Tearing – What you should know

You probably didn’t picture this part when you first envisioned the miracle of childbirth. Tearing, unfortunately, happens. Up to 95% of first time parents will experience some kind of genital tissue damage. Thankfully that percentage gets smaller and smaller with subsequent births, as tissues become more elastic. The fact remains, the vast majority of us childbearing people will encounter a tear.

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The Whats and Hows

There are a few different ways one can tear in childbirth. The most common being a tear in the perineum. The area between vagina and anus is simply the weakest link. If something’s got to give, that’s likely where it’ll be. Less commonly, tears will occur near the urethra, labia, or inside the vagina. Tears are graded on a scale according to severity. Less severe tears are mercifully more common. First degree tearing refers to damaged skin. It can appear as something similar to a scrape, or a shallow cut. Not all first degree tears will require stitches, and most will heal uneventfully.

Second degree tears are more severe. They effect the skin, and a portion of the underlying tissue. You can expect some discomfort, and a few weeks of healing time. A second degree tear, like a first degree, can be repaired with suturing in the delivery room under a local anaesthetic. The stitching process will take a bit longer, as they stitch layers individually.

Sadly, for 4% of birthing parents, tearing will be more complicated. There are two categories of serious tearing. Third and fourth degree lacerations. Third degree tears go through the vaginal tissues, through the perineum, and on to the muscles surrounding the anal sphincter. Most dramatic of all tear based birth injuries is the fourth degree tear. A fourth degree tear splits straight through all tissues seperating the vagina and anus. Third and fourth degree tears are serious complications. You may need a transfer if one occurs at a home birth or birth center (though not always). Some will need to be repaired in the OR. Recovery will be slower, and risks for long term side effects higher.

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Are you at risk?

Every birth carries a certain amount of risk of tearing. However, some circumstances carry a greater risk than others. Knowing your risk factors can help you maximize tear fighting tools. Some risks include:

•First birth

•Larger than average baby

•Unusually long second stage

•Extremely rapid second stage

•Shoulder dystocia

•Assisted delivery

•Previous serious tear

•Induction of labour

Occiput posterior presentation

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How to minimize risks

It’s not always possible to avoid tearing. If you’ve experienced a previous tear, know that it was absolutely not your fault. Tearing happens to most of us. I’m a birth professional, and I tore both times. That being said, there are tools we can use to help minimize your risks of a serious tear.

Avoid that episiotomy. Episiotomies were once standard issue. An episiotomy is a cut made with scissors, intended to create more room at the vaginal outlet. It was theorized to help prevent serious tears. The theory being a larger outlet would allow for passage of baby’s head without further tearing, and a cut would be easier to effectively suture than a tear. Unfortunately, this was not an evidence based practice. Routine episiotomies do not improve outcomes. The level of trauma to tissues is often worse than it would have been had a tear been allowed to form naturally. There’s a theory that the act of creating an incision deteriorates the stability of the tissues and creates further tearing. Try to tear a solid piece of cardboard. Now cut another piece down the middle most of the way, and tear again. The cut piece will likely tear much more easily.

For these reasons and more, ACOG has advised against routine episiotomy for decades. Some practices, however, have not followed that recommendation. It’s within your rights to decline routine episiotomy.  It may not always be avoidable, particularly in cases like assisted delivery, but you may feel it’s best to decline elective episiotomy.

There is evidence to support the use of warm compresses, massage, and counter pressure to aid in maintaining the structural integrity of tissues. Often, when women are allowed to labour “hands off”, they’ll reach down and support their perineum during crowning. It’s a common sense practice, and you may find it beneficial.

Push in a comfortable position. Your pelvis and soft tissues have a great deal of movement to undergo, to allow baby’s passage. When you’re pushing flat on your back, there simply isn’t as much room for your perineum to stretch. This isn’t an exact science. It’s okay to lie down if you’re exhausted and comfortable that way. Consider laying on your side if you need to lie down due to comfort needs or restriction of movement due to continuous monitoring or epidural.

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What happens next

Tears happen. It’s just an unfortunate reality. If you do suffer a tear, there are steps you can take to make recovery a little more pleasant. Allow yourself time to heal. In no other circumstances would we expect someone to bounce back immediately from genital trauma. Allow yourself the opportunity to heal. Rest when you can. Don’t push yourself.

You deserve appropriate pain relief. Taking a Tylenol and Advil combo is a safe and effective way to relieve pain and inflammation unless contraindicated. Ice is an incredibly valuable tool. We like to refer to these as “padsicles”. It’s a good idea to find a padsicle recipe you like, and make a batch before you give birth. Whether or not you tear, ice packs will relieve pain and swelling and greatly improve your early postpartum experience.

Care for your stitches the same way you would any other stitches. Try to keep the area as clean and dry as possible. No special measures necessary. Be sure to contact your care provider if your stitches become significantly more painful, or you develop substantial swelling or fever. If your stitches are uncomfortable, you may find a sitz bath provides a great deal of relief.

Watch out for the washroom! This has to be the number one topic parents bring up when discussing things they wish they’d been told before giving birth. Using the washroom can be extremely difficult with stitches in place. Your self care tools here will largely depend on the location of your tear. If you have a labial or urethral tear in particular, you can expect a stinging sensation when you urinate. Your hospital or birth center may provide you with a “Peri Bottle”. Using the Peri Bottle will dilute urine, and prevent stinging and pain during urination. Fill it with warm water, and spray a continuous stream over your vulva before and during urination. It’s also a great way to keep your stitches clean when you’re too sore to wipe. Stool softeners are a must for perineal tearing. The last thing you need is stress and strain on fresh stitches. Take your stool softeners whether or not you believe it’ll be necessary. You don’t need any unpleasant surprises on your first trip to the washroom, and you can always discontinue your medication afterwards if it turns out to be unnecessary. Some parents are too frightened to take them, believing it will cause them to have more frequent painful bowel movements. This is not the case. Stool softeners are not laxatives. They’ll simply make the event less painful when it occurs.

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Tearing is absolutely no fun at all. You won’t find a parent claiming it was the highlight of their birth experience. Thankfully long term side effects are relatively rare, and with a little self care, you’ll heal and make it through this.

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