Updated: Jun 20
Looking at your positive pregnancy test, you're a whirlwind of emotions, thoughts swirling around
your mind when the sudden realisation hits you..... "Oh CRAP, I've got to pass a whole baby - OUT OF THERE!?! "
Throughout pregnancy, many of us, (including myself) carry some concern as to whether you might tear during birth. A worry that is not at all helped by insensitive oversharing people who just love to tell you 'How many stiches my boyfriend's sister had' (or similar) - Yeah, thanks for that! I'm glad to tell you that I hope to calm your concerns a little.
While there are no guarantees, as many first-time mums do indeed experience some sort of graze, swelling, or tear, (much less chance if it's not your first baby), there are lots of things you can do to reduce your chances of needing stitches after childbirth. Or at the very least reduce your chances of having a serious tear.
First, let me reassure you. In over twenty years as a midwife, I have NEVER heard ANY woman say, "Oh my God, I really felt it when I tore!" NOT ONCE!.......In fact, most women have absolutely no idea whether they have or not - or whether they need stitches until the midwife or doctor checks. And just for the record, most stitches are placed as one continuous stitch (aka suture), not several individual ones as some might have you believe.
The reality is, at the time this might occur, ie. during crowning (when the widest part of the baby's head passes out of the vagina) most women are completely preoccupied with intense pressure sensations as their baby's head moves down, which is followed by a very short-lasting intense burning sensation as baby appears earthside.
Most women at this time are so beautifully overwhelmed and relieved they have actually given birth and consumed by the wonderful emotions of meeting their gorgeous baby.
Rest assured, in my experience, there really does not seem to be any difference in the reported sensations of those women who do not tear, those who have a minor tear, and those who sustain a more significant tear. The body's hormones are extremely clever at helping you out during the different stages of childbirth, and your concentration and energy at this time is most often focussed elsewhere.
Just so you're in the know about the differences in perineal tears (knowledge is power right?) there are a few different types and 'degrees' of tears, each graded according to depth and location.
First degree tears are fairly common and involve only the skin layer. They are usually sore for a few days, but heal quickly, often without treatment or intervention, although you might be offered stitches.
Second degree tears are also fairly common and involve the skin as well as some underlying muscle in the area between your vagina and anus (aka butthole) known as the perineum. You will be offered stitches in this case, and they are usually done quite soon after birth by your attending midwife, after offering you some local anaesthetic to numb the immediate area of course (if you chose not to have an epidural)
Third and fourth degree tears are much rarer (approximately 3 to 8%) - this is when the tear is very
close to, or involves the anal sphincter (the muscle you push open to allow poo to pass through) - In these rare cases, you will likely have your stiches in an operating theatre setting. This is to allow more light and better access for the doctor, and because this type of repair is much more intricate and needs to be done just right to reduce the chances of you having any long-term issues. For this procedure you will be offered regional anaesthesia (where they numb a large area), which might be a pudendal block (numbing just the genital area, a spinal or epidural (numbing the whole pelvic area). This is so that you have really good pain relief and are completely numb (and still). You will likely need a catheter (a tube to drain your wee for a short time) during and after the repair. This procedure will be done by a senior Doctor.
There can also be tears to the inner and/or outer labia (vaginal lips) which may also require small stitches.
An episiotomy is where a cut is intentionally made to the perineum. This is the one thing most women put on their birth preference plan as the number one thing to avoid. Thank goodness that episiotomies are no longer routinely done, and the rates of episiotomy have significantly reduced, in the UK at least. The use of episiotomy is now only reserved for cases where the baby needs to be born quickly due to heart rate concerns, or if you need forceps to help deliver baby, and often, but not always with ventouse (suction cup). Episiotomy is also occasionally offered if there is a real concern that you might tear badly, and the midwife or doctor feels that an episiotomy could reduce that chance. You should know that an if an episiotomy is indicated, it often needs to be done quickly, and without much warning. None-the-less, this procedure should ONLY be done with your explicit, and informed consent. You will of course be offered local anaesthetic to numb the area first.
Well, now that we know what we're talking about, what exactly is it that you can do to reduce your chance of tearing? Here are My Top 5 ways to Reduce Tearing at Birth!
Number 1: The Position You Birth In
Being upright and mobile in labour can be beneficial for SO many reasons, but not least because
giving birth standing, kneeling or even better squatting can significantly reduce your chances of needing forceps or ventouse to help deliver your baby (which often requires episiotomy) Furthermore being active and upright reduces your chance of needing an episiotomy for other reasons too.
Being upright, mobile and free to move around not only increases gravity helping your baby's head
to navigate through your pelvis. Movement also increases the amount of room in your pelvis for the baby to turn and move down as nature has designed your baby to do. Additionally, being upright helps to stretch the perineal and vaginal tissues more gradually, and triggers the natural urge to bear down as your body's birthing mechanisms kick in. Mobilising during birth can also help you stay 'in the zone', which can maximise the optimal levels of hormones required for contractions and birth to occur, also improving efficiency when pushing, and can often shorten the pushing phase too.
But what if I choose to have an epidural and I am not able to be mobile?
Research suggests that if you do have an epidural, giving birth in a side lying position after delaying pushing for some time after your cervix is fully dilated significantly increases your chance of avoiding tears. This position is preferable to sitting upright as it allows the opening of your coccyx (tailbone) increasing the amount of space your baby has when passing through your pelvis, making your pushing much more effective due to less resistance.
Number 2: Warm compress on the perineum
A warm compress pressed on the space between the bottom of your vagina and your anus (aka butthole to most - (or 'tinter' in Yorkshire slang - (you know who you are!)) just as you are pushing baby out can not only provide amazing relief as your tissues stretch, in addition, research has found that it can actually reduce your chance of tearing full stop, as well as reducing the chances of you having a 3rd or 4th degree tear - Hurrah! I love a simple but effective technique - I guess they knew what they're doing when they shouted 'Get some hot water and towels" on call the midwife. (It's just taken researchers years to 'prove' what we already knew! - as is often the case)
Be aware, a perineal compress should be done with your consent. If you are upright and mobile, or on all fours - this should not be compromised, you should NOT be encouraged to lay on your back to allow the compress to be more easily applied by someone else, because birthing on your back increases your chances of tearing! The compress shouldn't interfere with your movement, it can still be applied properly in the position that you feel you want to be in to have your baby, however that is.
Number 3: WHERE you decide to Give Birth
Some research studies looking at practices in the second stage of labour (once fully dilated) found that the overall rate of perineal tears was significantly different depending on the birth setting.
In one study, approximately half of women who had planned a home birth had no tear. About 40% had a first or second degree tear, and just under 1.5% having a 3rd or fourth degree tear.
Giving birth in a Birth Centre may also improve your chances of getting away without needing
stitches - between approximately 39% and 75% according to another study.
Rates of the more serious but rare 3rd and 4th degree tears are approximately 1.6 to 3.5 % in a hospital (the lower rate is for women who have birthed before). The rate in a home setting is approximately 1.5 - 2%. So not too different - but still rare.
Rates of episiotomies in planned hospital births are of course higher (at around 7-10%) when compared to home birth and midwifery led births together. This is because birthing in hospital even if you are considered 'low risk', can lead to a 'cascade of interventions' which can be associated with increased risk of needing forceps or ventouse - which in turn are associated with higher rates of episiotomies. Of course forceps and ventouse are not used in a home or birth centre setting.
If you are considered to be 'high risk' or develop risks in labour, then the offer of interventions are often made more quickly - you should always discuss 'risk factors' and the impact of any offered intervention on your birth choices with your midwife/doctor to help you to decide whether to accept it or not.
Research also suggests that having a midwife instead of a doctor supporting you when giving birth
can reduce the likelihood of needing stitches. Particularly needing stitches due to 'needing' an episiotomy. Most midwives are skilled at maximising your chances of achieving a natural birth, and rarely do episiotomies, home birth and midwifery led unit midwives are particular experts in promoting normal birth. Midwives, in general, don't use instruments to help deliver babies.
There are no research studies on perineal injury for 'unassisted' , doula / birthkeeper only, or 'free births' - I would really love to know what the rates are for these types of births, however this information is not available at the time of writing.
Number 4: Slowing the delivery of your baby's head.
Slowing the speed that your baby comes down through your vagina can help to reduce your chance of needing stitches. A slower passage allows the tissues to stretch more gradually rather than suddenly. "So how the bloody hell do I do that?" I hear you say!
Reducing the number of medications and interventions, in particular epidural, can help you to feel and follow your own natural urges to push, rather than having anyone directing you to push. We've all seen films where everyone is shouting PUSH! PUSH! relentlessly at a poor purple faced woman (who is usually on her back holding her legs, or with her leg in stirrups I might add!). Now, unless you really cannot feel any urge to push (as is sometimes the case with a very heavy epidural or spinal) there is no need for this kind of unnecessary 'carry on' from birth professionals for the vast majority of births.
The 'type' of pushing you do can help to reduce the need for stitches.
In an unmedicated, unmessed with, natural birth, the urge to push / when to push / how to push is usually felt naturally. The urge tends to come on gradually as your baby's head begins to move down and press on the internal perineal muscles. The urge gradually grows stronger as contractions peak and your body then sort of takes over the pushing all by itself.
The type of pushing I wholeheartedlly recommend you try to avoid is called 'Valsalver pushing'. This is when (some) midwives / doctors might ask you to "take in a deep breath, hold it in, and then bear down with all your might for as long and as hard as you can (often encouraging you to try to count to ten without taking a breath)", when you no longer have any 'push /breath' left, you then take another deep breath, and the long pushing is repeated again and again, approximately 3 times per contraction. This 'Valsalver pushing' is often encouraged if you are unable to feel the urge to push, such as with a heavy epidural.
Now, the reason I suggest you avoid this type of pushing is because; not only can this type of pushing override your natural sensations to push, cause you to become exhausted, cause baby's heart to temporarily decelerate, casue you distress and anxiety increasing your adrenalin (not helpful as it reduces your birthing hormones), and also gives you a banging headache. It can sometimes propel the baby faster than needs be through the vagina quite suddenly at the end instead of gradually, this can overstretch the tissues quickly and can result in a higher chance of tearing.
Note: this type of pushing should not be done routinely. This can be mentioned in your birth preferences, and discussed WAY before the pushing stage with your attending midwife - this (like everthing else) is absolutely your choice. Babies will still come without this type of pushing!
Having said this, very occasionally, right at the end of pushing, the midwife or doctor may feel that it is neccesary to try to speed things up for a good reason, for example if there is a real concern about the baby's heart rate. In these cases, at the very end of pushing, you may be asked to do this. If you are encouraged to do this, check with your midwife and ask why they are asking you to push like this, so that you can distinguish between those who encourage this type of pushing 'routinely' and those who feel that it is indicated for a clinical reason. This will allow you to decide whether it's in yours, and your baby's best interests or not.
The point at which baby's head is 'crowning' (when the widest part of the head is passing through the vaginal opening) is a point where a change in pushing to panting / blowing outwards is encouraged to try to reduce your risk of tearing. If you are pushing naturally, without others directing you, you will likely naturally slow down a little at this point, allowing your baby a slower passage through the vaginal opening.
If you are being directed, the midwife or doctor, at the point of crowning, will likely suggest that you stop pushing and will encourage you to breathe long slow breaths, blowing outwards to try to slow your baby's head down.
Number 5: Perineal Massage
Perineal massage is the practice of stretching the perineal skin and underlying muscles and tissues
(the 'hammock' type muscles that hold up your pelvic organs). During perineal massage the specific area to target are the muscles between the vagina and anus. The massage is done by inserting two fingers (if someone else is doing it for you), or your thumb (if you're self-massaging) inside the vagina and pressing down. Imagine your vagina is a clock, you would start at 3 o'clock, pressing down to six o'clock (towards your bottom), and back up the other side to nine o'clock sweeping back and forth with some pressure. This is often done with lubrication such as a vaginal gel, or a natural plant oil.
This research around this practice falls into two groups. Perineal massage done by your midwife or doctor during labour, just before the baby is born, and self perineal massage, done in late pregnancy. Both are performed to try to prevent or reduce tearing during birth.
So what does the research say? Does it work?
Perineal Massage during Labour by your birth professional
There was some recent research looking at perineal massage during labour, (Smith et al 2017 and the MEPPI study). The findings of this study supported perineal massage during labour. This has led to many maternity units offering perineal massage routinely. However, some would argue that the research methods used were not quite good enough to introduce this as 'routine care'. And of course, no intervention should be 'routine' The pros and cons of any intervention should be discussed with you, and your particular circumstances, also your feelings towards such a personal practice.
Perineal Massage at home in late pregnancy
The Research: In 2013 two researchers looked at the evidence from many studies including over 2000 women who practiced antenatal perineal massage for at least the last four weeks of pregnancy (Beckman & Stock 2013)
They found that women having their first vaginal birth who practiced perineal massage for four or more weeks before birth were overall less likely to require stitches, and less likely to have an episiotomy. Women who had given birth vaginally previously who practiced perineal massage were less likely to have pain at 3 months after birth. However, there was no difference in the amount of women needing stitches for second, third and fourth degree tears.
So, in summary, in order to reduce your chances of tearing, particularly if you're a first-time mum.
1. Consider daily perineal massage from 36 weeks using the technique described above.
2. Stay mobile and upright during labour, (especially when baby is about to come), to both avoid forceps/ventouse and to increase the space for baby to pass through. Or if you're unable to mobilise, birth on your side, or all 4's.
3. Stay off your back to push baby out, and just as your baby's head is being born, try to stop pushing by blowing out long breaths which can help baby's head to pass more slowly.
4. Consider having your baby at home, or in a midwife led unit to minimise the chance of interventions (which may lead to further interventions, and ultimately increase your chances of forceps/ventouse or caesarean).
5. Ask your partner or midwife / birth attendant to apply a warm compress (such as a facecloth in warm water) to your perineum as you bear down.
But ultimately, reassure yourself...
Most women are unaware if it happens because they are most often otherwise engaged.
If you do need stitches you will be absolutely be numbed!
Most women heal quickly, particularly with good postnatal hygiene practices such as regular perineal cleansing. Some find salt baths / certain essential oils to be helpful
Serious tears and episiotomies are relatively rare, especially in midwife led births
There are lots of things you can do to reduce your chances of needing stitches.
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So Please, PLEASE don't get hung up on thinking about this too much, now you know what you can do to help when the time comes. You have done your research, you have gathered the necessary knowledge and information, now it's time to put these thoughts out your mind and focus your energy elsewhere. Time to enjoy your pregnancy, to educate yourself on other issues, time to research your birth choices and preferences, and make an informed birth plan. Time to focus your energy on mentally and emotionally preparing, creating positive intentions and comforting associations, and planning a birthing space you can feel relaxed and in control in.
Thank you so much for reading. If you found this information helpful, please feel free to share with friends!
With love always, Paris x
P.S. - Check out my Organic Aromatherapy Range for Mum & Baby