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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 there are some things you can do leading up to, and during, your labor and birth to prevent this. I know all of 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. Keep in mind some women make it through a vaginal birth without any 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.

Article and Resources

In this episode, we are talking about tears during labor and what an episiotomy is, how you can prevent it, and a lot you can do to help your body heal in the event you do end up with a tear or an episiotomy. As much as I researched everything I could on birth while I was expecting, I was not aware that tearing was quite common, and I felt like this was something that I should have known about. I especially wished I knew 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 so 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 and this is referred to as crowning. As your skin stretches you may experience some pain and discomfort. Your baby’s head has the largest circumference and once their head is out there is less stretching and it is a very short time until the rest of their body is born.

The Ring of Fire

On a quick tangent, when your baby is crowning, meaning their head is coming out this is sometimes referring to as the ring of fire. This is alluding to a burning and painful sensation that can happen as your skin is stretching when they are crowning. I really dislike this the term “ring of fire”. It has such a negative connotation and if anything it instills fear. I get it and I see why some people call it that but the focus should really be on the positive. If your baby is crowning you are almost at the finish line. You will be able to both see and feel their head and it will be such a short time until you are holding 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 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 type of laceration during all vaginal births is between 53-79%.

Classifying Vaginal Tears

If you do tear your doctor or midwife is going to classify the tear in degrees. Vaginal tears are classified by four degrees with first degree being the most minor and fourth-degree 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, which are the 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 is torn
  • Fourth-degree tears involve the perineal muscles, the muscles that surround the anus, and the tissue lining the rectum.
  • Repairing Tears and Lacerations

A first-degree tear may or may not require stitches and usually heal within a few weeks. A second-degree tear usually requires stitches and heals within a few weeks. If stitches are required 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 follow with 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 larger tear from happening. Episiotomy has become one of the most commonly performed surgical procedures in the world.

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 the evidence does not support maternal benefits that were traditionally ascribed to routine episiotomy. In fact, outcomes with episiotomy can be considered worse since some proportion of women who would have had lesser injury instead had a surgical incision. Those who have 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 in the US the rate is closer to 30%. The AMA estimates 1 million episiotomies are taking place each year that are not improving outcomes for mothers.

One study shows since 2006 rates of episiotomy 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 examined the available evidence and recommends against the routine use of episiotomy. While routine episiotomies are generally not practiced today, the procedure is used in some cases. 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 for 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 you haven’t had any type of anesthesia or if the anesthesia has worn off, don’t worry, you won’t feel anything. 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 midline or median incision, which is done vertically. 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 done 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 difficult to repair. Research shows us that a midline incision results in more deep perineal tears, otherwise there was no statistically significant difference in 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 do feel anything, be sure to ask for another local anesthetic, there is no reason for you to be in any pain during this procedure.

Episiotomy with an Assisted Delivery

An assisted delivery is when your care provider uses forceps or a vacuum to assist your baby is coming 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, and of course if you prevent tearing, you will also prevent an episiotomy.

Perineal Massage

Perineal massage is an exercise done by you in the weeks leading up to birth to prevent tearing. The theory behind perineal massage is that by 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. Just in case there is something in your medical history or with your pregnancy that might make perineal massage not the best idea for you.

Overall, there isn’t a pile of evidence supporting perineal massage during pregnancy prior to birth for the purpose of shortening labor. There is a randomized controlled trial of 1,340 women that looked at the rates of an intact perineum, first and second-degree tears, and episiotomies. They found that for all of these outcomes the results were similar 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 any 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 to this. Generally, this is a practice you would perform on yourself and you could also involve your partner if you want to get creative. To see step by step instructions on how to massage your perineum and the evidence on how often you should do it, please check out this episode.

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, the same idea, the warm water should help soften the tissue to prevent a tear. This might be a little difficult for you to do yourself during labor so 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 and make sure your partner or anyone else who will be by your side and can be an advocate knows you want to do this. This goes for any of the preventative measures we are talking about. And just a note, do not be embarrassed about asking about this. 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 probably be tough for you to do yourself 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 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 a bit slower than taking a deep breath, holding it, and then pushing. When the baby starts to crown, so when their head is coming out, you can switch to using short, almost grunting, pushes.

It can be hard to keep these techniques in mind when you are in the midst of labor so talk about this with your partner, your doula, and any staff who will present to remind you to do this and they can even help guide you through some of this. For more information on breathing during labor check out this episode.

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. For more information on labor position, you can check out this episode.

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, this is especially true when you walk or sit. If the incision or tear is extensive, the tenderness can last longer. I know this doesn’t sound like fun but there is good news. There are a lot of things you can do to both give yourself some relief and to promote healing.

Cooling

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

Post Partum Healing Pads (Padsicles)

You can make your own soothing postpartum pads, or sometimes called padsicles. This is such an easy DIY and it feels amazing when you are sore after having a baby. To do this all you do is 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. You mix your ingredients together 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 which makes them a little more comfortable and effective and you just pop them in the freezer. 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 a great amount of them, and they are easy to make if you needed 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 this at a drug store, on Amazon, and they are pretty cheap $10-$15 at the most. If you don’t want to deal with this contraption you can just sit in a warm bath in your tub. While the warm water is soothing, you are going to add some ingredients to it for some added benefits. These can include Epsom salt, baking soda, witch hazel, herbs like plantain leaf, yarrow, calendula, and essential oils like lavender or chamomile. You can definitely use some creativity to use some different ingredients, and there are a ton of recipes online. There are also several pre-mixed bath herbs for postpartum care available. Bodily makes an amazing sitz salt you can add to soothe and promote healing. (Use code PREGNANCYPODCAST for 10% off)

Going to the Bathroom

After a tear or an episiotomy, it can sting when you go to the bathroom. To make going to the bathroom more comfortable you can use a peri bottle. This is a small plastic bottle with a cap like you would see on a bottle of dish soap) and the technical name for it is 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 great to rinse afterward. You are going to be really careful wiping during the beginning of your healing so after you rinse with warm water you can just 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 make sure 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 to press a clean pad (think like those round flat cotton pads) or you could 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 something available over-the-counter. This is all super glamorous I know, but I would much rather you know about this stuff before than be surprised by it and not know what to do later.

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 later to run around do a million things. Sitting on a pillow or padded ring can be helpful. Do you know that Boppy breastfeeding pillow that 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, get you a glass of water if it will save 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 medications definitely clear it with your doctor or midwife, especially when you are breastfeeding, make sure they take that into account in recommending any meds. To check on the safety of medications while breastfeeding the LactMed database is an excellent resource.

Signs to Watch Out For

Keep in mind 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, stay hydrated, all of these things will help promote healing. This isn’t something that heals overnight but expect that it will keep getting better over time. If you have any concerns that you are not healing well, get in to 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 definitely want to take care of that right away.

There is something called granulation tissue, and this happens when the tissue basically gets stuck in the healing process. If you are not consistently healing call your doctor or midwife. You have so much going on with your new baby you do not want to procrastinate in seeking help if you are not healing properly. If this does happen to you 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 when you are in labor you can make a more informed decision.

This is an excellent item to include in a birth plan. If you want to see an example of how this might be worded click here and I will send you a 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 you can word it and make it clear what you want.

 

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