We are in the business of easing fears and explaining the ins and outs (literally) of childbirth for our clients. The most common fear we hear is tearing when pushing during birth. We’re talking about your vagina here, so we won’t downplay what can happen. The thought of pushing this small human out can be frightful enough by itself, so we get it. We have gathered our most frequently asked questions about vaginal tearing here for you.
1) What is an episiotomy and how is it done? When would I need one?
An episiotomy is an incision made in the perineum (the tissue that stretches like the webbing between your thumb and index finger, at the opening of the vagina) to enlarge the vaginal opening. This is done with operating scissors, most often at a diagonal angle (medio-lateral), but sometimes straight down vertically towards the anus (midline). The doctor or midwife performing the episiotomy will numb the area with a local anesthetic, like lidocaine before making the cut. Episiotomies are no longer routinely done in the United States, but they are sometimes necessary. You might need an episiotomy if the baby needs to be delivered quickly, if the vaginal opening is too tight and needs to be enlarged, to assist a breech birth or if the vagina is tearing up towards the urethra and clitoris. You definitely want to control for that if you can, with an episiotomy.
2) Can you feel it when you tear?
Whether they have an epidural or not, most women do not feel themselves tear naturally. At the time that tears usually occur, when the baby’s head is crowning, the vaginal tissue is stretched as far as it can go, so the sensation of tearing isn’t felt. “The ring of fire” is the burning sensation felt with crowning (imagine the same type of feeling as stretching the corner of your mouth with your finger like a fish hook) and it in a sense maxes out your perineal nerves’ pain threshold.
3) What do the different degrees of tears mean?
There are four degrees for tears. A first degree tear is a tear in the lining of the vagina, not into the muscle. A second degree tear is the most common and it involves the vaginal lining and deeper tissue known as the submucosal lining. This type of tear, along with some first degree tears requires stitches. The third degree tear is much more involved and goes even deeper to the muscles of the anal sphincter. Repairing the third degree tear involves suturing each level separately, with important focus on the anal sphincter. The least common tear experienced is a fourth degree tear, often caused when there is a shoulder dystocia (the baby’s shoulder gets stuck and requires maneuvering) or forceps or vacuum assistance are needed. This laceration goes all the way through to the rectal lining and it requires a repair that includes multiple layers of stitches. Very rarely, a repair can require a revision if there is infection or damage to the repair.
4) How can I prevent tearing? (the million-dollar question)
There is no sure way to prevent tearing when pushing during birth, but there are some things you can do to decrease your chances of a more severe tear. A great way to allow your vaginal tissues and perineum to stretch when possible is to “labor down”. Laboring down is resting once your cervix dilates to ten centimeters. By not rushing into pushing just because you’re fully dilated, the baby can slowly descend and you can wait to push until you feel the urge to push. You can push slowly and as your body sends you the urge, unless there a circumstances where you really need to push (or not push) as directed by your doctor or midwife. Another trick to try is having someone, either your healthcare provider, a nurse, your partner or your doula hold a warm compress to the perineum during crowning and pushing. The warmth relaxes the tissues and the counter pressure creates resistance for the perineum.
5) What are some ways to ease the pain from a repair after birth?
You can use ice packs or cold compresses. Our favorite is a postpartum support and ice pack in one, from Mama Strut. You can also sit down delicately, with your legs together and sit on a soft cushion or chair (avoid donut pillows that can stress the area). You can do warm sitz baths or Epsom salt baths if your healthcare provider gives you the go ahead. Also, remember the peri-bottle you will get from the hospital is your new best friend. Use it to pour warm water over your vulva as you urinate to take the sting out. One of the most important things to do to help your recovery from birth is to rest. Recruit the help of your partner, family and postpartum doula to keep you off your feet and relaxed during your recovery. Cuddle your baby and let others pamper you as you heal.
Now that you have crossed your legs and thoroughly clenched your cheeks, know that not every woman tears during birth, but if you do, you’ll be healed in no time.