If you’re like most of my doula clients, you’d probably like to reduce your risk of tearing during childbirth.
When we talk about “tearing” during delivery, we’re talking about tearing of the tissues between the vagina and perineum.
I want to validate that it’s normal to be put off by the idea of a tear in some of your most sensitve tissues. It sounds super scary.
But. Let’s consider that this is one of the ways your body makes space for baby to come out. Just like your abdominal wall stretches to make space for a growing baby, your pelvic floor and perineum can stretch and yes, even tear, to let baby out.
Tears are not typically felt as discrete events in childbirth (you won’t notice… it just all rolls into the big birth finale). And, our bodies are pretty darn good at healing from them.
I don’t want minimize your concerns- I’ve been in your shoes. But I also don’t want to you to stay awake at night worrying about tearing during birth. I know you can use every extra moment of sleep right now! The more you know, the less scary it needs to be.
Vaginal tears are not all created equal.
Before talking about ways to improve your chances of birthing with an intact perineum (#lifegoals), lets talk about the different types of tears:
Perineal tears occur on a scale of first degree to fourth degree tears. Whereas a first degree tear might not even require stitches, a third or fourth degree tear is considered an obstetric anal sphincter injury (OASIS) and requires surgical repair.
First degree tears affect only skin. Second degree tears penetrate muscle of the perineum. Third and fourth degree tears impact the anal sphincter muscle.
As you might imagine, recovery from a third or fourth degree tear might be more complex than a first degree tear. Higher degree tears are more likely to create symptoms down the road and require active rehabilitation.
While tearing during delivery is not uncommon, there are a number of steps you can take during pregnancy and during labor and delivery to minimize your risk of tearing or incurring a severe tear.
Prepare your pelvic floor for childbirth during pregnancy
During pregnancy, you can prepare your pelvic floor by taking steps to balance the muscle tone of your pelvic floor muscles, learning to consciously relax your pelvic floor muscles and practicing perineal massage.
For more details on prepping your pelvic floor for labor (and reducing your risk of tearing!), visit this blog post.
Things you can do DURING childbirth to reduce your risk of severe tearing
Whether you did or didn’t prep during pregnancy, there is still a lot you can do during childbirth. I recommend discussing these options with your provider ahead of time. If you feel strongly that you’d like to have the option of any one of these, include it in your written birth plan.
1) Delay pushing until you feel an urge to push.
Research shows that folks who wait to push until they FEEL the urge to push have fewer perineal tears. (1,2)
2) Consider open glottis pushing.
Open glottis pushing is an alternative to the more common breath-hold (valsava) technique that you think of when you think of birth.
The common breath hold technique involves taking a deep breath, holding it in, and bearing down for a count of 10. In open glottis pushing, you take a deep breath and bear down, but you blow some air out of your mouth at the same time. Open glottis pushing results in less pressure on yoru pelvic floor and may reults in a slower, more controlled delivery (3).
If you’re interested in trying this technique, it’s particulary important to bring it up with your provider ahead of time. It’s also important to understand that if your baby shows any signs of distress, you will be coached to hold your breath and push- and you should always follow your providers instructions.
3) Stop pushing when your baby begins to crown.
This gives your perineum time to stretch and yield. You can lift your chin and pant (“puh-puh-puh”) to help relieve the urge to bear down. (4)
4) Ask your doctor or midwife to apply a warm compress to your perineum as your baby begins to crown.
Ask them if they can continue to offer mechanical support (pressure) on this region while you are pushing. Data suggest that althogh applying a compress might not prevent all tears, it does minimize the degree of tearing. (4,5)
5) Learn a few pelvic floor friendly pushing positions.
If you have flexibility in how you deliver your baby, consider positions in which the tailbone is free to move (2,6). The tailbone is free when you’re off you’re back. Options include squatting , hands and knees or side-lying.
If you have a choice, avoid lying on your back. However, for a variety of reasons, we don’t always have a choice of the position the baby is delivered in. Ultimately you should deliver in whatever position feels the strongest and safest for you and your baby.
Keeping it all in perspective
Remember, the goal of these techniques is to REDUCE the risk of tearing during delivery and minimize the risk of incurring a higher degree tear. Sometimes a tear is unavoidable and it doesn’t mean you did anything wrong.
Our bodies are also remarkabley good at healing from perineal tears. In fact, spontaneous tears generally heal better than episiotomies.
If you do experience a perineal tear, I recommend scheduling a visit with a pelvic floor physical therapist around your 6 week OB checkup. They’ll be able to help you assess healing, mobilize the scar and help you with any other post-birth rehab you might need.
If you are looking for guidance on returning to exercise after experiencing a vaginal tear, contact me. I offer 1:1 personal training to help you rehab and return to sport after a tear.
As you prepare for your birth, check out these other resources:
1) Simpson, Kathleen Rice, and Dotti C. James. “Effects of Immediate versus Delayed Pushing during Second-Stage Labor on Fetal Well-Being: A Randomized Clinical Trial.” Nursing Research, vol. 54, no. 3, June 2005, pp. 149–57.
2) Edqvist, Malin, et al. “Midwives’ Management during the Second Stage of Labor in Relation to Second-Degree Tears—An Experimental Study.” Birth, vol. 44, no. 1, 2017, pp. 86–94.
3) Ahmadi, Zohre, et al. “Effect of Breathing Technique of Blowing on the Extent of Damage to the Perineum at the Moment of Delivery: A Randomized Clinical Trial.” Iranian Journal of Nursing and Midwifery Research, vol. 22, no. 1, 2017, pp. 62–66.
4) Sveinsdottir, E., Gottfredsdottir, H., Vernhardsdottir, A.S., Tryggvadottir, G.B., & Geirsson, R.T. (2019). Effects of an intervention program for reducing severe perineal trauma during the second stage of labor. Birth (Berkeley, Calif.), 46(2), 371-8.
5) Aasheim, Vigdis, et al. “Perineal Techniques during the Second Stage of Labour for Reducing Perineal Trauma.” Cochrane Database of Systematic Reviews, no. 6, 2017.
6)Jansson, M.H., Franzén, K., Hiyoshi, A., Tegerstedt, G., Dahlgren, H., & Nilsson, K. (2020). Risk factors for perineal and vaginal tears in primiparous women – the prospective POPRACT-cohort study. BMC Pregnancy and Childbirth, 20(1), 749.
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