Tearing during birth is one of the biggest fears women have about birth. It is estimated that up to 90% of women will experience some degree of tearing during delivery. It may seem inevitable that it will happen to you. However, these statistics include a huge range of types and placement of tears.
Tearing during birth is a subject most mothers don’t discuss. So we’ve created this guide to birth tears to inform you without leaving you feeling like your insides will fall out after delivery. Let’s explore what you need to know about tearing during birth.
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Grades of Tear
Some tears are more serious than others. Medics classify the tear by which areas have been affected and how deep they are. Each type of tear will require a different care plan when you are postpartum.
1st degree Tear
This type involves only damage to the skin layers. It is often referred to as a graze. Think of it like a kid falling off a bike and ‘skinning’ their hands or knees. You won’t need stitches for this tear to heal. Women often report this type of tear as having an intense stinging pain, especially when passing urine.
2nd degree Tear
These types involve damage to the skin and muscle layers. It’s a fairly shallow tear. Most 2nd degree tears will require stitches; however[ it depends on the placement. You may also have the choice as to whether you would like stitches or not. If you need stitches, this is usually done by your obstetrician or nurse midwife in the delivery room. Most hospitals now use dissolvable stitches, which don’t need removed.
3rd degree Tear
This type involves damage up to your anal sphincter (the muscle around your anus). It’s a deep tear that will require a doctor to repair in a theater environment. You will receive a spinal or pudendal block, whilst they repair the area. If the tear is causing excessive bleeding or pain, it may be repaired under general anesthetic. A catheter is inserted into your bladder for repair and may stay in for up to 2 days depending on the severity of the tear. A course of antibiotics will be prescribed to prevent infection in the area.
Follow up should include involvement with obstetric, urogynaecology, colorectal, dietitians, physiotherapy and sexual counseling experts. They will develop a care plan to minimize or prevent long-term complications from the tear.
4th degree Tear
This type of tear involves damage to the rectum. They are a very rare form of tear accounting for around 0.5% of tears in first-time moms and 0.2% if you’ve already had a baby. Similar to the 3rd degree tear you will be repaired by a senior obstetrician in theater. The care plan and follow-up is the same as a 3rd degree tear.
This is a cut that the doctor makes during delivery. It’s classed as a deep 2nd degree tear and will require stitches. A cut is made to your perineum, the flat area between your vagina and anus. Your doctor will use sterile scissors and numb the area with a local anesthetic first.
An episiotomy is usually required to:
- Create room for baby to deliver
- Prevent severe tearing
- Instrumental delivery (forceps or ventouse)
- Deliver a distressed baby quickly
There is no evidence of any benefit for a routine episiotomy. If there is no clinical reason for an episiotomy evidence shows it is better to tear. The majority of tears are usually smaller, less painful and quickly to heal than an episiotomy. If you required stitches after a previous birth, your care giver may recommend an elective episiotomy. However, there is no current evidence to support the claim this practice.
Areas You Can Tear
The perineum is the flat are between your vagina and anus. The majority of tears and all episiotomies cause damage to this area. When legs are in stirrups, it is easy for doctors or nurse the view and stitch quickly.
Vaginal Wall Tear
This described the other area of that vagina that is not the perineum. This is where most grazes occur. High vaginal wall tears can often cause heavy bleeding after birth. They can be difficult to repair as they are rather difficult to view.
This is the lip of skin that extends from your vagina (labia minora). They are fairly common and easy to detect. Usually, they will heal without stitches. You may need stitches if you have a tear which is mirrored on each labia (bilateral tear). This is to prevent the two areas healing together when your legs are closed.
This tear will extend right up to your clitoris. A doctor will assess the area to make a decision, whether to stitch or not. Due to the sensitive nature most try to avoid stitches if possible. There is a concern of long term loss of sensation to the area, which can affect your sex life. It’s important to have follow-up with gynecology to asses any long-term damage to the area.
This describes a tear around the urethra area, i.e. the area you pee from. The rich blood supply to this area makes this type of tear result in heavy blood loss. Usually, stitches will be required to stop the bleeding. Although easy to see, this type of tear can be quite complex to stitch. You may also require follow-up from a continence nurse.
Any damage to the cervix during delivery is classed as a cervical tear. These are most commonly caused by quick labors, instrumental deliveries and previous cervical treatment. A speculum exam is required to see any damage. Unless they are causing heavy bleeding, they regularly go undiagnosed. Stitches are usually only indicated if medics need to stop your bleeding.
What Causes Tearing During Birth?
After your cervix is dilated your baby’s head begins to move down the birth canal. Contractions push your baby downward until the head reaches the perineum. The skin in the area needs to thin out and stretch over your baby’s head. At this point you can see baby’s head, or feel it with your hands. This stage is usually described mother as the ‘ring of fire’ due to the intense stinging sensation. If the skin doesn’t stretch enough, then a tear typically occurs due to the strain on the skin. Due to the intensity of labor, most women do not feel the tear at the time it happens.
Tear are more likely to occur with:
- First babies
- Asian heritage
- Large babies
- Quick births
- Pushing for a long time
- Certain baby positions (e.g. posterior, de-flexed head, arm beside face)
How to Prevent Tearing During Labor
As tears are so common there is no way of knowing if or how severely it will happen to you. The only method which is 100% effective is to opt for an elective caesarean. If that sounds a bit drastic, we’ve developed these tips to increase your chances of avoiding a tear.
We don’t mean taking a daily spin class but merely to keep active. This can be hard in late pregnancy. However, regular yoga, walking or swimming are great options. Exercise improves your blood circulation and keeps your skin health. You will have more stamina for birth, and your skins’ elasticity will improve. Include a healthy balanced diet and increase your fluid intake to help your body fully prepare
2. Pelvic Floor Exercises
These are also known as Kegel exercises. They are designed to target the pelvic floor muscles you use during birth. Most women do these to tighten the area to prevent them becoming weak as you grow older. In pregnancy, it’s important to learn how to control these muscles. Controlling the muscles includes learning how to relax as well as tighten them. Relaxing the muscles during the pushing stage of labor can help prevent a tear occurring.
3. Controlled Breathing
The body is designed to push your baby out without being directed by a nurse or doctor. The fetal ejection reflex is an involuntary sensation which will make you want to push even if you can’t help it. Pushing hard into these contractions can increase the risk of tearing. Aim to pant or breathe out as these contractions happen. The best method is to pretend you are blowing out a candle during the contraction. This prevents baby being forced out and gives the skin time to stretch.
4. Warm Compress
Pressing one on the perineum can improve blood flow to the area. This helps to provide heat relief and encourage the skin to stretch up. Alternatively consider delivering in a birthing pool if you have one available in your area. The warm water provides this for the whole area and increases relaxation.
5. Perineal Massage
In the last few weeks of pregnancy, you can massage your perineum. The aim is to improve elasticity to the area to reduce the risk of tears. Studies have shown it to reduce the likelihood of episiotomy. This technique can help you become more connected to your body before birth. Not all women are comfortable with such an intimate massage; however, it won’t do any harm to try.
6. Care Providers
We’ve already discussed the importance of following your body’s instincts when pushing. Some care providers like to instruct pushing putting you at greater risk of tearing. The place of birth may affect how relaxed you are, or the position you deliver in. You may want to ask your care provider what their rates of tears or episiotomies.
7. Avoid Epidural
Before opting for an epidural, we recommend exploring alternative pain relief options. Studies show that epidurals increase your chances of an instrumental delivery. This means you are more likely to have an episiotomy. Epidurals also block the fetal ejection reflex which can lead to directed pushing. Women who are induced are more likely to opt for an epidural as the contractions do not have a natural build up.
There is a lot of evidence to show that the position you birth in will influence if your likelihood of tearing. It is known that lying positions are more likely to cause a tear. This is because your pelvis cannot open as wide as it would when you are upright. This puts more strain on certain areas of the pelvic floor leading to tears.
The best position is one which you feel most comfortable. When left to choose your women naturally opt for upright positions. This is your body’s way of optimizing your pelvis to let baby though with greater ease.
The best positions to prevent perineal tearing is:
- On Hands and Knees (All fours)
- Supported Standing
- Side Lying with supported leg
Long Term Effects of Tearing
Most tears are minor and heal quickly without any complications. Deeper tears and those in certain places can cause long-term health complication. To avoid these complications it is important for you and your healthcare provider to take steps to prevent tearing during birth.
Pain is the number-one complication of tearing. This usually subside but may be ongoing depending on the damage caused by the tear. In the short term, tears cause higher rates of infection, constipation and immobility. Long term implications include fistulas and urinary/fecal incontinence.
The psychological aspect is a huge issue among women with tear trauma. For some women, it can trigger postpartum depression. Coping with severe health issue such as incontinence can require a lot of mental health counseling input.
Your choice to have more children can be affected if you have a bad tear. The trauma may cause you to fear becoming pregnancy again. If you do opt to have more children, you will need to consider the modes of delivery. Most women opt for a planned caesarean after a 3rd or 4th degree tear.
A combination of pain, fear and lack of sensation can affect your sex life after a tear. The stress often results in a low desire to have sex. It important to discuss any concern with a professional. Lack of sex can start to cause relationship issues with your partner.
The costs of all of the long term issues, caused by a tear, are huge. Health care bills for operations, mental health counseling, sex counseling, marriage therapy runs into the thousands. Ensure you have good health insurance, which covers these costs, before you give birth.