The Internal Work
A Beloved Childbirth Preparation Skill
In a vaginal birth, everything inside is important. Though, it’s a bit mysterious, hard to approach, and extremely difficult to show even with 3-D illustrations. What is hidden inside leaves us feeling mystified. Birthing Better fathers and mothers demystified the vaginal birth canal, by learning how to prepare the soft tissues for labor and birth, and they reaped tremendous benefits by doing so.
You’ve probably heard about perineal massage. This is a common skill people employ to prepare and aid the second stage of birth. But let’s think more deeply. There is a lot of tissue that is involved in the birth process. The Internal Work is one of the skills developed by birthing families because they wanted greater resilience for the second stage of labor. They discovered, as well, that this Internal Work brought newfound clarity and autonomy to the birth process for themselves.
Here is why mothers and fathers developed this skill. They wanted their vaginal birth to be forthright, to not last for hours, and to not damage them or their baby. They wanted to recover from a vaginal birth without the very common issues that women experience, some of which last for years, such as a sore tailbone, loose vaginal tone, pain having sex, prolapses, or peeing when coughing, running, or laughing.
Cross-sections make our vaginal birth canal appear as a tiny tube that our big baby has to move through. And that is unnerving.
Let’s take a look at a cross-section of a pregnant woman. Cross-sections make our vaginal birth canal appear as a tiny tube that our big baby has to move through. And that’s unnerving. Reality smacks us in the face during the second stage of labor. We feel how big that object really is. That big head has to come down into the top of the vagina after the cervix opens, and then move down through three inches of our vaginal “tube” and eventually to the opening where women sometimes experience the “ring of fire.” Perineal massage focuses on that last part of the opening.
In many births, from full dilation onwards, mothers feel perceptually blind and unprepared. Instead of just focusing on the outlet of the vagina with perineal massage, we need to know how to prepare and soften all the tissues inside all three inches of that vaginal space, so that our baby can open all this soft tissue, instead of stretching it with the risk of tearing or needing an episiotomy (not to mention the potential need to push for hours, and ending up with one or more of the vaginal or pelvic floor issues mentioned above).
The three inches of the vaginal soft-tissue canal has several areas: The top, back, sides, and bottom (or floor). Once you feel where all those parts are, then you can also know and understand better where your baby will be throughout her journey down, through, and out the body.
Preparing our baby’s birth canal takes five minutes a day, for eight weeks, if starting at about 32 weeks. If you’re further along when reading this, the birth hormones are likely increasing, so you can do a bit more with each session and you can do a session twice a day.
Birth Canal “Landmarks”
The bony pelvis contains a central open space—the passage —surrounded by the pubic bone at front, two hip blades on the sides which run down to the sit-bones, and a sacrum and tailbone at the back. These bones compose and define the pelvic “inlet,” the “mid-pelvis,” and the pelvic “outlet” where the baby comes out. People easily feel these bones and know them well. During pregnancy, your baby lives right above the top of your pubic bone, in the womb or uterus.
The Pelvic Inlet
If you put your hands on the top of your pubic bone, you are at the level of the pelvic inlet. From the top of the pubic bone, try drawing a circle around your body, passing across the middle of the hip blades, all the way back to a single point on the sacrum. This circle is where your baby enters into the pelvis.
From there, the baby descends into the mid-pelvis, which leads to the cervix at the top of the vagina. The cervix opens up at the entrance to the vaginal canal, though it is tightly closed all of our lives except in birth. The top of the vagina also supports around the cervix, creating a ceiling above which the organs of the body sit. During a vaginal birth, the cervix must open fully, and all the tissues around it must retract in all directions—to the frontal pubic area, to the sides of the hip blades, and to the back of the sacrum. Then the baby can move down into the soft tissue of the vaginal canal and pelvic outlet.
The Pelvic Outlet
The outlet consists of the lower pubic arch at the front of the vagina, the sit-bones, on either side of the buttocks, and the tip of the tailbone at the base of the sacrum. For the baby’s birth, the vaginal canal has to open up equal to the circular space formed by the pelvic outlet, consisting of the pubic arch, sit bones and sacral tailbone.
All our bones are covered with soft tissue that is soft and slippery (if we are relaxed). Once the cervix is fully dilated at the mid-pelvis, the baby moves into the top of our vaginal canal. If there are no constrictions, then as the baby moves into this position we will feel the need to begin pushing. Pushing is our body’s uterine effort to push our baby down through the three inches of our vaginal canal. Hormones aid in relaxing the soft-tissues of this area. That’s why when we’re fully dilated, our baby doesn’t instantaneously arrive—we have to let the space open, and push the baby down through this canal.
Vacuum, forceps, episiotomies, or tearing can happen with this final passage if the baby is not moving, or if the space is not opening. Our baby is moving through that hid- den and mysterious inner space of the vaginal canal, which looks like a thin tube on the anatomy cross-section but is, in fact, a large, open space made up of soft-tissue, including muscles.
The space can expand, but the soft tissue throughout that space can be tight in various places, inhibiting the descent of our baby through and out, as well as causing varying degrees of internal discomfort.
The Vaginal Birth Canal
The front area of the vaginal canal is located by the interior wall of the pubic bone.
The top of the canal is where our cervix is, together with the soft tissues of the vagina at the highest level.
The back of the canal rests against the sacrum, tailbone, and rectum, including muscles that run from our sacrum to our sit bones.
The sides of the canal are the soft tissues that surround the whole space from the back area to the front.
The bottom, or floor, consists of soft tissue that you can touch and feel from the outside, including the perineum and everything between our sit bones around the perineum.
The goals for doing the Internal Work are
- Reduce potential short- and long-term trauma to your body during second stage labor.
- Reduce potential trauma to your baby during second stage labor.
- Allow for an easier, safer second stage labor.
- Learn the space to be able to assess where we are in labor.
Who Does the Internal Work?
Families do this themselves. Women can do it themselves. Or, if they choose, they can employ their husbands or partners. We found that about 80% of fathers are keen to do this work. As an aside, when fathers learn this skill, they mature as men. They shift from simplistic sexual thinking of the organ to realize how important it is for both the baby and the mother’s birth. This change in thinking matures them and their relationship. Women doing the work themselves and/or with their partner is ideal.
In general, the work is all about finding the tender places inside, and gently doing circular massage everywhere there’s internal tension. Fathers use their middle finger to do the massage. Mothers use their thumbs—each one in turn, to reach both sides of the internal space.
Five minutes from 32 weeks onward is ideal, but doing any is better than none, as each session will help us grow comfortable with the inside of this space as it relates to birth, helping us comprehend where and how the baby will move along in her descent through the vaginal canal.
Important Rules for Partners Helping
- Always be gentle, very gentle. This is not vigorous sexual energy. Gentle.
- Sit by her side.
- Make certain to wash your hands before you do this.
- You can use a small amount of oil when necessary.
- Only use your middle finger and go slowly.
Tips for Women
- Face your right thumb toward your left side. Sit on a toilet birth stool, and/or put your left leg up on something low.
- It’s easier then to use your right thumb to work the tissue on your left side. Use your index finger to massage the outer tissue and to help move side to side.
- Then use your left thumb to work on your right side.
- We can easily reach most parts (bottom, back, sides) of the inside when we use each thumb.
- Don’t be surprised if you can massage more vigorously on your own body compared to your partner. Your baby is both part of you and separate from you, so you will feel the intimate relationship between how your body opens and stretches as your baby moves through you.
Instructions for Partners
The Entrance/Exit of the Birth Canal
Place the tip of your middle finger with tip facing down just at the entrance of the vagina, and stop there. Make eye contact and make certain that both of you are comfortable with proceeding. That entrance tissue is the “exit” from your baby’s viewpoint. Your baby perceives the vagina while exiting out from the inside and works to open up that tissue.
This tissue is the bottom, or floor, of the birth canal and the last part of the birthing journey. The skin, soft tissue and muscles between the vagina and rectum around the perineum is what the commonly known “perineal massage” refers to. At birth, this thin tissue needs to stretch open to the size of a grapefruit. “The ring of fire” sensation happens if this tissue is tense. Always keep this in mind.
With your middle finger on the inside of the tissue between the vagina and rectum, you can use the thumb to massage the tissue in between. Gently ring around the tissue from side to side, gently massaging this tissue open. With birthing hormones and progression of the baby, you should feel and know that over time, this tissue will need to open up to accommodate something the size of a grapefruit. If required to stretch at this time, this is what causes potential damage and difficulty.
The Bottom of the Birth Canal
First, work on the bottom, or floor, of the birth canal. Then you’ll work on the back wall, then move on the sides. Then you’ll learn to “check” the top. Do NOT massage at the top or on the front (cervix or pubic bone).
Just moving your middle finger into the vagina a very little bit, you can feel the inside tissue of the rectum. If the woman tenses up at your touch, recognize that this tension will be what your baby experiences as well. Tension at the bottom of the birth canal creates “the ring of fire” sensation at birth, and can sometimes cause tearing, the need for episiotomy, or possibly long-term damage. The goal of doing the Internal Work is to reduce the multiple tensions that naturally exist in the tissues of the vagina.
The bottom of the birth canal includes the tissues between the back of the vagina near the rectum, the muscles on either side of the rectum, and the tissues and muscles behind the rectum.
Feel on both sides of the rectum. Now, gently press down from the inside toward the ground. This is what the baby will do. Then press backwards toward her butt and toward the tailbone. Your baby does this as well. This is normally not comfortable to experience, especially for the first time during second stage labor. Ask her to soften and relax into the sensation, which is the ideal response for this internal sensation. This softening and relaxing becomes a learned response that becomes natural over time.
The Back of the Birth Canal
Find the tailbone and then feel the muscles on each side of the tailbone and sacrum that run from the edges of the sacrum to each sit bone. Massage those muscles, because they hold the sacrum from moving when the baby presses against the back. As the baby comes down into the middle part of the birth canal, then turns the corner around the pubic arch, she begins to open up the
bottom. Once the baby has turned this corner of the pubic arch, she’ll be opening up the lower part of the soft tissue including the back of the vaginal birth canal. That’s when you can see the baby’s head opening up the vaginal exit.
The more Internal Work you have done throughout the birth canal, the easier the second stage will be. Women will soften and “open up” rather than stretch with tension against the baby’s efforts. It takes fewer contractions to open up tissue that is soft than tissue that is tight.
The Sides of the Birth Canal
The sides of the birth canal run alongside the flat hip bones that make up the mid-pelvis extending down to the sit bones. You’ll be working on the tissue that covers these bones. You’ll feel if the inside of the bones on each side feel the same or are different. Rarely are they the same. For example, if one hip blade is more convex and the other more concave, then your baby will position his head toward the more open side. This applies to all the tissues as well—the baby moves toward the more open places, yet still has to deal with those areas that are tight.
Your purpose is to help prepare the passageway to open up as your baby moves through this final space of the mother’s body in the second stage of labor.
Of course, there is a difference between doing this on another person and doing it on yourself. When doing the Internal Work on another person, you can more clearly discern the bottom from the back and sides. When doing it on yourself, it’s more about massaging all the places that you can reach on the side you’re working on. Massage on the side and back of your rectum and use your index finger to work from the outside as well. This will come easily after a couple sessions.
Softening all the tissue inside assists your baby’s effort to open you up gently. Sadly, we really can’t see or feel ourselves as clearly as the other person can. However, by doing this ourselves, we get connected to a part of our body that we might otherwise feel disconnected from while approaching birth. We have so much control over our ability to reduce and prevent birth trauma by getting serious about doing the Internal Work.
Our thumb can easily reach all the way back to the muscles near the back of the birth canal. Keep in mind, with our thumb we only work on one side at a time. Just work the muscles and tissue between your sacrum and sit bone.
You will also gain an embodied sense of which positions compress this area or tighten these muscles, thus affecting the sacrum’s mobility. This work will actually help serve your instincts during second stage when you must choose positions for birth. Once you are familiar with this area, it’s easier to choose positions that will keep your unique sacrum and sacral muscles mobile.
We are always working on one side at a time. That means we can’t compare one side to the other as easily.
So just work on where you feel tension or where you find yourself tensing up. Internal tension creates more resistance for your baby.
For partners and women, do not massage on the top of the birth canal near the uterus where your cervix is located. Here, you will only be “checking” for changes prior to, or during, labor.
Directions for “checking” are the same for women and men because both will use the padded side of the middle or index finger to feel for these changes.
After you feel oriented inside to the bottom, back, and sides of the internal space, begin to use your middle finger so the pad is facing upwards. First, just place the tip of your middle finger into the very beginning of the entrance. Near the pubic bone, just above, you’ll be touching and feeling a puffy place. That is where the urethra is located. Don’t massage there.
Now move your finger in a bit more deeply and curl your finger toward the pubic bone. You’ll notice that the pubic bone is now under the tip of your middle finger and it feels like a shelf. Your baby has to come under, or turn the corner of the pubic arch, in order to apply pressure and open all the tissue of the sides, back, and finally the bottom of the birth canal.
Slowly slide your finger up along the wall of the front of the vagina above the pubic shelf and you’ll run into the top of the vagina. This is where the front of the cervix will retract, and when you’re partly dilated, you can feel this change. As the cervix dilates more, the top of the vagina is also pulled to the sides and back (to the hip blades and sacrum). When fully dilated, the front of the cervix is most easily felt on the front wall of your pubic bone where the upper vaginal tissue meets the front of your body.
The top of the vagina and birth canal is where the cervix is located, separating the vaginal canal from the uterus and internal organs above. The cervix is like the opening neck of a balloon and hangs down into the vaginal birth canal.
For your baby to move out of the uterus, the opening of the cervix has to reach 10cm, approximately 4 inches. If you bring both hands out in front of you and touch the two index fingers and two thumbs together forming a circle, you’ll see an approximate visual of this spatial size and dimension. The cervix has to open up all that way. Contractions are what accomplish this.
The stretching, pulling, and retracting as the cervix opens is what causes the pain during contractions, particularly after the cervix is 5cm dilated. (Consciously breathing into this space and learning relaxation and softening skills, you can greatly ease and manage the contraction pains.)
Once the cervix is retracted and open, then your baby moves into the bigger space of the top of the birth canal. The cervix is pulled to the sides and back, though we cannot feel these areas by touch. We can only touch and feel the cervix retracting toward the front. This is also what makes the vaginal canal so mysterious.
What can hinder your baby’s descent after full dilation are the tense muscles that cover the back of this canal, connecting your sacrum and sit bones. Your baby has to move the sacrum back and out in order to move around, and not bang up against, the pubic shelf. If the sacrum can move easily, then the baby “turns the corner” and begins to open up the exit of the vagina.
Partners can see and hear the birth process from the outside, which means they can help their partner if she is needing support to cope and manage throughout the process. Learning teamwork and birth skills together allows a partner to offer help (if the mother desires) in valuable ways.
Both psychological and physical trauma is part of the historic picture of women “suffering” in childbirth. We can help change this for ourselves by learning how to work through the birth process! While many women don’t like labor pains and sometimes feel psychologically scarred after birth due to the unexpected stresses or intensities of pain, rarely do labor pains themselves cause permanent physical damage.
However, the baby’s head passing through a tight vaginal canal can more often leave us with long-lasting physical problems. Just five to 10 minutes of Internal Work per day for eight weeks can reduce or prevent this trauma. A father who helps at the request of their pregnant partner can be so important for the family’s birth experience! The results of this Internal Work for families have been spectacular.
Notes on How to “Check” for Changes in Pregnancy and Labor
The first stage of labor is when contractions retract and open the cervix to 10 cm or 4 inches. The second stage is the pushing phase of labor. Here, the baby is moving through the soft tissue of the vaginal birth canal. This stage can be prolonged if the vaginal canal is tight or tense.
We can “check” progress for ourselves either sitting or standing. What do most of us feel for? We check for change. When do we do that? When we don’t know where we are in the process of pregnancy or labor. It’s really that simple. Here’s a common scenario.
In pregnancy, you can check if the tissue at the top of the vaginal canal is “puffy” or “smooth.” If it’s puffy, this indicates that the cervix is not “effaced.” If it is sort of puffy, this means it’s “partly effaced.” When the tissue is very thin and smooth, this means the cervix is “effaced.” You can feel this change by checking yourself periodically in the last week or two before birth.
When labor first starts, we check ourselves to get a baseline understanding of what’s happening. At birth, we see if we can find the cervix. If not, this means we’re not very dilated. If we can feel and trace an “arc” (which is the cervix beginning to open), it means we’re dilating. If the cervix is retracted close to the inside of the pubic bone shelf, this means we are almost “fully dilated.” When it’s retracted all the way to the pubic bone, then we are “fully dilated.”
Then we can begin to check for the baby when we feel inside. If after checking and you’re not certain, then it means your baby hasn’t come into the inlet of your pelvis, referred to as “-2 Descent or Station.” If you can feel a flat expanse, then your baby has come into the inlet but not yet into the mid-pelvis, called “-1 Descent.” If you can feel a curve of the grapefruit (baby’s head), that means you are at “0 Descent.” If you feel like you’re “sitting on a ball,” then you’re at “+1 or +2 Descent.”
The families who developed the Birthing Better skills learned to check themselves whenever “things change.” That’s a vague statement now, but during birth it becomes very clear. If you feel you’re stuck doing the same thing for hours, you can check where things are inside. If you notice a change externally, you can check internally to see.
The internal changes occur to the tissues, cervix dilation, and baby’s head presentation. If you don’t feel that things are changing, then think about the positions you are using. At some point, labor can change very frequently. If your labor is progressing well, then changes occur frequently, within an hour or two. Checking yourself gives you and your partner a baseline as to how labor is progressing.
Birthing Better families just wanted to know where they were. They’d love to have known, “How much more time is this going to take?” We can know the former, but not the latter. Families discovered that by preparing the body for birth, including the vaginal birth canal, and by learning additional birth skills together, they could achieve what they hoped for—more progressive labors, which means laboring for shorter instead of for many hours or even days.
Checking where you are helps enormously to adapt during the activity of birth, including which positions to take and which skills to apply. The Internal Work allows us to know and feel good knowing where we are. It comes from empirical experience and feedback from over 50 years of families who have done the work. They know it works. But we have to do it ourselves for it to work. Together, Common Knowledge Trust agreed to hold all these phenomenal skills and promote the common sense “Concept” that skills, in general, are beneficial for preparing our pregnant bodies for birth and helpful in the activity of birthing our babies.
P.S. We find pelvic floor exercises to be excellent, especially up to 24 weeks of pregnancy and for the years between pregnancies and after the birth. From 24 weeks pregnant and onwards, we really need to learn how to be open, pliable, flexible, and how to soften to let our baby out, rather than strengthen the pelvic muscles. We can do exercises and learn skills that help us soften for birth.
P.P.S. Women who experienced sexual abuse prior to pregnancy or birth found that their experience would not interfere with their births if they could perceive that there are many things that go on “down there” every day that we don’t react to or associate with the abuse. We pee, we have cycles, we change tampons, we deal with potential health problems, etc. When we identify birth as just one of the many functions going on “down there,” we can help safen a pleasant, calm birth experience for ourselves.