Tearing in Birth: What is the Norm?

If there was ever one hill almost every doula would die on, it would almost certainly be that episiotomy and tearing are not by default, a normal part of birth. While episiotomy is blog for a different day, now is the perfect time to dive headfirst into perineal tears, labial lacerations, and everything in between. Let’s discuss why they occur, how to prevent them, how to know how severe they are, and how to heal them.

When we think about tearing during childbirth, we often jump to thoughts of torn perineums, but the truth is that tears can affect almost every part of the vagina and vulva. Each tear comes with its own set of challenges, and some are more avoidable than others. However, no matter the location(s) of your tearing, healing will require care, delicacy, and kindness towards yourself.

• - Perineal Tearing: Tearing of the perineum is the most common and widely discussed area where tears take place. This is the tissue located between the vaginal opening and the anus. These tears are typically graded in degrees, which we’ll dive into in a moment, but generally the less tissue/structures involved the lower the degree. The perineum is the area of the vagina and vulva that stretches the most as your baby descends down and out of the birth canal. In cases of natural, physiological tearing your perineum will be the area most affected.
• - Labial Tearing: Labial lacerations are far less common than tears in the perineum, but are seen most often in situations where an episiotomy is performed, a birth is instrument assisted, or a baby is born quickly. While these tears are easily repaired with a few stitches, it’s not uncommon for doctors to leave them to heal naturally, or even miss them entirely. In many cases these tears may leave behind a slight deformity. These deformities can be fixed with reconstructive surgery in most cases.
• - Periurethral Tearing: Periurethral tears are tears to the tissue around your urethra, the tube that drains your bladder. These tears are often superficial and only require stitching if they bleed freely. Because these tears don’t involve muscle they typically heal faster than perineal tears and typically heal without complication. These tears are most often observed when a baby is born face up, also known as sunny side up.
• - Clitoral Lacerations: While the thought of having your clitoris tear is admittedly worrisome, rest assured that these tears are rare, occurring in an estimated two percent of births. Similarly to periurethral tears, clitoral tears are observed more often when a baby is sunny side up. They can also be the result of instrumental or precipitous birth. In most situations clitoral tears will heal within one to two weeks.

Perineal Tears and their Degree

To rate the severity of perineal tears we use a 1st, 2nd, 3rd, and 4th degree rating system. These degrees relate to the depth and involved structures affected by the tear. For example, a first degree tear is considered a “graze” or “skid mark”. They affect only the top layer of skin and often won’t require any stitching. A second degree tear will affect the skin, and some of the muscle in the perineum. Second degree tears will require a few stitches to heal properly. A third degree tear refers to a laceration that affects the skin, muscle of the perineum, and extends into the anal sphincter muscle. Third degree tears will require stitching and may be done in an operating theater. Finally, fourth degree tears refer to tears that extend all the way into the lining of the rectum. Stitches will be required, as will some level of reconstructive work. Complications of third and fourth degree tears can include scar tissue buildup, fecal incontinence, and pain with intercourse.

How To Prevent Tearing

Before we talk about preventing tears, we should talk about why they sometimes occur naturally. The obvious answer? While your birth canal can stretch up to three times it’s typical size, it takes a little work to get it there. Is tearing sometimes part of physiological birth? Absolutely. Does it happen 100% of the time? Absolutely not. Here’s how we can work with our body to give it the best opportunity to birth your baby without tearing.

• - Perineal massage: This massage technique involves the use of your or your partner’s fingers to gently stretch and mobilize the tissue just inside the lower wall of the vagina and the tissue between the vaginal opening and the anus. These gentle stretches prepare the perineum to expand and mold around the shape of your baby. Always start with clean hands, use a warm lubricant like grape seed or olive oil to lend more moisture and hydration to the tissues so they can stretch more freely, and build up the intensity of the stretch slowly.
• - Avoid pushing on your back: In order for the vagina to expand to three times its size, we have to give it the room to do so. Pushing on your back can close the pelvis by up to 30%, which will in turn impede the birth canal’s ability to fully expand as your baby passes through. Pushing in a side lying, hands and knees, or even squat position removes any outside pressure that could close off the pelvis and will in turn greatly reduce your chances of tearing.
• - Say no to purple pushing: You’ve probably heard the phrase “ring of fire” in relation to the moment your baby begins to crown. It can often be instinct to forcefully and quickly push your baby through in attempts of shortening the time spent with that sensation. This is an almost sure path towards a third or fourth degree year. In parents who have gotten an epidural, providers may use purple pushing, or coached pushing.To learn how to push with your body instead of against it, check out The Secret Sauce to Pushing. This is another sure path to severe tearing. To combat this instinct or coaching technique, we say “blow out the candle”. As your baby crowns, the sensations will build until they seem bigger than you. This is when we tell you to blow out short small breaths, as if you were blowing out a singular candle. This pause in pushing will allow more time for the blood flow to rush to the surface of your tissues which allows them to stretch more. The more blood flow, the more expandable.

How To Heal A Tear

While most tears will heal within four to six weeks, they still require care in order for them to heal well and bring about the least complications. Avoiding any further trauma to the area is most important. Instead of wiping with toilet paper as you usually would, try using a peri bottle to cleanse the area and gently pat dry. Sitz baths come highly recommended as they can increase blood flow to the area which in turn soothes the affected area and promotes a quicker healing process. As your tears heal they may become itchy and tender. Using something like dermoplast spray can relieve the itching and tenderness you encounter as you heal. Monitor the area for any signs of infection, such as a green or yellow discharge and/or a strong foul smell. If you begin to think you may have an infection, touch base with your provider right away.

Tears Happen

In closing, it’s important to understand that tearing naturally is sometimes part of physiological birth, but is by no means a given. Taking control of how you birth, where you birth, and who catches your baby are all factors that play into your likelihood of experiencing a tear during birth. It is perfectly possible and normal for first time mothers to make it through childbirth without anything more than a graze. Your body knows how to make space, it just asks for your steadfast cooperation and commitment.

This blog post was written by a former Tranquility by HeHe doula.