Do you have to cut or tear?

We carry babies for 9+ months (it really is almost always + by the way). We deal with the aches and pains and miseries and weirdness of pregnancy. We make it through the intensity of labor and finally make it to the birth. We push and breathe and squat and grunt and then………

We have to WHAT?!?!

Tear? Get cut? Why? Sometimes our tissues just get strained and stretched beyond their capacity and some tearing happens. Sometimes, LOTS of tearing begins to happen in many directions and your wise and compassionate care provider might suggest a well-placed cut to prevent more severe tearing.

I wasn’t a big fan of pregnancy because of morning sickness, but I honestly liked giving birth. I could take a lot of things in stride and tolerate a lot of discomfort. I had a pretty severe tear with my first because she had a little fist up by her face on her way out. She came out Superman style. She was a large-ish baby at 8 1/2 pounds, but it was that fist that did the damage. My recovery was long. I had a lot of sharp pulling pain down there for several months. It was very hard to find a comfortable position for sitting or laying down. I wish I had known a little bit more about the meaning of this pain. I’ve learned since then that it wasn’t normal and that there might have been help for it.

I had some minor tearing with my second baby. He weighed in at about 9 1/4 pounds. I honestly did not feel much discomfort as he was born. The experiences at this stage, the “pushing” stage, vary widely. There may be a very intense “ring of fire” sensation. There may be just LOTS of pressure and stretching (which is what I felt with my first). There may be stinging. There may also just be a feeling of great relief.

And then what?

After the baby and placenta are delivered and you’ve had some magical or dazed or confused or freaked out (or all of the above) moments to touch and see your baby, you may be told that you experienced some tearing. You may be told that you need a few stitches. For a lot of women, this is surprising, because we think we should have felt something that sounds that bad, but with all the pressure sensations and excitement about the baby emerging, it might be completely unnoticeable. Sometimes, your care provider will tell you the degree of severity of the tearing (first degree, second degree, etc.). They may also tell you WHERE the damage occurred.

Most often, it’s the perineum.

The perineum is the bridge of tissue separating the vaginal opening and the rectum. This is the most common place for tearing and there is often at least a slight tear in the vaginal tissue along the perineum.

You can have a very superficial 1st degree tear of the perineum that involves only surface skin tissue and may not even require sutures.

A second degree tear goes a little farther toward the anus and deeper, getting into some perineal muscle tissue and even possibly deep into the vagina. These tend to get stitched.

A third degree tear is identified by any or all of the above PLUS additional tearing of the muscle surrounding the anal sphincter. These require extensive stitching, even possibly by a surgeon in an operating room. Recovery can take much longer and can have an effect on pooping and intercourse.

A fourth degree tear extends through the anal muscle and into the mucous membrane lining the rectum. These are usually repaired in an operating room under anesthesia and can also have a long recovery time and possibly have long term effects on pooping and cause painful intercourse.

Sometimes, you can have tearing of the labial tissues, even toward the urethra. These tears are usually very superficial and less painful although there might be some strong stinging with urination.

Sounds scary right?

It does if you focus on the worst outcome possible, but the worst tearing occurs in only about 1% of vaginal births. Most are managed very easily with either no stitching or with just a few well-placed sutures done on the bed while you hold your baby after just a shot of local anesthetic.

Is there anything I can do to prevent tearing?

Possibly. I don’t think that anyone can say that there is one thing you can do to guarantee an intact perineum though.

perineal massage

Some say that perineal massage can help. I would agree, but only because it can help you understand the feeling of your perineum stretching. It’s very uncomfortable, and feeling it for the first time can be shocking. Many women tense up when they feel it for the first time during the pushing phase of labor. Being tense down there doesn’t help you avoid tearing. If you practice and understand what to expect, you can be more likely to stay relaxed and help your baby ease out slowly. This might prevent some tearing.

How to do it? Look at some images of a vagina/perineum/anus. Get into a horizontal position on your back. Ask your partner to lubricate two fingers and insert them into your vagina, then begin to gently apply pressure downward on the perineum using a semi-circular sweeping motion. Your partner can gradually add more pressure as you feel ready. It is SO VERY uncomfortable, but breathe through the discomfort and teach yourself to relax into it each time before increasing pressure. This should help you prepare and help you relax and ease your baby out slowly to potentially preserve your tissues.

baby positioning

Good baby positioning. This is not the first post that has mentioned baby positioning. It’s not even the second or third. This matters for so many reasons, but in relation to avoiding tears, it’s so important to do whatever you can to help baby be in a great birthing position. If the baby has descended correctly into the birth canal (head down and facing your back), and there are no other limbs in the way, the crown of the head (top/back) should emerge first. The baby’s chin is tucked to make this happen. This position will present the baby’s smallest part first, and will allow the tissues time to stretch more gradually and for the baby’s natural rotation and movement to allow baby to emerge with the least amount of stretching possible.

slow and steady

Take it slow. Very often, the baby will “crown” and then go back in! And this might happen over and over. This may be frustrating. We tend to think that once we can see the head, the rest should just slip out. You may have the urge to hurry the baby out, but it can help your tissues to allow this. Gentle pressure and slow stretching can possibly help you avoid tearing or at least more severe tearing.

To cut or to tear…

An episiotomy is a purposeful cut of the perineum and posterior vaginal wall and can happen for many legitimate reasons.

• If your baby is not in an ideal position and it seems clear to your care provider that a little extra space could help, it may be time to say yes.
• If baby needs assistance using forceps or a vacuum, an episiotomy can help avoid more severe tearing.
• If tearing in an “upwards” direction begins, an episiotomy may help avoid more severe tearing of the labia. We want to avoid labial tears because damage to the urethra is possible.
• If the baby is in distress and the delivery process needs to be expedited, an episiotomy may be helpful.

While it is generally not recommended to perform an episiotomy without medical necessity, it does sometimes happen anyway, so ask your care provider ahead of time how he/she feels about episiotomies. If they say it’s standard practice, but you’d rather not, it’s a good time to let your will be known!

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Joyful Beginnings