The Vagina Bible. Jen Gunter
or cervical infection are at no higher risk of having a premature delivery if they are sexually active.
Contrary to urban myth, sexual intercourse close to the due date with a male partner does not appear to trigger labor. Many people talk about exposure to prostaglandins, substances known to trigger labor, from ejaculate, but it is not supported by science. Most studies show that heterosexual sex has no effect on triggering labor or on reducing the risk of cesarean section. The idea that a penis is mighty enough to bring on labor is, to be honest, a bit eye-rolling. Nipple stimulation when the cervix is ripe can trigger labor for some women, but you don’t need a penis for that.
It’s recommended to avoid sexual activity for women in some higher-risk situations, such as ruptured membranes, placenta previa (where the placenta implants over or next to the cervix), and those who have a high risk of premature delivery (for example, twins or a previous preterm delivery).
Many people have heard about reports of fatal air embolism in pregnancy from both receptive oral sex (cunnilingus) and penile-vaginal sex. An air embolism is a stroke or heart attack due to a large air bubble entering an artery or vein and traveling to the brain, heart, or lungs. The placenta has a direct connection with the maternal bloodstream, and so with enough pressure it is possible for air to travel up through the vagina into the uterus and enter the bloodstream. Air can be introduced by oral sex or with penile thrusting.
Air embolism is described in fewer than one in a million pregnancies, so it is hard to give science-based recommendations. It is best to avoid blowing air into the vagina during oral sex, and some have suggested that the risk of air embolism during penile penetration may be greatest in positions where the uterus is above the level of the heart, but that recommendation is not based on any studies.
Ancient Obstetrical Practices That Should Be Forgotten!
Before I trained as an OB/GYN, shaving, enemas, and cleaning the vulva and vagina with antiseptic were common, but now we know these practices are outdated. This isn’t The Pregnancy Bible, so I can’t go into every question you should ask your provider, but if the person delivering your baby supports a practice that is more than twenty-five years out of date, such as shaving or enemas, I might wonder about the currency of other aspects of their medical care. It’s best not to shave yourself before labor either, as this causes microtrauma and may increase your risk of infection.
During delivery, you may have a bowel movement. It is completely normal. Your OB/GYN or midwife should not even notice, that is how routine it is for us. We just wipe the stool away. If it were harmful for the baby, we would not have evolved so the baby’s head emerges next to the anus!
Perineal Trauma
Trauma is part of vaginal delivery (it’s obviously part of a C-section as well). The vulvar and vaginal tissues have evolved to stretch, tear, and recover—the increased blood flow, how quickly the cells of the vagina are shed and replaced, and the extra folds of vaginal mucosa are very helpful.
Both tearing and an episiotomy (a surgical cut) are collectively called perineal trauma. Many women ask how many stitches they needed, but that is not a reflection of the severity of the injury. A single stitch can be run like a hem and close a large tear. Multiple tiny stitches may be needed to repair a much smaller laceration to achieve the best cosmetic result. What you should ask is the extent of the injury, which is described by OB/GYNs in degrees based on muscle injury:
• First degree does not involve muscle. It is limited to the vaginal mucosa, the vestibule (vaginal opening), and/or the skin of the vulva.
• Second degree extends into muscles and can vary significantly in size, meaning a small partial tear of the muscles beneath the vestibule or all the way through the muscles of the perineal body, stopping just before the anal sphincter.
• Third degree involves all the muscles of the perineal body and the rectal sphincter (it is further subdivided by how much sphincter is involved).
• Fourth degree extends all the way through the anal sphincter into the rectum; fortunately this occurs in only 0.25–2.5 percent of births.
First- and second-degree lacerations should be repaired if they are bleeding or if not repairing them would lead to an unsatisfactory cosmetic result. Absorbable skin sutures or surgical glue can both be used. However, third- and fourth-degree lacerations should be repaired surgically (sutured)—if not, there is a higher risk of fecal incontinence. A first-or second-degree laceration has no increased risk of urinary or anal incontinence, but the risk is increased with third- and fourth-degree tears.
Routine episiotomies are not recommended by the American College of Obstetricians and Gynecologists (ACOG). The most recent data tells us that 12 percent of vaginal births in the United States involve an episiotomy, down from 33 percent in 2000. The number of episiotomies should keep going down, given ACOG’s policy advising against them. Episiotomy is associated with a larger injury and an increased risk of incontinence. In general, an episiotomy is only indicated in an urgent or emergent situation. I don’t know any OB/GYN who practices routine episiotomy, although I have no doubt that a few still do. This is definitely something to inquire about at one of your prenatal visits.
The risk of tearing during a vaginal delivery ranges from 44 to 79 percent—any provider who tells you they can guarantee no tears is not being honest. Most factors that lead to tearing are not within your control, including the size of your baby, whether or not this is your first delivery, and genetics. An epidural has not been shown to affect the risk.
Some interventions that may have a mild to moderate impact on reducing tearing or the need for episiotomies include the following:
• Perineal massage starting at 34–35 weeks. Women or their partners insert one or two lubricated fingers vaginally about two inches into the vagina and apply pressure downward for two minutes, then on each side for two minutes, for a total of ten minutes at least one or two times a week. Coconut oil, olive oil, and lubricant for sex can all be used. For women in their first pregnancy, perineal massage reduces the risk of tearing that requires stitches by 10 percent and the need for episiotomy by 16 percent. What this means in practical terms is that if your risk of tearing that requires stitching is 50 percent, with massage that risk is now 45 percent. If the risk of episiotomy is 12 percent, with perineal massage the risk is now about 10 percent. Perineal massage may also help reduce pain after delivery, although this association is less clear.
• Perineal massage once you are fully dilated (the second stage of labor) may lessen the severity of the tear, but not the risk of tearing.
• Perineal support, putting a hand or a towel on the perineum and applying gentle pressure, hasn’t been adequately studied to say if this helps protect from tearing or not.
• Warm compresses on the perineum during pushing may reduce third- and fourth-degree lacerations.
• Delivering on your side may have the lowest risk for a tear, but the studies are not high quality, as requiring a woman to deliver in a position for study is not feasible or ethical.
If you do have a tear that enters into the anal sphincter (a third- or fourth-degree tear), a dose of intravenous antibiotics may be recommended at the time of repair as this reduces complications in the first two weeks (8 percent complication rate with antibiotics and 24 percent without).
Pain Control After a Vaginal Delivery
Swelling, bruising, tearing of muscles and skin, need for stitches, and hemorrhoids can all contribute to pain after a delivery. In general, the longer the labor, the greater the pain because there is usually more swelling. Also, fatigue affects pain processing—if you haven’t slept for forty-eight hours and then you pushed for four hours, you will likely have more pain than someone who had a good night’s sleep, woke up, and then had a two-hour labor and pushed for five minutes. Other factors that affect pain include the need for a vacuum or forceps and whether this is your first delivery or not. Genetics and previous pain experiences are also important. Another unique factor is how your baby is doing—the stress of a sick newborn may affect how you process pain.
There are so many individual factors involved in how we process pain it is generally