Something that almost always comes up within my first sessions with clients is tearing, people are so terrified of the prospect of a perineal tear and are wishfully hoping that I have some secret formula that will prevent them from getting one. I’m not a magician so unfortunately I don’t, but usually by the end of our session they leave feeling comfortable with the fact that they might tear, but that it’s totally cool. Hopefully you’ll feel the same by the time you’ve finished reading this blog.
So the first thing I want to talk about is how normal it is to tear, later on in this blog post I will discuss what we can do to try and prevent tearing because there is some research that suggests certain things can help as we prepare for birth, but actually I think what we all need to work on is this collective fear we have of tearing. And I get it, it’s probably the most intimate part of our bodies and thinking about it tearing seems excruciating but it’s actually incredibly common to tear, research suggest that up to 9 in 10 first time parents having a vaginal birth will end up with some sort of tear, so if you are having your first baby - it is quite likely. The RCOG (Royal college of gynaecology) states that "For most women, these tears are minor and heal quickly"[1] I know our brains immediately go to thought of horrendous episiotomies or those horror stories we’ve heard from people who have said “oh my auntie tore from front to back during childbirth” but the majority of tears are not like this. They are minor, there are 4 different classifications of tears which happen during childbirth and I’ll take you through them now.
First-degree tears are small and affect only the skin, they usually heal quickly and without treatment so for a first degree tear you don’t even need stitches and these are the most common types of tears. So I’ll say that again in case it hasn’t quite sunk in, the most common types of tears don’t need any form of stitches and heal quickly, the majority of people don’t even realise it has happened and anecdotally I have never had a client who has felt a tear in real time. A second-degree tears affects the muscle of the perineum and the skin so these may require stitches but as with everything it is your choice, if left many are capable of healing without stitches but that’s something only you can decide on and obviously in the moment you can discuss it with your chosen healthcare professional should you have one. Again these usually heal quickly and in my experience are also rarely painful, I’ve had a second degree tear both times I’ve given birth and I genuinely had no idea either of them had happened until I got examined afterwards, it didn’t hurt when it happened and it didn’t hurt afterwards either. I also opted to have stitches too, the first time I didn’t realise I had a choice and in hindsight I don’t think I needed them as they weren’t even sure if it was a first or second so stitched it just in case, but the second time around it was a little deeper and we left it for an hour and a half after birth but at this point it was still bleeding fresh blood - again this did not hurt and was minor but the fact that it was still bleeding led me to accept stitches and that was another easy healing journey.
Finally you have your third and fourth degree tears which are what everyone assumes we mean when we talk about tearing, Third- and fourth-degree tears are deeper, they’re known as obstetric anal sphincter injuries as they extend into the muscle that controls the anus. These deeper tears need repair in an operating theater and usually require a spinal or epidural, in the UK only 3.2% of of people giving birth suffer a third or fourth degree tear, they are incredibly rare! Some things which increase the risk of third or fourth degree tears are induction of labor, episiotomy, instrumental delivery with forceps, and a birth weight of 3000 g or more, but even then the risk only increases minimally.[2]
So that’s your low down on the different types and as I said, it’s best to reassure yourself that actually tearing is quite common but it’s really unlikely to be as bad as you had probably previously thought. Your body prepares incredibly for birth and tearing is not a failure of birth, it’s just something that can happen for a multitude of reasons, your body does an incredible job of stretching and opening, sometimes these things just happen, or sometimes a “risk” factor or intervention contributes to it.
And now I want to talk about the process of being stitched up and caring for tears and stitches. So remember first degree tears don’t require stitches and second degree tears sometimes do/sometimes don’t - it’s always your choice, the skin around our vagina and perinium is incredibly resilient and can heal itself generally well when left alone so have a think about what you are comfortable with and make informed decisions around whether or not you want to accept stitches. Stitches for second degree tears are done using local anesthetic which just numbs the area so they will do a small injection into your vagina, again I know this sounds really awful, but in my experience it really isn’t that bad, I of course can’t speak to everybody and I’m sire for some people it has probably felt pretty shit but for me it was a slight sharp scratch that was over as soon as I noticed the discomfort and then it’s numb so you don’t really feel the stitches being done. These stitches can be done wherever you are, you don’t need to transfer to the theater, so if you’re at home they will just do the stitches there on your sofa or your bed or which is super handy because I know if you were planning a homebirth and then you’d just read that up to 9 out of 10 first time parents tear you’d probably panic that that would mean a hospital transfer but as long as it’s first or second degree (which it’s most likely to be) then you’re fine you can just stay at home and have them done there. And same for MLU and hospital births, the stitches will just be done by your midwife in the room you give birth in. It’s a straightforward process which usually only takes a few minutes. These stitches are dissolvable so they don’t require any follow up appointments and usually dissolve within 1 to 2 weeks.
Looking after tears is a pretty self explanatory topic but I do have some handy tips for you, obviously the area can feel a bit sore after birth whether you’ve torn or had stitches or not so you want to go easy on yourself and let your body and your pelvic floor rest. You want to keep the area clean but obviously when you go to the toilet that can make the tear sting so I have 2 top tips for this, you can either use a peri bottle/spray bottle and spray water on the tear as you wee which can ease the discomfort or you may want to hold a warm compress/flannel against the area for the same reason and to protect the area and then when you’re done you want to pat yourself dry to keep the area clean and comfortable. Other things which can helps tears and stitches are bringing warmth to the area to promote healing, so you may have heard of using “padsicles”, padsicles are recommended all the time for soothing tears but actually I don’t recommend them at all, so they are pads that you put in the freezer and then take out and wear in your underwear as it can feel quite soothing and was thought to promote healing but actually we now know that this in counterintuitive to healing and it’s more important to bring warmth to the area. So try and heat up your pads before popping them in your pants instead, this is obviously as lot easier to do if you use reusable menstrual products which are great for if you’re feeling sore after birth because they are soooo much more comfortable but I get that they’re not for everyone. You can heat up pads on the radiator for example or if you can’t do this then you could also just sit on a hot water bottle or heated rice pack and this will do the same job. Like with all things, this is your choice and if you’ve used padsicles in the past or you want to just give them a try then you do you!
You should also try and eat easily digestible food so bowel movements are not too difficult and stay super super hydrated, this is obviously important in the immediate postpartum anyway but you will thank me if you remember this when you pee after birth as it’s a lot more pleasant if your wee is super diluted against a tear. Pelvic floor exercises can promote healing too as they strengthen the area and the muscle which may be fusing back together. And if you are in pain at any point then take painkillers as needed, paracetamol is safe to take immediately postpartum even if you’re breastfeeding so have some on hand should you need it. One final thing I recommend for healing up tears and stitches is arnica, arnica is a herb which is used topically for healing bruises and muscle wounds, it decreases inflammation and relieves pain and soreness amongst lots of other things so it’s great to take after birth in general I always tell my clients about it and encourage people to pop some in their birth bag as you can take it straight after giving birth, I used the tablets so I just took them both times after birth and then kept them up in the following days and I feel they helped with my general healing so I thought they were worth a mention, I had the Weleda ones but you can get them fairly easily, I’ve seen them in Boots and Superdrug too.
So now let’s finish up by chatting about preventing tearing. I do wanna start off by saying that none of these things guarantee you won’t tear, they’re suggestions of things that may minimize the risks of tearing based usually on small scale studies. Doing these things may lessen your chances of having a third or fourth degree tear by a substantial amount so they may be worth doing but as with everything - take what feels right for you, don’t force anything or do anything that makes you feel uncomfortable. Some people will practice every single one of these things and will still end up with a small tear, other people will do absolutely none of these things and get out without as much as a scratch as there are lots of variables we cannot control which can cause smaller tears. First thing is good birth preparation, and you’re probably thinking - of course you would say that because you’re a birth preparation teacher, and that’s true but that means that I’ve seen first hand how important it is and also research backs this up! When we understand how birth works and we have trust in our bodies then we’re less likely to tear because we’re not creating resistance or tension in our pelvic floor, we just let our bodies do its job. Keeping our shoulders, jaws and throats relaxed helps massively, this area is directly linked to our pelvic floor and when we relax those muscles we in turn relax our pelvic floor, a relaxed pelvic floor is much easier for a baby to descend through without doing any damage than a tensed up one.[2] Birthing in water has been proven to reduce the risk of tearing so again always worth a shot if this feels comfortable for you, water is also a great non pharmacological option which has a tonne of benefits outside of those already mentioned here.[3]
Following your bodies lead/not being forced to give birth on your back can contribute to preventing tearing, I mentioned at the beginning how having an epidural increases the risk of having a third or fourth degree tear and that is likely down to the fact that you would be laid on your back which may (or may not!) prolong the second stage of labour, if you can follow your bodies lead and get into positions which feel conducive to the labour you are having then you’re less likely to tear. There are many examples given in the paper “A review and comparison of common maternal positions during the second-stage of labor” about the benefits of an all fours position for reducing tearing, one of them states “A randomized controlled trial conducted in China which compared maternal and neonatal outcomes between hands-and-knees position and supine position, the authors found that the women giving birth in hands-and-knees position had lower rates of episiotomy and second-degree perineum laceration (including episiotomy), and higher rates of intact perineum and first-degree perineal tears when compared with those in supine position”[4] Again this is why birth preparation is great because you’ll learn all about these topics in depth! If you do have an epidural then trying to either have a mobile epidural where you can still move around a little or requesting the use of something like a peanut ball to create space in your pelvic outlet is your best bet.
The next couple of things are divisive, the first is perineal massage, you’ve probably heard of this one, people always ask me if they should be doing perineal massage and honestly it’s up to you. There are pros and cons to doing it, I would always say if it’s uncomfortable or you don’t want to then do not force it, people have been giving birth since the beginning of time without doing it, it’s a relatively new phenomenon. The biggest study I could find on perineal massage is from 2020 and looked at studies including 3467 people giving birth. It concluded that “women who received antenatal perineal massage had significantly lower incidence of episiotomies and perineal tears, particularly the risk of third- and fourth-degree perineal tears. Better wound healing and less perineal pain were evident in the antenatal perineal massage group. Antenatal perineal massage reduced the second stage of labor duration and anal incontinence with significant improvement in Apgar scores at 1 and 5 min”.[5] So this makes it sound amazing doesn’t it and obviously for some people it is! For others it isn’t, I’m not trying to be a debbie downer I’m just trying to be realistic because I know people can really get their hopes up that doing this massage will be their savior and then can feel really disheartened when they still tear. But as I’ve said a million times tearing is normal! If you want to give perineal massage a go then go ahead by all means, it’s worth a try for most of us but just under 3500 patients in multiple studies is still small scale so it’s not gospel that doing it will prevent tearing. There is a really good podcast episode by Evidence Based Birth all about perineal massage if you want more information and discussion on it, I’ll leave a link to that in the references.[6]
Something else you can do is have a midwife or birth partner place a warm compress against the perineum during crowning and birth of your babies head, this is generally referred to as a “hands on” second stage of labour and again this works well for some but not for others. The jury is still out really and the research is lacking, I’ll leave the most up to date research from The Cochrane library which quantified all of the recent research into the references for you to decide on for yourself, the research concluded “We found that massage and warm compresses may reduce serious perineal trauma (third- and fourth-degree tears). However hands-off techniques may reduce the number of episiotomies but it was not clear that these techniques had a beneficial effect on other perineal trauma. There remains uncertainty about the value of other techniques to reduce damage to the perineum during childbirth.”[7] Your midwife will likely offer this to you during labour so it is worth having a think about if you would accept it or not and having it on your birth plan, of course you can change your mind at any point, during birth you might decide you want to give it a go after being adamant you wouldn’t, or you could give it a try and decide you hate it - that’s fine, the midwife can just remove their hands.
And finally, most importantly, in my opinion, is avoiding coached pushing and allowing your body to push your baby out which it what it is designed to do. Of course in certain circumstances this is harder to achieve, for example if you have an epidural, but otherwise there is generally no reason why you should be coached to push. If you’ve never given birth before this may sound strange, all we ever see on TV is people laying on their backs with midwives shouting “PUSHHHHH” whilst pregnant people go blue in the face straining and screaming, but trust me - your body has got the pushing part covered and you don’t need to physically push. In 2017 Medway Maternity won the Award for Excellence in Maternity Care from the Royal College of Midwives for their achievement in reducing third and fourth degree tears in women during childbirth from a national average of almost 6% to just 1%, they did this by implementing a programme called STOMP, which encouraged upright all fours positioning, and support to breathe naturally through contractions instead of coaching women to push. Also, instead of pulling babies out as soon as their heads emerged, the midwives let them come out at their own pace, while supporting their weight to reduce pressure on the perineum.[8][9] What an incredible outcome, I can only wonder why this initiative hasn’t been implemented nationwide.
So that’s the lowdown on tearing, healing and prevention, I hope this has been a helpful read! Check out the references below for further information.
References: