- What is a perineal tear?
- First-degree perineal tear
- What causes a perineal tear?
- 7 Tips To Help Prevent Perineal Tearing
- Will an episiotomy stop tearing?
- Recovering from perineal tearing
Perineal tearing is a common occurrence for as many as 90% of women who give birth vaginally. For mothers and mums-to-be who want to give birth naturally tearing during birth is something they dread to think about and perhaps even panic as the due date gets closer. While it may be impossible to avoid tearing for many women it can nevertheless be reduced and managed much better with research and an understanding of why/how it happens.
A perineal tear has a clear distinction from an Episiotomy which is a deliberate incision by a surgeon.
What is a perineal tear?
Much of the information online has been written very formally which can lead to a lot of confusion online for women who just want straight answers, so we’re going to make this article as simple as possible. A perineal tear is a name for the involuntary laceration (ripping) that can occur to the skin and tissue between the vagina and the anus. It is literally a description for your skin being ripped up during labor from a variety of reasons.
The severity of ripping/tearing can differ from woman to woman and from birth to birth. This has lead to different classifications depending on the extent of the tear – first, second and third-degree tears. We are going to break them all down for you.
First-degree perineal tear
A first degree perineal tear has little tearing which may be limited to the vagina only and hasn’t traveled much towards the anus. It’s very likely that most, if not all, women who have given birth naturally will have suffered a 1st degree perineal tear.
Second-degree perineal tear
For it to be classed as a second degree, the tearing must have gone beyond the vagina but not reached the anal sphincter or the anus. This degree of tearing is still fairly common.
Third-degree perineal tear
A third-degree tear extends all the way to the anal sphincter but not yet the anus.
Fourth-degree perineal tear
A fourth degree perineal tear is a tear that extends all the way from the vagina to the anus. This is a serious tear.
What causes a perineal tear?
The cause for the tearing of the perineal is pretty clear – it is the pressure and stretching of the birth canal by the much larger baby. Although the vagina and the birth canal is relatively robust and stretchy, more often than not there is simply not enough room for the baby to come out without some sort of trauma. The different scales of severity you may encounter can vary greatly by:
- The position of the baby
- The direction of the head going through the birth canal
- The size of the baby
- Whether or not this is the mother’s first vaginal birth
- Too much pushing
7 Tips To Help Prevent Perineal Tearing
It’s important for every mum to be to know how normal and common tearing is during birth and to not overcomplicate things by worrying for no reasons. We’ve spoken to some mums as well as Jen our go-to former midwife so see if there are some things you can try to help reduce your chances of tearing or if you are going to tear to try and limit it to first or second degree. Let’s begin.
1. Prepare yourself physically
Labour is a physically draining event that can take it’s toll on even the strongest women. If you are in good health you are more likely to have a quick and easier labour and if it’s quick and easy then you’re less likely to tear. Throughout the pregnancy eat as healthily as you can, stay as active as much as possible and you will build yourself a great foundation which will reap rewards during labour.
This is perhaps one of the easiest (most of the time) and effective ways to reduce the risk of tearing indirectly.
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2. Don't push too hard or too often
We think one of the biggest cause of perineal tearing is putting too much pressure on the perineum by trying to push the baby out too hard and too often. A textbook vaginal birth would involve pushing a baby our a slow and steady pace that the perineum can keep up with. If you’re trying to push the baby out too hard you run the risk of applying too much pressure to an area that hasn’t got the chance to get used to the stretching.
Try to remain as calm as possible and push in controlled and calm bursts.
3. Birthing position matters - 4 positions to try
Your birthing position plays a big part in your birthing experience and can help reduce tearing and make labour much easier for mum and baby. Let’s start by saying one of the worst positions you could be in to prevent tearing is the lying down position commonly depicted in TV show fake births. The lithotomy position, as it’s medically called, puts a lot of pressure on the perineum and reduces the size of your pelvic floor. Although lying down may feel like it’s a comfortable position, in reality it’s the position that needs more effort from the mother and baby hence the increased risk of tearing.
So, what are the best birthing positions to prevent tearing?
A. On all fours
This position is similar to the doggy style sex position. This position puts less stress on the perineum but also allows the woman to channel her efforts all over due to the weight being distributed evenly across four limbs. The added bonus of this position is that the birth canal is naturally pointed downwards which enables gravity to give the woman a much-needed hand. This position may feel awkward at first as your bits are in the air and you are a bit vulnerable – you’ll get used to it and after a while, you won’t care. This position is what I took when I gave birth and my tearing was minimal. Ask your midwife about this one as we’re confident they will agree.
B. Kneeling forward
This is a popular position as it’s quite comfortable over long periods of time and isn’t too stressful on the back. The position is essentially kneeling down but you’re resting your front on something supportive such as the end of a bed that’s been folded, a chair, a medicine ball, the edge of the bath or anything, really. The image below demonstrates what we mean by this position.
C. On your side
I bet laying on your side is something you’re used to by now and you might be pleased to hear that this position is also good for tearing prevention but we must add that it’s not the best. Laying on your side allows your pelvic floor to be at its normal position and not too stretched and because the baby will be coming out sideways as opposed to horizontal there’s less stress to the area between the vagina and the anus. Even in this position you’ll still need to remember to stay calm and not push too much.
Squatting isn’t our best position choice for preventing tearing but we do think it’s better than lying down. As long as your knees are not too wide apart as to stretch the perineum you’ll be fine. Squatting can also be quite tiring over a long period of time whereas on all fours, kneeling and laying on your side allows you to be supported while you go through the motions.
4. Perineal massage
A perineal massage before labour can help reduce the risk of tearing and the need for an Episiotomy by softening the area between the vagina and the anus. A perineal massage can be performed by yourself or by your partner, however many of the mums we spoke to preferred to self-massage due to the sensitive nature. We recommend starting to massage the area at around 35 weeks with the goal of performing it once or twice a week.
Before you start, make sure that your hands are clean and your nails are short as this could cause discomfort if you’re inexperienced. Get yourself into a comfortable position and in a peaceful environment that you’re unlikely to be disturbed in.
- Rub some perineum oil on to your fingers and thumbs and around the entrance of your vagina
- Place your thumbs inside your vagina and press them firmly towards the direction of your perineum and firmly massage in a U shaped motion as if the bottom of the U was in the direction of the perineum.
Doing this will feel uncomfortable at first and it will become less uncomfortable the more you do it but it will never not be uncomfortable just so you know. Try to do it for one minute in your first session. With time and experience this will be able to reach five minutes, the longer you can last the more effective this massage has become and should show clear progress.
There is no clear evidence that the massage works but it would be impossible to prove or disprove. Use your own judgement.
As the name (almost suggests) the Epi-No is a device for women who just don’t want to try the massage or simply can’t. It’s essentially a balloon which goes inside the vagina that slowly and gently expands to help the vagina get used to stretching. It may seem like an odd thing to do but many women prefer this due to its simplicity and relative comfort.
6. Water birthing
Water birthing has been known to provide a peaceful and calming environment for mum and baby. The warm water can relax and soften the skin which can help prevent tearing and because it can relax so much the reduced pushing and pressure also greatly reduces the risk of tearing.
Not everyone can have a water birth depending on your hospital’s resources and it may not be in your birthing plan, however. Remember to research water birthing thoroughly and speak with your midwife about it before making any decisions.
7. Keep the area wet and warm
Keeping the skin surrounding the vagina and anus wet and warm with flannels can soften the skin up making it much more stretchy to be able to handle tearing a bit better. Warm, moist towels can also give the mother some much-needed comfort which she will surely appreciate.
Will an episiotomy stop tearing?
An episiotomy is a surgical procedure where a precise incision is made to the perineum where the likelihood of tearing is quite high. An episiotomy is a touchy subject where some people believe it is the better option whereas the other side believes it will increase the likelihood of tearing and in fact increase the chances of tearing.
An episiotomy increased the chance of tearing as the skin has already been lacerated and has a weaker “seam”. An expression we use at BFM is to consider which piece of paper is easier to tear in half – one which has already been snipped with scissors or a piece of paper that is undamaged.
We believe that if you do everything you can to reduce the risk of tearing above then you’ll likely have first or second degree tearing at worst which will heal without problems.
Of course, this should not be considered qualified advice and as always you should speak with your midwife and make your own judgment which works for you.
Recovering from perineal tearing
If you’re reading this part then congratulations on the birth of your baby(s)! Now it’s time to look after your new bundle of joy as well as yourself. This brings us to the section with help and advice on recovery and healing for perineal tears. There is more than one stage of perineal tears which we’ve discussed at the beginning of this article so there will be some differences in recoveries depending on which one of these you’ll have encountered. At this point, you should have some stitches put in and you’ve been sent home with orders to take it easy. Unless you’ve had fourth degree tearing in which case you will probably have needed surgery and a different type of recovery plan.
We’ll start by giving general advice on recovering from tears first and then the specifics after.
Don't overdo it
Some mothers want to get right back on the horse and go at 100 miles per hour after giving birth. Our advice is if you’ve had perineal tearing from the birth to take it easy and let your body recover. Hopefully, you’ll have a good network of friends, family and a husband/partner around to help lighten the load. When we say take it easy we don’t mean lie in bed or a sofa all day but just avoid going back to the gym, doing heavy lifting or ever exerting yourself with an action which could stretch the perineum.
Some tips to help you take it easy:
- Make sure to take naps and sleep when the baby sleeps
- Let friends and family help you – never say no to an extra hand!
- Don’t lift anything heavy
- Eat healthily
Not only should you try and take it easy, you should also make sure to be as comfortable as you can after giving birth. Being comfortable means:
- Take pain relief when needed such as paracetamol
- Wear comfortable loose fitting clothes
- Take regular hot baths/showers
- Have a comfortable seating position at all time, especially when doing it for long periods of time i.e feeding the baby
It’s important to keep the perineum clean and hygienic as to not attract infections. If you’ve had a tear you should try and have at least one full shower or a bath a day – it may be a little tender and sore but it’s crucial for healing that it’s always clean.
To make things easier you can purchase a softer cleaning tower or sponge so lightly dab the areas opposed to scrubbing. When drying out, do a dabbing motion on the area and/or let it dry naturally – do not aggressively pull or tug in case you cause damage to the stitches. At no point use a hair dryer to do it as this can dry out your skin and maybe cause the skin to burn.