Tearing During Childbirth: What You Need To Know
One of the most common fears I hear from clients is, “I’m scared of tearing”. Either the idea alone is enough to bring anxiety, or they’ve had a friend or family member who had an experience with a severe tear and a difficult recovery as a result. If you find yourself having these same thoughts and fears, just know you are not alone. There is no 100% guaranteed way to avoid all tearing during the birth of your baby, but there are ways you can prepare and support those sensitive tissues and muscles during pregnancy and labor to give yourself the best chance of keeping that sensitive area intact and free of damage.
Types of Tears & How They’re Classified
Perineal tears are the most talked about - these are the tears that happen in the diamond-shaped area of skin and muscle between your vaginal opening and your anus. It is also possible to have tears in the vaginal wall, labia, clitoris and other parts of the vulva. A tear can be classified as first, second, third or fourth degree. First degree tears involve the skin - may or may not need stitches and typically heal on their own without them. Second degree tears involve the skin and muscle - this is the most common type of tear and requires stitches. Third degree tears extend from the vagina, through the perineum and involves the anal sphincter muscle. Fourth degree tears involve the vagina, perineal tissue and muscle, anal sphincter and further rectal muscle, tissues and occasionally involve the bowel. 3rd and 4th degree tears are considered OASIs, or Obstetric Anal Sphincter Injuries. These types of tears are the most severe and depending on the extent of the damage may need surgical repair in the OR, and a much more lengthy healing process.
In a childbirth education class or through media, you may have heard of something called an episiotomy. An episiotomy is a deliberate cut in your perineal tissue and muscle made with your consent by your provider while your baby is being born. Episiotomies used to be commonplace as an alternative to tearing. The idea was that the provider would make a clean cut in an attempt to make space and aid in the birth of baby’s head, but evidence shows that episiotomy may actually increase the instance of 3rd and 4th degree tears. Thankfully, episiotomies are not standard procedure anymore, but it’s a good idea to ask your provider if there are any instances where they would consider an episiotomy, and let them know about the measures you’d like them to take in order to protect your perineum as much as possible.
How and When to Support The Perineum
The perineum is a very small area that has some big connections within the tissue and muscles. The muscles within this area work to support your pelvic floor and the nerves within help with urination, bowel movement sensation, and sexual function. Understandably, if any of these structures are damaged, it could result in other issues that will impact your recovery time and your quality of life after birth. There are several things you can do, both now and during your labor and delivery process, that can help support and protect your perineum.
Things You Can Do Now:
See a Pelvic Floor Therapist to assess or resolve any prior weaknesses.
Research pushing techniques and practice them along with mindful breathing.
“Laboring Down” before actively pushing/waiting until you feel the urge to push may help reduce active pushing time, giving baby time to slowly stretch the tissues and muscles as they come down.
Delivering baby’s head between contractions, or using a shallow and fast breathing technique while crowning.
Open-Glottis pushing - grunting or breathing through pushing. Practice this while having a bowel movement, pay attention to what muscles you are contracting while exhaling purposefully (like you’re blowing up a balloon).
Upright positions to use: hands-and-knees, squatting, semi-reclined, standing. Other positions that may be beneficial: side-lying.
Ask your care team and support team (partner, doula, etc.) to help facilitate a calm, peaceful, non-urgent environment for pushing, where you feel comfortable following your body’s lead.
During birth, there are a few different options for perineal support, specifically during the pushing stage, which is when most tearing happens.
Options for Perineal Support During The Pushing Phase
Smart Positioning
In one study review, upright positioning was found to decrease the instance of episiotomy, assisted deliveries (forceps or vacuum) and severe perineal trauma, but researchers found no decrease in perineal tears requiring stitches. However, side-lying was shown in one trial to result in a significant increase in intact perineum.
Warm Compress
One meta analyses showed warm compress resulted in a decreased risk of severe tearing and episiotomy, and an increase in rate of intact perineum.
A Hands-Off Approach OR A Provider With Skillful Hands-On Methods
The jury is still out when it comes to evidence for hands-off or hands-off methods during pushing. Some of the evidence shows that an experienced provider (in this case, a midwife) utilizing a hands-on technique actually showed a lower rate of severe tearing. However in another review, a hands-on technique was linked to an increase in more 3rd degree tears than a hands-off approach.
**Ask your provider how they protect the perineum to get a sense of their experience level and how they will work to prevent tearing if they use a hands-on approach**.
Perineal Massage
A review of 5 studies showed that perineal massage during pushing showed a 50% decrease in severe tears. Showed a general decrease in use of episiotomy and severe tearing especially in FTMs (first time moms).
You take all these steps, and you still tear….now what?
Unfortunately, there is no 100% guaranteed way to avoid tearing during labor and birth. You can do all of the right things and still end up with a tear; there may be weaknesses in the skin or muscles of your perineum that you couldn’t have known about before. Or there were other circumstances of delivery that caused more damage than you could have anticipated (for example: shoulder dystocia, forceps, vacuum assist). So what happens next? Your provider will assess the extent of the tearing in the moment and repair accordingly right there in your L&D room. If the tears are extensive or involving nearby structures like your urethra, other specialists may be called in to help repair the damage and/or you may need a more in-depth surgical repair in the OR. Afterwards, your nurse will instruct you on how to care for your perineum as it is healing. Most stitches for 1st and 2nd degree tears will dissolve on their own within a few weeks. You can use ice packs, dermoplast, sitz baths and a peri bottle filled with warm water to ease discomfort, and your provider may instruct you to alternate Tylenol or Motrin to manage pain, and if the tear was more extensive, they may prescribe a stronger pain medication.
After you get home, sitting on a Boppy Pillow or lying down can help ease the pressure or discomfort on the area. It’s important to have a postpartum plan in place that leaves room for physical and mental rest and recovery for yourself. It’s also a good idea to plan a visit to a Pelvic Floor PT to help regain strength in your pelvic floor, or address other issues such as fecal or urinary incontinence, or pain during sex (6 weeks postpartum and onward).
Tearing can also cause emotional and mental trauma ranging from mild to severe, based on other circumstances of the damage or of the birth itself. Know what mental health resources are available to you, and don’t be afraid to ask for help mentally healing from this part of your birth story if it was traumatic for you. Contact your care providers and/or support people/doulas if you have any questions, concerns, or just need a safe space to share thoughts, feelings and emotions.
For more information and evidence on protecting your perineum, check out these links:
Evidence Based Birth - Protecting The Perineum Series
Mamaste Fit - 3 Tips for Gentle Pushing
American Pregnancy Association - Perineal Massage During Pregnancy