Tearing during birth
Vaginal tears that occur during labour are experienced by around 90% of women.
In fact, minor tears are so common (99% of all tears are minor) and heal quite fast, that it appears to be a normal part of the birth process.
Yet, most women fear tearing during birth and want to avoid it at all costs.
While it might be impossible to avoid some vaginal tearing, it is possible to reduce the likelihood of severe vaginal trauma.
Why do tears happen?
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 begin to bulge and stretch around the head. If the skin and perineum have not stretched sufficiently then a tear can happen.
Factors that increase the likelihood of tearing are:
- Big baby
- Asian ethnicity
- Posterior position of baby
- Increased weight gain in pregnancy
- First vaginal birth
It is very uncommon for women to actually feel themselves tearing, due to the intensity and pressure that occurs during this stage of labour. Often women will be told they have a small graze or tear and express surprise as they didn’t feel it happening.
What types of tears are there?
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. Both 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.
How to avoid tearing during birth
Here are 9 suggestions to reduce the chances of vaginal tearing during birth:
#1: Prepare your body
Sounds simple but ensuring your body is prepared for the work of labour is a must. Not only is labour a peak body performance (think endurance running), parts of your body are going to do things they have never done before.
Considering the amount of time modern women spend sitting and not moving, we definitely need to include some form of exercise in our daily routine during pregnancy. Exercise improves circulation, which in turn improves skin elasticity. Improving blood flow to the perineum and vagina through orgasm can also improve tissue health.
Good nutrition and hydration support your skin and muscle health. Include plenty of good fats, especially omega-3s (from fish, chia seeds, walnuts and pumpkin seeds) and grass-fed or free-range lean protein.
A wide range of vegetables completes a healthy diet and will include nutrients such as Vitamin E, Vitamin C and zinc. These will provide your body with the ability to stretch during and recover after labour.
#2: Pelvic floor exercises
Common advice to pregnant women is to do pelvic floor exercises (known as Kegels) to strengthen the muscles in the pelvic floor. The idea is that after birth, the pelvic floor muscles will snap back into shape and you are less likely to experience incontinence (weeing yourself).
During the second stage of labour, you want your pelvis and vagina to open and the muscles to relax, maximising the space for baby to descend. It seems counterproductive to spend all this time tightening the muscles in that area when we actually want the opposite to happen at the crucial time. So what is the right thing to do?
Lengthening and improving the coordination of pelvic floor muscles with the other muscles in the body can be achieved by using squats and pelvic floor exercises together. Learning to relax the pelvic muscles is also important and performing pelvic floor exercise correctly can help you to identify those muscles and then relax them.
Read more here about squats and Kegels, how to do them correctly and why both have a place in preparing for birth.
#3: Labour in water
Immersing yourself in a large warm bath is the ultimate relaxation image. During labour, warm water has a multitude of benefits (BellyBelly’s article here explains lots of them).
A Cochrane Review in 2009 determined there were no differences in tearing between birthing in water than land, yet many midwives and women swear by warm water softening perineal tissues and easing the sensation of the crowning stage.
#4: Birth position matters
The position you are in when pushing has a big influence on whether you are more likely to tear. Lying down, lithotomy position (lying down with legs held up) or semi-reclining positions put pressure onto your tailbone and perineum, reduce the size of the pelvic floor and increase the likelihood you will tear.
The best position for birthing your baby is the one you choose instinctively for yourself and you feel most comfortable in. Women who are free to move about during labour will find the position that helps them cope with contractions at each particular stage. Some women like to float free of gravity in water, others like to have their feet firmly planted on the ground.
The least stressful positions for the perineum include:
- On all fours, on hands and knees.
- Leaning forward in a supported standing, kneeling, or sitting position
- Lying on your side.
While squatting and kneeling are useful upright positions, if the woman’s knees are very wide apart the perineum is being stretched sideways and may increase the likelihood of tearing.
#5: Breathing rather than pushing out baby
During the pushing stage, the fetal ejection reflex is moving the baby down and out of the uterus, into the vagina and out into the world. These strong pushing contractions are involuntary and will move the baby out without the mother pushing or bearing down. Women have given birth in their sleep and while in comas!
When you feel the urge to push, this is actually your uterus already contracting and pushing the baby down. Most women have an instinctive response to bear down during these contractions. You don’t have to push with your whole body while holding your breath in order to birth your baby. This reduces oxygen to you and your baby, and tenses your muscles instead of relaxing them – remember your baby needs to come out not be held in. Breathing down with your contractions allows your baby to descend slowly and with less trauma to your pelvic floor.
As your baby’s head pushes onto the pelvic floor, the perineum begins to fan out and stretch. The baby’s head is crowning and many women experience an intense stinging sensation – the ‘ring of fire’. The body is signalling to the brain to stop, slow down and let the perineum and labia stretch to accommodate the baby’s head. Often this stage can be very intense and you may feel as though you just have to bear down and get the baby out right now.
Because women are often being told ‘how to birth’ during labour, women tend to rely more on their care providers instructions than what feels best for them. If women are not coached during this stage, they will instinctively begin panting, blowing or breathing.
#6: Use warm compresses
During the crowning stage, a warm flannel or compress held to the perineum can reduce severe tearing. The warmth increases the blood flow to the area and if counter pressure is used can feel very relieving.
Some women find the warm compress very comforting and others prefer their care providers to adopt a hands-off approach.
#7: Perineal massage
Preparing the perineum during pregnancy has been shown to reduce the risk of tearing in mothers having their first vaginal birth. Perineal massage can help a woman to become familiar with her own body and have confidence in its ability to stretch and birth her baby.
If you are not comfortable with the idea of perineal massage remember it’s not a ‘must’. While it does reduce the risk of perineal trauma, it appears the reduced risk might be due to a decreased likelihood of having an episiotomy. Researchers aren’t positive why this is, but one theory is that women choosing perineal massage are more motivated to avoid an unnecessary episiotomy. Episiotomies increase the risk of needing stitches, so less risk of episiotomy means less risk of perineal trauma.
For more information check out BellyBelly’s article on perineal massage.
#8: Choice of birthplace and carer
How can your care provider influence your tearing risk? If they believe in natural birth and your body’s ability to labour then they are less likely to interfere.
Care providers who are more focused on instructing during labour will undermine your confidence and instinct. This can interfere with the hormones that you need to produce for a natural birth, increasing your pain, tension and fear. The more tense you are, the less likely you are going to release your baby from your body without trauma.
#9: Avoid an episiotomy
An episiotomy is a surgical cut made to the skin and muscle of the perineal area, to enlarge the vaginal opening. Episiotomies were first employed when forceps came into vogue in the late 1700s and were believed to lessen the damage to both mother and baby, such as tearing, brain damage to babies, pelvic floor tearing etc.
Evidence now shows that episiotomies do not protect the perineum during birth and in fact increase the chance of a third or fourth degree tear. Once the cut is done the baby’s head emerging causes the cut to tear deeper into the muscle. Tears will heal much better than episiotomies as well. The scar tissue from an episiotomy can be weaker but will not restrict the perineum’s ability to stretch in future births. A previous episiotomy is not an automatic reason for an elective c-section.
Episiotomies can cause infections, perineal trauma, urinary and fecal incontinence, and painful sex. Yet this is still a common practice in many countries such as the US.
An episiotomy may be required if your doctor performs an assisted birth (forceps for example). A great way to avoid an assisted birth is to avoid an induction of labour (with medication, like Syntocinon or Pitocin, which is artificial oxytocin) and epidurals, both which often go hand in hand. This is why the phrase “the cascade of interventions” exists because once you start one intervention (usually the induction), you almost always need another.
When choosing a care provider, ask about their use of episiotomy and what their belief is regarding natural tearing during labour. Are they familiar with the use of support techniques such as warm compresses, perineal massage, positioning etc?
Hiring a doula is also a great way to reduce stress and tension during labour, and to support you to find the positions and methods that help to maximise your chance of avoiding a tear.
Recommended Reading: 6 Ways To Heal Your Perineum After Birth.