By Hayley Oakes LM, CPM ~
Second to the fear of the ‘pain’ (although I like to call it intensity) of childbirth, I find that most women are nervous about the idea of vaginal tearing during birth. Or some women have little to no fears about the birth but a heightened anxiety about tearing and the potential of needing stitches ‘down there’. While tearing is somewhat common, there are some ways of preventing it from happening during childbirth.
What is a vaginal or perineal tear?
A tear is a natural opening of the tissues (versus a cut your care provider makes, which is called an episiotomy) inside of your vagina or in the area that’s between your vagina and butt (your perineum).
What are the types of tears?
There are four degrees of severity of a laceration with the first being minor to the fourth being significant.
1st degree: Superficial skin tears most of the time called “skid marks”, which most likely don’t need stitches unless actively bleeding.
2nd degree: Tear went through the skin and into the perineal muscle. This requires a few stitches.
3rd degree: Tear went through topical skin layers, through the perineal muscles and the first layer of anal sphincter muscle. This will require a more thorough repair that your midwife may be able to perform depending on her training. Otherwise, transferring to the hospital or having a physician come to the birth setting to do the repair is necessary.
4th degree: Tear all the way through your rectum. This is very rare and usually comes with a complicated delivery. This will need a repair by a physician, so, again, you will need to transport to a hospital unless a physician is available to come to your home or birth center. (1)
How often does tearing happen?
Even with the most gentle births, about 50-70% of mothers will have some kind of vaginal laceration (usually 1st or 2nd degree tears). (2) This can be due to many things, including the baby’s position, its size, a rapid delivery or the health of one’s vaginal and perineal tissues.
There can be more significant tears when there is a higher risk birth, i.e. maternal obesity, breech presentation (baby is butt down), shoulder dystocia (when the baby’s shoulder is lodged behind the mother’s pelvic bone inhibiting the baby’s descent and getting ‘stuck’) or when instruments like a vacuum extractor or forceps are involved to assist with the delivery. (4)
Would a cut just be better in preventing a tear?
NO! Midwives only perform episiotomies if medically indicated, i.e. distress in the baby (characterized by deceleration in the heart rate) at the time of crowning and needing to get the baby out ASAP. While an episiotomy is still a somewhat routine procedure in the hospital (12%), the evidence shows that this should not be done (unless truly medically necessary) as the risks (severe perineal trauma and healing complications such as postpartum anal incontinence) outweigh the benefits. (3,7)
Also, a greater risk of a severe tear is more likely with an initial cut. For example, when you cut a piece of fabric, it is much easier to then rip apart the material versus trying to tear it apart without making a snip first.
Do midwives use anesthetic in suturing the tear?
YES! Most out-of-hospital midwives carry a topical anesthetic and/or an injectable medication called Lidocaine. Although, not all midwives use anesthetic, as there is risk of causing more inflammation to the tissues after injecting the medicine, which doesn’t allow for the edges of the tissues to come together as precisely. (1)
However, while we midwives are all about natural birth, having a needle and thread in your vagina is not so ‘natural’ and most feel it’s okay to use numbing medication for that part of the birth experience. Once numbed, you shouldn’t feel anything sharp or painful except pressure of the midwife’s touch.
What is the postpartum recovery like with a tear?
If a tear happens, the healing process is very manageable. By following the strict instructions from your midwife of being off your feet for the first week, using ice pads and doing herbal sitz baths, the stitches will absorb in the first 7-10 days and the swelling, inflammation and soreness should resolve within 2 weeks. (1) However, it takes at least 6 weeks for the repair to heal completely, so be kind to your perineal area until then by taking things slow. Being up and about right after the birth will cause more pain, swelling and will prolong healing time.
As one physician said to me, the vaginal tissues are the most forgiving part of the body. The body is designed to find equilibrium and harmony and will overcompensate and adjust if need be. To that end, the tissues in the vagina want to go back together as they did before.
What can be done to prevent tearing?
Nutrition is everything. Having a balanced diet provides optimal nutrients to maintain a healthy, stable pelvic floor. Specifically, vitamin C and E contribute to the skin’s elasticity, which will help the perineum stretch during the birth. (5)
Finding a balance of pelvic tone is important as there is a risk of that area being both too weak or too tight. The increasing weight of your growing baby puts pressure on that area, compromising the amount of pelvic tissue strength. When tissues are too too weak in the last weeks of pregnancy, there is a risk that they will release too much during the pushing phase, which can cause a faster delivery but more tearing. And we don’t want a super toned pelvic floor either. This can cause a longer pushing stage and potentially more tearing from a baby trying to get through your ‘pelvic wall of steel’. We see this a lot in our practice with mothers who practice dance, pilates and/or who were horse back riders. (6)
A good gauge as to the tone of your pelvic floor is sticking one finger in your vagina and clenching your perineal muscles around it to assess what the strength is (or have your partner test while making love). The amount of ‘grip’ around your finger is your best measurement of tone. This may be characterized as feeling nothing, superficial tone (just the tip of finger), moderate tone (3/4 of the finger) and strong tone (entire finger). Another good barometer of pelvic tone strength is whether or not urine escapes when coughing or laughing. If it does (!), it’s time to do some more strengthening.
During pregnancy, you can start by doing a basic Kegel muscle exercise of clenching (like you’re trying to stop the flow of urine while on the toilet – or it escaping while laughing or coughing) and releasing. At a certain point, you will master that and will advance to ‘Kegels 102’, which is when you hold the clench for a little longer than a second – maybe 5 or 10 seconds, and then release. This will help build the deeper muscles of your pelvic floor (as there are multiple layers).
If you have a super strong pelvic floor than a good exercise is doing the opposite of a Kegel. Instead of clenching and engaging the pelvic floor muscles, the focus is to relax and release them. Physical therapist, Dr. Brianne Grogan writes about the ‘reverse Kegel’ on her blog. She says that all pregnant need to learn how to ‘let go’ in order to give birth. Below is her instruction of how to soften your pelvic floor.
“Imagine your pelvic floor as an elevator that starts at a lobby and can go up two floors, or can go down to a light-filled, completely non-threatening basement. Your baseline level of pelvic floor tension (i.e. no contraction and no relaxation) is the “lobby.” Start here. Imagine the elevator doors sliding closed as you begin your pelvic floor muscle contraction. Gently lift your pelvic floor elevator up to the first floor by contracting your pelvic floor muscles halfway. Do not fully contract; in other words, do not allow your pelvic floor elevator to go all the way up to the second floor.
Next, relax fully and visualize your pelvic floor elevator lowering past the lobby and going all the way down to the basement. Really, fully, and deeply let go. Release any tension that might be held in the pelvic floor as you imagine the elevator doors sliding open to reveal a light-filled basement. Relax your pelvic floor enough that you stop just short of urinating.”
This is exercise is beneficial especially for the crowning phase, as clenching will only hold the baby back and cause a tighter “ring of fire” (for those of you who don’t know yet, that’s what the crowning phase is called. And it has nothing to do with Johnny Cash).
Lastly, imagine doing an egg toss, you want to give into the egg and not just stick your hand out straight as that will crack the egg. Having some mobility to your perineal floor will allow for optimal stretching and not ‘crack’ the tissues, like an egg.
Squatting has been shown to help reduce the occurrence of tearing during birth as it has the effect of stretching your perineal floor like a hammock. So, we have a soft egg toss, a hammock… Who doesn’t want that for their vagina?
Squatting is a very important movement for a pregnant woman. However, in our culture squatting is usually performed in reps during exercise a few times a week. But you can begin squatting every day by using a footstool or what’s called a “Squatty Potty” near the toilet while going to the bathroom. Gail Tulley from Spinning Babies says, “Proper squatting lengthens the pelvic floor for benefits of both muscle control and muscle relaxation. In other words, less urinary incontinence and easier fetal descent in birth.”
This is something that is recommended by some birth professionals as a way to ‘stretch things out’ prior to birth to prevent tearing. However, the only decrease in perineal trauma that massage has been linked to is the decrease in use of episiotomies. (8)
The bigger benefit of perineal massage during pregnancy is to emotionally prepare for the sensation of the aforementioned ‘ring of fire’ and prevent tightening up and thus tearing.
Perineal massage is a good way to practice and condition yourself to not hold back when pressure, burning or some discomfort is felt in your vagina, which is of course one’s natural propensity. It is an opportunity to breathe and soften into that new sensation, as you will be encouraged to do so by your midwife at the time of crowning, right before your baby is born. You can either do this solo – probably easiest in the shower with one foot up on a ledge using your thumb or your partner can help you using the index and middle fingers of both hands in the vagina to apply downward and outward pressure around the perineum.
Moisture and heat
While you’re in labor and close to having your baby, the use of sterile, hot, wet compresses applied to your perineum by your midwife allows for the tissues to soften and become more relaxed while beginning to stretch. You can also use an unopened bottle of a food-based oil (unopened so it’s fresh and food-based, i.e. olive or grape seed oil because it’s natural and less irritating to the skin) to help lubricate tissues, as some women feel the burning of stretching as a dryness, making it more difficult to soften (and push more) into that sensation.
Even if you were not laboring in the tub (or you were but without a lot of progress) it may be a good idea to get back in the tub for the moment of birth. A water birth will be beneficial in reducing the incidence of tearing. Hydrotherapy, in general, promotes an overall sense of decreased tension, pain, and thus fear and anxiety allowing your body to relax more with the sensations of discomfort.
Lastly, what you do with your mouth affects your vagina. The fascia that is covering your pelvis and pelvic floor connects all the way up to your face and jaw. If your face is relaxed, your perineal tissues will be as well. There is a saying (only in the birth world), “open mouth, open vagina”. Doing things to soften your face will also help soften your vagina! Smiling, ‘horse breaths’, singing, and kissing your partner at the time you are crowning can also allow for greater stretching, relaxation and an intact perineum.
1. Frye, Anne. Healing Passage: A Midwife’s Guide To the Care and Repair of the Tissues Involved in Birth. 6th ed. Portland, Or: Labrys, 2010. Print.
2. Haelle, Tara. “ACOG: New Recommendations on Obstetric Lacerations.” Medscape. N.p., 24 June 2016. Web. 4 June 2017.
3. Hook, Christina D., and James R. Damos. “Vacuum-Assisted Vaginal Delivery.” American Family Physician. American Family Physician, 15 Oct. 2008. Web. 04 June 2017.
4. Walker, Molly. “ACOG: New Guidance to Prevent Vaginal Tearing During Delivery.”Medpage Today. Medpage Today, 24 June 2016. Web. 04 June 2017.
5. Bruce, Elizabeth. “Everything You Need to Know to Prevent Perineal Tearing.” Midwifery Today, no. 65.
6. Bergen, Nikki. “Exercise Tips From a Pregnant Pelvic Floor Physiotherapist.” The Belle Method, 27 Oct. 2015, thebellemethod.com/uncategorized/exercise-tips-from-a-pregnant-pelvic-floor-physiotherapist/.
7. “Ob-Gyns Can Prevent and Manage Obstetric Lacerations During Vaginal Delivery, Says New ACOG Practice Bulletin.” 22 June 2016.
8. Dekker, Rebecca. “What Is the Evidence for Perineal Massage During Pregnancy to Prevent Tearing?” Science & Sensibility: A Lamaze Research Blog About Pregnancy, Birth and Beyond, 18 Dec. 2012, www.scienceandsensibility.org/blog/what-is-the-evidence-for-perineal-massage-during-pregnancy-to-prevent-tearing.