Perineal Tearing During Childbirth
The risk of having a vaginal tear during delivery is probably one of the top fears that a lot of women or birthing parents-to-be have in the last weeks of pregnancy. Although common, they are not always as scary as they sound and there are some strategies and techniques that can be preventative in some cases. With this post I want to share about how vaginal tears happen and what can be done to prevent and treat them.
Typically, vaginal tears during childbirth occur at the perineum, which is an area of tissue between the vagina and anus. Tearing of the perineum can happen spontaneously during labour as the muscle tissue is stretched from the baby passing through the vaginal canal. 53-79% of women sustain some type of vaginal tear during delivery, and most are considered to be mild.
There are 4 degrees of perineal tearing based on severity.
1st degree: Superficial tear of vaginal mucosa and perineum
2nd degree: Deep perineal tear not affecting the anal sphincter
3rd degree: Partial or total tear through anal sphincter
4th degree: Grade 3 with extension through rectal mucosa
There are some risk factors that can increase the risk of sustaining a moderate to severe (3rd-4th degree) tear. These factors include having a large baby, having a longer second stage of labour, being induced, having a forceps or vacuum assisted birth, or having baby in a face up position. You also have a higher risk of tearing if it’s your first vaginal delivery.
There are some strategies that can be implemented to reduce the risk of tearing during vaginal delivery. In the last month or so of pregnancy, perineal massage and stretching can be performed as often as daily to prepare the tissues. Research shows that this is effective in reducing the risk of first or second degree tears during a woman’s first vaginal delivery. By manually stretching the perineum, you improve the flexibility and mobility of the tissue, while also getting the body comfortable with the stretching sensation. A pelvic physiotherapist can teach you how to do this technique.
There’s also evidence to show that different birthing positions can influence the ease with which baby is delivered, thus affecting the risk of tearing. If you’re laying on your back, the baby must go “uphill” and all the pressure is directed backwards towards the perineum, which can cause tearing. Pressure can be dispersed around the entire vaginal opening in alternate positions such as squatting, kneeling, or being on all fours. The Society of Obstetricians and Gynaecologists suggests that “women should be informed of the benefits of upright positioning in labour and be encouraged and assisted to assume whatever positions they find most comfortable.”
Another consideration for minimizing the risk of tearing is pushing technique. There are two main methods of pushing when it comes to breathing. Closed glottis pushing, which is also called Valsalva, is when you take a big breath and then hold it before you push for the length of the contraction. Open glottis pushing involves using an active exhale to push when the urge develops. It has been suggested that pushing with an open glottis allows for a more controlled descent of the baby and can minimize the strain on the perineum that causes tearing. A pelvic floor physiotherapist can review breathing and pushing techniques with you and give you strategies to practise in the weeks leading up to a vaginal birth.
If you do sustain a perineal tear during delivery, you will likely have stitches, unless the tear is very small. In the early days of healing you can use ice to reduce pain (frozen maxi pads or “padsicles” are great!), and you’ll want to take it easy to avoid straining the healing tissue. This includes keeping the bowels regular! When you’ve been cleared by your doctor or midwife after the initial healing period, a pelvic physiotherapist can help you manage any pain or discomfort that remains at the site of the stitches, and prevent things like ongoing pain with intercourse. Treatment includes things like massage and manual therapy to the perineum and the surrounding tissues, as well as exercises for the pelvic floor to improve blood flow to the area, muscle strength, and overall tone.
-26th Edition of the Advances in Labour and Risk Management – Society of Obstetricians and Gynaecologists of Canada, 2019-2020.
-Management of spontaneous labour at term in healthy women – Journal of Obstetrics and Gynaecology Canada Vol. 40 – Issue 2. 2018
-Beckmann MM, Stock OM. Antenatal perineal massage for reducing perineal trauma. Cochrane Database of Systematic Reviews 2013, Issue 4.