Most women are fearful when it comes to labor and childbirth especially when it involves tearing. “It’s important to normalize the notion of vaginal tearing and not to fear it, because it happens so often,” says Katie Page, a certified nurse-midwife in Forest, Virginia. Get the facts about down-there tears, so you know what to expect.
Vaginal tear is a spontaneous (meaning a doctor didn’t make a cut) laceration to the perineum (the area between the vagina and rectum) that occurs when the baby is pushed out. “During birth, the vagina has to stretch enough to allow a baby, whose head is the size of a cantaloupe, to come through it,” says Sherry Ross, M.D., an ob-gyn and women’s health expert at Providence Saint John’s Health Center in Santa Monica, California. “Hopefully, the vagina will stretch just enough without tearing, but often a tear does happen.”
Why Tears Occur During the second stage of labour, the baby’s head descends into the vagina and moves down onto the perineum. The perineal skin (the area between your vagina and anus) must thin and stretch over your baby’s head. As the baby’s head begins to crown, the labia and vaginal opening begins to bulge and stretch around the head. If the skin and perineum have not stretched sufficiently then a tear can happen.
Factors that trigger tearing are:
*Posterior position of baby
*Increased weight gain in pregnancy *First vaginal birth
Classification of tears
Tears or lacerations of the perineum are classified into four types.
The most common are first and second degree tears.
A first degree laceration occurs when the skin has torn but is considered small and doesn’t require any or only a few stitches.
A second degree tear involves skin and muscle underneath and usually needs a few stitches. More severe tears are less common and occur in around 1% of births, usually as a result of an episiotomy.
Third degree lacerations are a tear in the vaginal skin, perineal skin and the muscle that extend to the anal sphincter (muscle around your anus).
A fourth degree tear is the same as a third degree one except it extends into the anal sphincter and the tissue around it.
Third and fourth degree tears can impact on the pelvic floor function and anal muscles.
It’s hard to predict which women will have a tear but there are things you can do to minimise your risk of a tear, or the extent of a tear if it does happen.
Recovering after tear
If you experience a first- or second-degree tear, you can expect some discomfort—especially when you’re sitting straight up—for a week or so. Having a bowel movement or doing anything that causes an increase of downward pressure, like coughing or sneezing, will hurt, too. By week two, the tear should be pretty well healed and the stitches will have dissolved, “but the nerves and full strength of the muscles can take several more weeks to heal,” says Page. (Sex at six weeks will likely be uncomfortable, too, depending on the location of the tear and the quality of the stitching.)
Healing for third- and fourth-degree lacerations takes longer, with two to three weeks of initial pain. And discomfort during sex, or while having a BM, may last for several months. (Stool softeners and a diet of fiber-rich foods can help with the latter, says Page, as can cold compresses and herbal sitz baths.) Since severe tears into the vagina or rectum can cause pelvic floor dysfunction and prolapse, urinary problems, bowel movement difficulties, and discomfort during intercourse, it’s important to share all of your symptoms with your doctor, no matter how embarrassing they may seem.
Ways to avoid tearing
1. EAT RIGHT & EXERCISE
You may be wondering how your diet and exercise can help with minimizing vaginal tearing during childbirth. But it’s true that good nutrition, hydration and exercise can help improve your skin and muscle health as well as your circulation and skin elasticity. A lot of us don’t do regular exercise and sometimes this comes to a complete halt when we are pregnant. But labor is a marathon and pushing requires endurance, flexibility and strength. It’s important to get your body moving to help improve your blood flow which in turn improves your skin’s elasticity.
Also, having sex and orgasms are helpful since it can help improve your blood flow from your perineum to your vagina as well as improve your tissue health. So keep that passion and love alive!
2. CHOOSE YOUR CARE PROVIDER & BIRTH LOCATION WISELY
Having gone to hundreds of births myself, I have seen how many different doctors and midwives work during the pushing stage I also notice how the place you choose to give birth can affect your birth’s outcome. Some care providers are more aggressive and instructive during pushing and others are more patient and gentle. Get to know your care provider and ask him/her questions about how they assist their patients when they are pushing. Ask what their opinion is on natural tearing versus episiotomies, what their episiotomy rate is as well as the support techniques they use. (For example, warm compresses, perineal massage, positioning, etc.) Generally midwives have a significantly lower rate of clients tearing and cutting episiotomies.
3. DO YOUR KEGEL EXERCISES
You may think that Kegels are counter-productive when it comes to preparing for birth, but that couldn’t be further from the truth. Yes, you need your pelvis and vagina to be relaxed and open during the second stage of labor, however, you also need pelvic floor strength to help baby descend and deliver. Kegels (pelvic floor exercises) help strengthen those muscles which give you the strength to push your baby out. However, Kegels should be accompanied with squats since together they will improve the lengthening and coordination of your pelvic floor muscles. If you do not practice relaxing your pelvic floor, lengthening those muscles while working on your strength, then that won’t help.
4. PRACTICE PERINEAL MASSAGE
Your body has never pushed out a baby before so it’s good idea to prepare your perineum for this type of stretching. You can do that by doing perineal massage. Perineal massage during pregnancy has been shown to reduce the risk of tearing in mothers having their first vaginal birth. By stretching and opening your pelvic floor and vagina before birth, this can prepare your body for what’s to come and reduce pelvic trauma. Perineal massage can also be done by your care provider during the pushing stage to help stretch your perineum as your baby’s head is descending.
5. GET AN EPI-NO
I’m actually a BIG fan of Epi-Nos. Too bad that are not sold in the US because they are not FDA approved. Which I find absolutely ridiculous. It has been proven in studies to be beneficial in decreasing damage to the perineum during vaginal childbirth. What woman wouldn’t want one? I have had several clients purchase them while they were overseas or have had friends ship it to them and I will say, they really do help. All of these women either had either very minimal tearing or no tearing at all. If you can get one, I recommend it.
6. GET A DOULA
Yes, hiring a doula is also a great way to reduce your chances of tearing. A doula helps relieve stress and tension during labor. The more tension you hold, the more likely you will tear. She helps you move into different positions during labor and pushing and she uses different methods to help you stay relaxed and strong.
7. AVOID AN EPIDURAL
Studies have shown that women who don’t get pain meds during labor are more likely to have their perineum intact after giving birth. There are two main reasons for this. Firstly, an epidural prevents you from assuming the best positions for giving birth. You are limited to only pushing on your back or maybe your side. Secondly, a great majority of women who receive epidurals are unable to feel what is happening in their bodies and do not have the urge to push. They then have to rely on their doctor, nurse, doula, partner telling them when to push and how to push even though their body may not be ready. These two reasons are major risk factors for tearing.
8. LABOR IN WATER
For most people, taking a nice warm bath or shower are the perfect places to help your body and mind fully relax. The same is true when you are pregnant and in labor. There are so many benefits to laboring in the water and one of them is that it can help soften the perineal tissues. Not only that, laboring in water while in transition and during pushing can also ease the sensation of the baby’s decent and the crowning stage.
9. GET INTO GOOD PUSHING POSITIONS
The position you are in while you are pushing could determine whether or not you will tear. To minimize the chances of tearing, the best positions are:
- On all fours, on hands and knees.
- Leaning forward in a supported standing, kneeling, or sitting position
- Lying on your side.
Squatting and kneeling are also great pushing positions, however, if the woman’s knees are too far apart the perineum will be stretched sideways and may increase the likelihood of tearing.
Ultimately, the best position while pushing is the position that your body chooses. Listen to your body and do what feels best and right for you.
10. BREATHE MORE WHILE YOU’RE PUSHING
As long as you and your baby are doing well, it’s encouraged that you breathe more during the pushing phase. Breathing helps stretch your pelvic floor and reduces tearing. When your baby is this low in your pelvis, you will feel the urge to push and bear down during each contraction. That is good and normal. But listen to your body. If it’s too much tension breathe through it and allow your body to stretch as your baby descends lower. You don’t have to push with all of your might while holding your breath in order to birth your baby. Actually, the faster your baby comes out, the less time your body has to stretch which then causes it to tear. Breathing with your contractions allows your baby to descend slowly and it will help you have less pelvic floor trauma
11. USE WARM COMPRESSES
When your baby is crowning, a warm compress held to the perineum can reduce tearing. The warmth of the compress increases the blood flow to that area and the counter pressure also can feel very relieving.
12. AVOID AN EPISIOTOMY
If you don’t know what an episiotomy is, it is a surgical cut made to the skin and muscle of the perineal area, to enlarge the vaginal opening. For some doctors they are a routine procedure on almost all patients. For other doctors it is done only when performing assisted births (for examples, using forceps or a vacuum).
Tearing naturally is a lot better than having an episiotomy for many reasons:
- The cut of the episiotomy increase the chances of the mother having a third or fourth degree tear. This happens because the baby’s head presses against that cut and causes it to tear deeper into the muscle.
- Tears heal better than episiotomies.
- Scar tissue from an episiotomy restrict the perineum’s ability to stretch which cause more tearing in future births.
- Episiotomies can cause infections, perineal trauma, urinary and fecal incontinence, and painful sex.
Make an appointment with your healthcare provider for additional treatment if you’re experiencing unexpected bleeding, pain, or vaginal swelling following birth, or if your vaginal tear isn’t healing or is getting worse.