Overview

When your skin is stretching during birth, it can tear. It is common for first-time mothers to have some tearing during vaginal birth, and there is also the possibility that you could have an episiotomy, which is a surgical incision. The good news is that you can do some things to prevent this leading up to and during your labor and birth. I know this can sound scary, but it shouldn’t be. The benefits of a vaginal delivery far outweigh the downside of a tear or an episiotomy. Remember that some women make it through a vaginal birth without tearing, so it is not unavoidable. If you do end up with a tear or incision, there is a lot you can do to make yourself more comfortable, give yourself some relief, and help your body heal afterward. 

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As much as I researched everything I could on birth while expecting, I was unaware that tearing was quite common, and I felt like this was something I should have known about. I especially wished I had learned more about how to prevent it and how to treat it afterward. You have the benefit of getting many hours of research, information, and tools all packaged into a short episode and article so that you will be much better prepared.

The Perineum

Your perineum is the area between your vaginal opening and your rectum. This is a sensitive area. Your perineum stretches during birth. Especially when your baby’s head is emerging, referred to as crowning. As your skin stretches, you may experience some pain and discomfort. Your baby’s head has the largest circumference. Once it’s head is out, there is less stretching, and it is a very short time until the rest of its body is born.

The Ring of Fire

When your baby is crowning, their head is coming out, sometimes called the ring of fire. This alludes to a burning and painful sensation that can happen as your skin stretches when they are crowning. I dislike the term “ring of fire.” It has such a negative connotation; if anything, it instills fear. I get it, and I see why some people call it that, but the focus should be on the positive. If your baby is crowning, you are almost at the finish line. You can both see and feel their head, and it will be a short time until you hold that little one in your arms. Keep your focus on that. 

How Common is Tearing?

During the birth of your baby, it is very common to tear your perineum. This is especially true for your first birth. This study shows that the rates of tearing with a first baby are 90% and decrease to 69% in subsequent births. According to the American College of Obstetricians and Gynecologists, the rate of some laceration during all vaginal births is between 53-79%.

Classifying Vaginal Tears

Your doctor or midwife will classify the tear in degrees if you do tear. Vaginal tears are classified by four degrees, with the first being the most minor and the fourth being the most severe.

First-degree tears only involve the skin around the vaginal opening or perineal skin. These usually are not very painful, although you could experience some burning or stinging with urination.

Second-degree tears involve the perineal muscles, between the vagina and the anus that support your uterus, bladder, and rectum.

Third-degree tears involve injury to the perineum involving the anal sphincter complex (the muscles around the anus). 3a is less than 50% of the external sphincter thickness torn. 3b is more than 50% of the external sphincter thickness torn. 3c is when both the anal sphincter and internal sphincter are torn

Fourth-degree tears involve the perineal muscles, the muscles surrounding the anus, and the tissue lining the rectum.

Repairing Tears and Lacerations

A first-degree tear may or may not require stitches, usually healing within a few weeks. A second-degree tear usually requires stitches and heals within a few weeks. If stitches are needed, this usually takes place in the delivery room with local anesthesia. Third or fourth-degree tears can require repair in an operating room and can take months to heal. Some complications can be fecal incontinence and painful intercourse. Third and fourth-degree tears are much less common than the more mild first and second degree.

Episiotomy

An episiotomy is a surgical incision made with either a scalpel or scissors. As far as we know, the first report of an episiotomy goes back to the 1700s. Since that time, rates of episiotomy worldwide have increased substantially. In the first half of the 1900s, there was an increasing move for women to give birth in a hospital with the involvement of a physician, and the increases in rates of episiotomy followed this trend. The thinking was that a clean cut would be easier to repair than a jagged tear. Doctors also believed that an episiotomy could prevent a more significant tear from happening. Episiotomy has become one of the world’s most commonly performed surgical procedures.

The Evidence on Episiotomy

Research has shown us that routine episiotomies are not evidence-based, and a better policy is restricting their use. The American College of Obstetricians and Gynecologists has advised against routine episiotomy since 2006.

In 2007 the Journal of the American Medical Association found that the evidence does not support maternal benefits traditionally ascribed to routine episiotomy. Outcomes with episiotomy can be considered worse since some women who would have had lesser injury instead had a surgical incision. Those with an episiotomy may be more likely to have pain with intercourse in the months after pregnancy and are slower to resume having intercourse. Clinicians have been the primary agents to exercise choice to conduct or not conduct an episiotomy rather than patients. Rates of episiotomy of less than 15% of spontaneous vaginal births should be immediately within reach. The AMA suggests episiotomies should be at 15%, but the rate is closer to 30% in the US. The AMA estimates that 1 million episiotomies are taking place each year that are not improving outcomes for mothers.

One study shows that since 2006, episiotomy rates have decreased to around 11.6% of vaginal births. This rate varies greatly depending on the hospital. Of the top 10% of hospitals that used episiotomy most frequently, the mean adjusted hospital episiotomy rate was 34.1%.

Today organizations like the American College of Obstetricians and Gynecologists and the World Health Organization recommend against the routine use of episiotomy.

While routine episiotomies are generally not practiced today, the procedure is sometimes used. According to ACOG, contemporary data indicate that there are insufficient objective evidence-based criteria to define the indications for episiotomy—and specifically routine use of episiotomy—and that restrictive use of episiotomy remains the best practice. The most common reasons for an episiotomy are shoulder dystocia or operative vaginal delivery or if an issue arises where your baby needs to be delivered quickly. 

How an Episiotomy is Performed

If you need an episiotomy and haven’t had any anesthesia or if the anesthesia has worn off, you will receive an injection of a local anesthetic to numb the tissue. You won’t feel your care provider making the incision or repairing it after delivery. 

There are two types of episiotomy incisions. The first is a midline or median incision, which is vertical. This is the easiest to repair, but it has a higher risk of extending into the anal area. The second is a mediolateral incision, which is at an angle. This offers the best protection from an extended tear going to the anal area but is often more painful and might be more challenging to repair. Research shows us that a midline incision results in more deep perineal tears; otherwise, there was no statistically significant difference between the two. The type of incision used is usually at the discretion of your doctor or midwife, so this may be something you want to bring up ahead of time if you prefer one over the other.

After an episiotomy, your care provider will stitch you up with stitches that will dissolve, and again you won’t feel a thing. If you feel anything, be sure to ask for another local anesthetic; there is no reason for you to be in pain during this procedure.

Episiotomy with an Assisted Delivery An assisted delivery is when your care provider uses forceps or a vacuum to help your baby come out. A study showed that in a forceps delivery, the performance of an episiotomy decreases the risk of perineal tears of all degrees. When they analyzed the type of episiotomy, mediolateral incisions seemed to be more protective against perineal trauma in women undergoing forceps delivery.

Preventing Tearing and an Episiotomy

The good news is that there are some things you can do leading up to and during your labor and delivery to help prevent tearing. If you avoid tearing, you will also prevent an episiotomy. 

Perineal Massage

Perineal massage is an exercise you do in the weeks leading up to birth to prevent tearing. The theory behind perineal massage is that stretching this area leading up to your birth will allow it to stretch more easily and without tearing when your baby is crowning. The first thing you should do if you are considering this is to run it by your care provider.

Overall, there isn’t a pile of evidence supporting perineal massage during pregnancy before birth for shortening labor. A randomized controlled trial of 1,340 women looked at the rates of an intact perineum, first and second-degree tears, and episiotomies. They found that the results were similar for all of these outcomes in the massage and the control groups. The only significant difference was in the rates of third-degree tears. This was 3.6% in the group who did not perform perineal massage during labor and 1.2% in the group who did.

As long as your care provider gives you the okay for perineal massage and you are comfortable doing it, there isn’t a downside. Generally, this is a practice you would perform on yourself. You could involve your partner if you want to get creative. Please check out this episode to see step-by-step instructions on how to massage your perineum and the evidence on how often you should do it.

Applying Heat

Applying a warm compress or warm oil to your perineum helps increase blood flow to the area and softens the tissue and the muscles there. This can help prevent tearing. If you are considering a water birth, warm water should help soften the tissue to avoid a tear. This might be a little difficult for you to do yourself during labor. You want to enlist the help of your partner, your doula, a nurse, your midwife, or your doctor.

This is an example of an excellent item to include in your birth plan. Make sure your partner or anyone else who will be by your side and can be an advocate knows you want to apply heat. This goes for any of the preventative measures we are talking about. Do not be embarrassed to ask a member of your birth team to apply heat during labor. Birth workers deal with this stuff all the time, and it is nothing to be embarrassed about. 

Lubricants

Using a lubricant, like warmed mineral oil, can help to decrease friction and help the baby slide out a little bit easier. Again, this will be tough for you, so enlist the help of your doula, a nurse, your care provider, or even your partner. 

Slow Pushing

Slow pushing is another excellent way to allow your skin time to stretch during labor. Your initial thought is probably that you want to push that baby out as soon as possible, but there are benefits to slowing down this process.

To slow down pushing, try to exhale pushing. This is where you slowly breathe in and slowly exhale. It may also help to make a low or deep sound as you push. This will make the pushing stage slower than taking a deep breath, holding it, and then pushing. When the baby starts to crown, you can switch to short, almost grunting, pushes. It can be hard to keep these techniques in mind when you are in labor. Talk about this with your partner, your doula, and any staff who will present. They can remind you to do this, and even help guide you through breathing and pushing. See this episode for more information on breathing during labor.

Labor Positions

We often think of the most common laboring position of being in a hospital bed on your back. There are some downsides to this position, including that there is a higher probability of a vaginal tear. The reason for this is that position puts more pressure on your perineum. The best position for your labor will change as your labor progresses. Upright and squatting positions are evidence-based to shorten the second stage of labor. See this episode for more information on labor positions.

Healing After a Tear or Episiotomy

If you have an episiotomy or a tear during delivery, the wound will probably be sore for a few weeks, especially when you walk or sit. If the incision or tear is extensive, the tenderness can last longer. This doesn’t sound like fun, but there is good news. You can do many things to give yourself some relief and promote healing. 

Cooling

Cooling can help a lot when your perineum is sore and tender. You can do this with an icepack, chilled maxi, or witch hazel pad. Witch hazel is from the leaves and bark of the North American Witch-hazel shrub and is astringent and anti-inflammatory, and is often recommended for use after childbirth. You can pick this up at a drug store, Amazon, or Target; it is available everywhere. You can also use witch hazel pads commonly used for hemorrhoids.

Post Partum Healing Pads (Padsicles)

You can make soothing postpartum pads, sometimes called padsicles. This is such an easy DIY, and it feels fantastic when you are sore after having a baby. To do this, you only add a few ingredients to whatever pads you want to use and freeze them. Then after you have your baby, you have ice-cold soothing pads to help you feel better and promote healing. Some of the ingredients you may want to include are witch hazel, aloe vera gel, and lavender oil.

There are hundreds of recipes online for these. Mix your ingredients and then pour or spray the mixture on the pad. You can use aluminum foil to layer the pads, so they do not stick together. I recommend putting them in a bowl when you freeze them so they will be slightly curved, making them more comfortable and practical. Voila, you will have soothing pads to help you cope a little easier with some postpartum healing. These are most effective during the first few days, so don’t feel like you have to stock your entire freezer with them. 12-20 is perfect, and they are easy to make if you need more.

Sitz Bath

A sitz bath or an herbal bath can also give you some relief and promote healing. A sitz bath is a small plastic tub that fits over your toilet. You fill it with warm water and sit on it. You can find these at a drug store or on Amazon, and they are pretty cheap, $10-$15 at the most. If you don’t want to deal with this contraption, you can sit in a warm bath in your tub.

While the warm water is soothing, you will add some ingredients to it for some added benefits. These include Epsom salt, baking soda, witch hazel, herbs like plantain leaf, yarrow, calendula, and essential oils like lavender or chamomile. You can use some creativity to use different ingredients, and there are many recipes online. There are also several pre-mixed bath herbs for postpartum care available. Bodily makes an excellent sitz salt you can add to soothe and promote healing.

Going to the Bathroom

After a tear or an episiotomy, it can sting when you go to the bathroom. You can use a peri bottle to make going to the bathroom more com. This is a small plastic bottle with a cap, as you would see on a bottle of dish soap) and the technical name for it is a perineal irrigation bottle. If you have your baby at a hospital or birth center, they should send you home with one. You use the peri bottle to squeeze warm water on your vagina while you pee, and that will help, so it doesn’t sting and works excellent to rinse afterward. You will be careful wiping during the beginning of your healing, so after you rinse with warm water, you can use the tissue to pat dry or just air dry if that feels better.

Many women are pretty intimidated to go #2 after delivery. First, you don’t want to force or strain anything and ensure you have plenty of fiber in your diet so you are not constipated. Don’t worry; it is probably worse in your head than it will actually be. One thing you can do to prevent discomfort and stretching while going #2 is press a clean pad (think like those round flat cotton pads) or use a witch hazel pad against the wound when you are passing a bowel movement. You could also use a stool softener. Please run it by your doctor or midwife first, even if it is available over the counter. I know this is all super glamorous, but I would much rather you know about this than be blind sided. 

Moving Around and Getting Comfortable

You will want to be careful about moving around and sitting down. Listen to your body and make yourself comfortable. If walking doesn’t feel great, hold off on going on walks. You need to heal; there will be plenty of time to run around and do a million things later. Sitting on a pillow or padded ring can be helpful. Do you know that the Boppy breastfeeding pillow is so popular? If you have one, try sitting on it, it is quite comfortable after you have had a baby.

How Your Partner Can Help

A tip for your partner is to minimize the amount of walking or moving around you have to do. Your partner can change your baby and get you a glass of water if it saves you a trip to the kitchen. The first few days are the most challenging, and the more you heal, the easier it is to move around.

Medications

Your care provider might order prescription medications or recommend an over-the-counter pain reliever or stool softener. If you are taking any medicines, clear them with your doctor or midwife, especially when breastfeeding. To check on the safety of medications while breastfeeding, the LactMed database is an excellent resource.

Signs to Watch Out For

Remember that after you have your baby, you are healing, and depending on the severity of a tear or an episiotomy, you will need to take it easy. Your job is to snuggle up with your little one and let your body heal. Keep taking your prenatal vitamin, eat well, and stay hydrated. All of these things will help promote healing. This doesn’t heal overnight, but it will improve over time. If you have concerns that you are not healing well, see your doctor or midwife. Some signs you should call your care provider are if the pain intensifies, if you have a fever, or if the wound produces a pus-like discharge. These could be signs of an infection, and you would want to take care immediately. 

There is something called granulation tissue, and this happens when the tissue gets stuck in the healing process. If you are not consistently healing, call your doctor or midwife. Do not procrastinate in seeking help if you are not healing correctly. If this happens, your care provider can treat it with silver nitrate, which will help to speed up the healing process and stop the tissue from being granulated. 

Talking to Your Doctor and Informed Consent

If you have specific wishes about an episiotomy or measures you want to take to prevent tearing, please discuss it with your doctor or midwife. An episiotomy is a procedure that should come along with informed consent. Having a conversation before you are in labor will allow you to talk through the pros and cons with your doctor and share your position so that you can make a more informed decision when you are in labor.

Your Birth Plan

This is an excellent item to include in a birth plan. If you want to see an example of how this might be worded, you can get a free copy of the plan I used for the birth of my son. Of course, you will want to tailor your birth plan to your specific wishes, but it would give you a good idea of how to word it and clarify what you want.

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