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I’d like to discuss birth over the intact hymenal ring. A doctor showed me how she avoids cutting the perineum. Midwives and doctors often miss recognizing an intact hymenal ring and instead see the following situation as in indication for episiotomy. 

Notice when there has been a complete halt in descent after the baby has appeared at the perineum and is:

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In a good position
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The skin and muscles of the perineum are stretchy but not opening (a paradox)
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5 cm of scalp has stayed visible and not changing for 30-60 minutes without rocking in and out
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The perineum has thinned but is not slipping over baby’s head
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Baby’s skull is molding to the shape of the vaginal opening (if left that long)
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And most telling, there is a whitening (or greyish) bowtie fascial stretch showing through the skin in the middle of the perineum while the skin on the edge of the vagina is not stretched to the maximum and has good blood return
I learned about this at a birth in which I served as a doula. The obstetrician pointed out to me that there was a bowtie shaped pucker midway across the perineum. The edge of the perineum was stretchy and not tightly stretched over the head.  The blanched skin was external and at the location of the internal hymenal ring. For half-an-hour or more the baby’s head sat on the perineum while this bowtie blanched whiter.

The perineum was threatening to open at the middle rather than tear from the edge. The edge had good blood perfusion and could be moved without showing threat of a tear by gently slipping a finger between the perineum and baby’s head. The middle of the perineum looked taut, grey-white and increasing pressure striations showed it was about to tear from the center.

The doctor got a scissor. 

My gut tightened. My skin crawled. And my perineum contracted in memory of my own birth and resistance on behalf of this woman. 

The doctor said, “In this case, we don’t do an episiotomy. This is an intact hymenal ring and we simply lift the perineum so we can put two fingers between the perineum and baby’s head to expose the hymenal ring and then we snip only the hymenal ring.”
The doctor made a tiny cut through the hymenal ring and the perineum was left intact. The baby’s head slipped out immediately with the doctor withdrawing the scissor. No repair was necessary for the hymenal ring. The cut was not to muscle, fascia, or even mucosa. 

I so appreciate the teaching of this observant obstetrician who knew how to preserve the integrity of the perineum even when a thick and intact hymenal ring delays the birth.
It’s possible this is as frequent as 1 in an 100. The hymenal ring had broke to the sides but a particularly thick hymenal ring may not always break in the center, midline. 

Zoey Anderson, doula and massage therapist and one of our new Spinning Babies Aware Practitioners has also experienced such a birth with a savvy physician, 

Thanks for sharing this Gail! I’ve seen the same thing once. The doc made it very clear to everyone that she was only cutting the hymnal ring. Before she cut it she had everyone in the room be quiet and listen. She plucked it like a string and it made a sound. The woman had an [epidural] and didn’t feel any of this. Baby hadn’t been there as long as in your case, and took two [more contractions] to be born. 

Often the interpretation is mistaken for a tight or strong perineum. Intense squatting over months can develop musculature in the perineum that won’t sweep over the baby’s presenting part easily.* The muscle in that case is notably developed. In this case the perineum seems the same as those that dilate normally and without tearing but for the pale gray stretch mark developing in the moment at the middle of the perineum. 



See pictures of a breech birth in which this was the case in our digital download, Breech Birth; Quick Guide
Come visit the blog. Spinning Babies Blog. www.spinningbabies.com
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