Adriana Lozada explains why and how tearing can occur during birth, and why episiotomies are increasingly rare. Plus, what you can do to avoid tearing.
Are you or were you worried about tearing during labor? Tell us how you processed this aspect of birth on Instagram @birthfulpodcast.
Related Birthful episodes:
- What Actually Happens After Giving Birth, Physically and Emotionally, with Meedlen Charles
- All About Your Pelvic Floor, with Lisa Gillispie
- Talking Pelvic Health with a PT, with Sara Reardon
- Perineal Protectors? Midwife Thinking
- Perineal ‘Bundles’ and Midwifery, Midwife Thinking
- Antenatal perineal massage for reducing perineal trauma, Cochrane review
- Perineal techniques during the second stage of labour for reducing perineal trauma, Cochrane review
- Methods of repair for obstetric anal sphincter injury, Cochrane review
- Interventions for women in subsequent pregnancies following obstetric anal sphincter injury to reduce the risk of recurrent injury and associated harms, Cochrane review
- Antenatal maternal education for improving postnatal perineal healing for women who have birthed in a hospital setting, Cochrane review
- Aspirin (single dose) for perineal pain in the early postpartum period, Cochrane review
- Secondary suturing compared to non‐suturing for broken down perineal wounds following childbirth, Cochrane review
- Topically applied anaesthetics for treating perineal pain after childbirth, Cochrane review
- Surgical repair of spontaneous perineal tears that occur during childbirth versus no intervention, Cochrane review
- Perineal tears recovery and care, NCT First 1,000 Days New Parent Support
- Care of a third- or fourth-degree tear that occurred during childbirth (OASI), Royal College of Obstetricians and Gynaecologists
- First- and second-degree tears, Royal College of Obstetricians and Gynaecologists
- Third- and fourth-degree tears (OASI), Royal College of Obstetricians and Gynaecologists
- Perineal Tear: What to Expect at Home, MyHealth Alberta
Real Talk About Vaginal Tears and Episiotomies
I’m Adriana Lozada and you’re listening to Birthful. And today, I am taking about 10 minutes or so to talk to you one-on-one about a topic that I want us to dive deeper into. This week, it’s vaginal tears and episiotomies. And before we get into it, I want to say that as awful as the idea of a vaginal tear can seem, most people do not feel it when it’s happening. Because well, they’re feeling a lot of other things in that area already.
Lozada: Meaning, that it’s difficult to separate the sensation of crowning and emergence of your baby’s head and the sensations from the tear itself, which is probably a good thing since tears are incredibly common. In fact, they happen in about 90% of first time births. Now, usually vaginal or perineal tears tend to happen in the area between the vagina and the anus, but they can also happen inside the vagina or around the labia and even towards the clitoris.
Lozada: A question that I hear a lot while care providers are maybe repairing a tear is, “Did I tear a lot?” Or “How many stitches do I need?” And the thing is, perinatal tears are not classified by the number of stitches, they’re usually done in one running stitch. So you can’t even really count the number of stitches. Instead, they’re classified from a first degree tear to a fourth degree tear. And that is depending on how deep they are. Now, another thing is that some people tear in several places.
Lozada: So then each of those individual tears would require different repair needs. Although, the most severe tend to only be between vagina and the anus. So let’s look a little closer at those classifications. A first degree tear is one that only affects the skin. And these very often don’t even need to be repaired as they tend to be small, or maybe just even abrasions, kind of like scrapes, and then the body’s going to heal them well on its own. Now a second degree tear is one that goes a little deeper into the muscle tissue.
Lozada: And this is one of the most common tears. Now, depending on where they happen and how long they are, they may not need any stitching or they may require some more intensive repair. If they do need stitches, then usually that’s done by your care provider in the same delivery room using a local anesthetic. If we go a little deeper, a third degree tear is one that goes from the vagina to the anus, going into the muscle that surrounds the anus called the anals sphincter And then a fourth degree tear is more extensive than a third degree in that it goes through the anals sphincter into the rectum.
Lozada: Now, third and fourth degree tears are the most rare. And thank goodness, because they tend to be the most intense. And they’re usually lumped together under a somewhat ridiculous acronym of OASIS which stands for obstetric anal sphincter injuries. Some research have that the incidents of them happening, of these third and four degree tears happening in first births can be as high as 11% combined. And then other statistics have the third degree tears be a 3% and a fourth degree tear at 1%. All of that is for first time birthers, but it could be up to 11% combined.
Lozada: The OASIS are usually repaired in the OR using a spinal or an epidural, so regional anesthesia. And as you can imagine, these deep tears can tear a longer time to heal and can create issues such as fecal incontinence, pain, pain during intercourse, and also significantly impact the quality of life. Because while they can make it difficult to sit or to stand or carry anything that involves the use of your pelvic floor. Now, an episiotomy is what and a care provider makes a cut outward from the vaginal opening.
Lozada: Episiotomies used to be routine, but current evidence has made it quite clear that they are rarely necessary and that they do increase the chance of third and fourth degree tears along the line of the cut and also can create more postpartum pain and discomfort with the incision, taking more time to heal than say, a spontaneous tear. These days, episiotomies are most commonly still used when there is a need for an assisted instrumental delivery, like when using forceps or a vacuum. If you do end up with a first or second degree tear, the postpartum discomfort will usually go away in about two weeks, often less.
Lozada: And if you do end up needing stitches after a repair for any type of tear, then these stitches will dissolve and be absorbed on their own, usually by six weeks. Although, your perineum might not completely recover until four to six months, regardless of if you had a tear or not. If you did have a tear, it’s really common to feel some stinging when you pee afterwards. And then the best thing to do for that is to use a squirt bottle to rinse off. In fact, in the hospital, they give you what they call a Peri Bottle, which is a squirt bottle specifically for this use.
Lozada: And then after squirting, you then gently pat with toilet paper instead of wiping. You may also really enjoy using some cooling pads during the first 24 hours after birth to lessen the discomfort and the swelling, even if you didn’t tear. And then using some moist heat afterwards or doing some sits baths can help promote healing by increasing the blood flow to the area. Oh, and if you’re having pain while sitting, then a hemorrhoid pillow can really help. And don’t forget to ask your care provider about pain killers. And definitely make good use of the stool softeners they give you at the hospital.
Lozada: Now having said all this, is there a way to lessen the chances of tearing? Now the truth is that the research is inconclusive with the thing that probably helps the most is to have warm compresses applied to the area while you’re pushing. But even that is not a guarantee. Some people do swear by perineal massage. And some research says that the pushing position matters. Some say a big baby will increase the chance of tearing, but I have seen people have 10 pound babies without tearing while others have significant tears with six pound babies.
Lozada: So it’s probably more the position of the baby and your own position than their size. Because some things that likely minimize the risk of tearing are those that give the perineum the most support while lessening the stress and forces applied to that area. So for example, a prolonged pushing stage, or having Pitocin or holding your breath while pushing, they’ll all put extra pressure on that area. And not to mention, that prolonged pushing stages also increase the chance of needing forceps or vacuums, which then increases the chance of a third or fourth degree tear. Your baby’s position, how you are pushing and what position you are in influences these forces.
Lozada: So a couple of good ways to minimize these are to avoid holding your breath, letting your baby come out as slowly as you can, after they start to crown. And then see if you can bring your knees together a bit if they’re wide apart during that crowning and pushing stage, so that you can decrease the strain on those tissues that are already quite strained from the forces of your baby’s head coming out. And if you’re thinking, “If I bring my knees a little bit closer together or too close together, my baby can’t be born.”
Lozada: There have been lots of cases where babies have been born with people who had their legs closed as they were in a side lying position. And then the baby really came out the back basically. Some good news is that if you’ve already had a baby, then your chances of tearing again decrease significantly. But regardless of if you tear or how your baby is born, I would recommend a visit to a pelvic PT specialist to assess the state of your own unique pelvic floor.
Lozada: Great, if you can do it during pregnancy, but especially after giving birth.
You can connect with Birthful on Instagram at Birthful podcast. And to learn more about Birthful and my birth and postpartum preparation classes, go to birthful.com.
Birthful was created by me, Adriana Lozada, and is a production of LWC Studios. The show’s Senior Producer is Paulina Velasco. Jen Chien is Executive Editor. Cedric Wilson is our Lead Producer. Kojin Tashiro is our Associate Sound Designer and mixed this episode. Thank you for listening to and sharing Birthful. Come back for more ways to inform your intuition.
Lozada, Adriana, host. “Real Talk About Vaginal Tears and Episiotomies.” Birthful, LWC Studios, November 3, 2021. Birthful.com.
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