and my breathing so I didn’t push her out too fast and they provided perineal support. 

I did not have to go through the repair process. Thank goodness! 

Recovery from birth without a perineal injury is so much better (as you can imagine)! I felt like myself just days after giving birth. But there was still some swelling so I still made sure I took care of my perineum (a bigger challenge when you have a baby and another child). 

I feel pretty lucky that I didn’t have any lasting pain or incontinence issues after giving birth.  Unfortunately many people do develop chronic pain or some degree of incontinence after childbirth as a result of the perineal injury. Having serious perineal trauma can affect your recovery, your ability to care for yourself and your baby and can impact your mental health. Perineal injury can lead to problems with incontinence, pain with sex and chronic pain in general.  If there was some way to help avoid or at least reduce the severity of a perineal tear, we have a duty to inform those who are pregnant. 

Is there anything you can do to help reduce perineal injury? 

YES!

The most important factor that influences your risk of a perineal injury will surprise you. 

To learn more, read Perineum Discussion Part 2: Besting Your Chances for Minimal Injury

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My Top 2 SURPRISING tips to help prepare your home for sleep with your new baby

– Dr. EeVon Ling, ND, YDD Doula and Sleep Consultant


Expectant parents can easily get caught up in getting all the things for their baby.  When thinking about what you’ll need in preparing for baby, the item of consideration should answer the following question: 

“How is this going to make my life EASIER as a parent?”

(Yes, yes, developmental benefits for your baby are important too, but the reality is that babies, especially newborns, need very few things outside of diapers, clothing, food, a safe place to sleep and YOU). 

When working with expectant families, I am of the mindset of making things easier for the parents (because raising a baby is very hard work!) and this should extend to arranging the home so it can maximize sleep for everyone.  

Here are my top tips to help prepare your home for sleep with your new baby: 

  1. Have various safe options of where a baby can sleep. 

Your baby can sleep anywhere, it does not have to be in a bedroom. Having alternative sleep locations gives you flexibility. If your home has several rooms or different levels, having these options could also be safer because your baby can always be near you. 

Here are some suggestions: 

  • Pack-n-play (also called a playard)
  • Bassinet for stroller 
  • Baby box (on the floor) with a mat that fits tightly on the bottom
  • Empty laundry basket (on the floor) with a mat that fits tightly on the bottom
  • Floor mat or floor mattress in the middle of the room away from the wall and other furniture and pets. 

Having on-the-go options are particularly useful: 

  • Age appropriate carrier (with head support and you should be able to see the baby’s airways while being carried)
  • Stroller that lies flat or has a bassinet (could be used indoors too)

**A safe sleep location is one where the baby can lie flat on their back, there is no risk of falling out, getting entrapped in a tight space or being strangled or suffocated, and there are no blankets, loose fabric, stuffies or very soft surfaces (these can all pose as suffocation risks). There are many things that parents use for baby that are not considered safe (such as swings, dock-a-tot, baby bouncer, car seat, any surface that is very soft or that is inclined etc). If you are using such things, it is important that your baby is supervised by an awake adult. 

  1. Have alternative places for the other parent to sleep.

Here are some suggestions: 

  • A couch that converts into a bed (such as futon sofa or pull-out couch, or at least a couch with a firm base of cushions long enough for an adult to sleep comfortably on for many nights)
  • A twin sized mattress for the floor (If you think you’ll use it regularly, it should be a proper mattress versus a blow-up mattress or cot.) The mattress can later be used by the child when they are older. It can also be moved around as needed. 

This suggestion of a separate sleeping place usually surprises (even shocks) many families. Some feel it’s “unfair” if one of them (usually the dad or non-breastfeeding parent) gets to sleep while mom has to stay up all night with the baby. It’s only unfair if the sleepless parent is also expected to take care of the rest of the house and family at full capacity. The intention here is that the fully rested parent can do all the other house chores while the exhausted parent (usually mom or the breastfeeding parent) only has to focus on resting and feeding the baby. It is also my belief that 1 fully rested parent is better than 2 very exhausted parents. 

I am going to fully disclose what we did after we had our first baby. Our first born child was a terrible sleeper (a-breastfeeding-waking-every-hour-terrible-kind-of-sleeper). We initially all slept in the same room. But my husband has a fundamental need for more sleep than me. He also had a job that required his full alert attention. And he was fully hands on with taking care of our dog and housework. So, we made the decision of buying a futon couch for the living room and he would sleep there full-time for nearly 4 years (we had 2 children). This was the best decision for us. At the very least, we had a proper extra bed for anyone to sleep on if needed (for a while we switched when the second baby arrived, and I slept out on the futon in the living room with the baby sleeping in the stroller bassinet next to me). Having these options is what saved us, especially living as a family of 4 in a 700sq ft condo. 

Now, even as I’ve made these suggestions, I don’t advise that you immediately run out and buy a bunch of new stuff. In fact, you can wait and see how it goes after the baby is born. Keep these suggestions in the back of your mind in case you need a solution. 

If you would like to feel more fully prepared for sleep with your newborn I offer the Prenatal Newborn Sleep Program and Home Assessment. It’s a great way to prepare you home and your mind for life with a newborn. 

And if after your baby is born you need help with any sleep challenges, I also offer sleep consultations. All services are eligible for benefits coverage as naturopathic services. 

If you’d like to learn more, book a free 15 min meet and greet with me!