If you're wondering or worried about tearing during birth, you're not alone! Tearing during birth is a common fear of pregnant mothers. When a woman is pushing her baby out during that second stage of birth, sometimes the perineal, vaginal, or labial tissue can give way and tear. While it's obviously something better to avoid, it's also something we don't need to fear.
Not only are there significant ways to reduce your likelihood of tearing but it's encouraging to know that that tissue is designed to be able to give way when needed and it's also designed to heal really well and quickly all on its own. When we can reframe low degree tearing into something that is actually at the service of our bodies and our babies, it can be really empowering rather than feeling like something went "wrong." Think of it this way: your body is intelligent enough and designed well enough to open wider when needed and to know how to heal that afterwards.
What's also comforting to some women is that many women don't feel the tearing as it is happening - not only does the baby's head block some of those nerve sensations but there's also a lot of other much bigger sensations going on as that baby is coming out and mom is often not even thinking about tearing in the moment.
But, of course, we'd all appreciate it not happening at all, right? Interesting to note that like so MANY outcomes and things in labor and birth, a whole lot depends on the provider and place of birth and their routine practices and approach to the pushing stage. Some providers have a tear with nearly every vaginal birth mother, some very commonly see 3rd and 4th degree significant tears, while others almost never have a significant tear with their clients. We highly recommend asking your doctor or midwife how often they see tearing and what their normal approach is to the pushing stage. This will give you valuable insight into how they view birth, how they practice, and what you're likely to encounter. Then, of course, make any changes or plans appropriately.
THE BEST NINE TIPS FOR AVOIDING A TEAR:
AVOID COACHED PUSHING. Follow your body's lead and instincts with pushing and request that your birth team does the same unless you decide otherwise. When you are following the lead of others rather than when and how your body is telling you to push, you are much more likely to tear. When others are telling you to "hold your breath and push with all your might", you are exerting a whole lot more force than likely necessary or that you naturally would and your tissue is far less likely to withstand that extra force. Wait until the fetal ejection reflex is naturally pushing your baby out without any extra force willed by you or coached by anyone else.
CHOOSE YOUR OWN PUSHING POSITION. Lying on your back increases the pressure on your perineum and leads to more tearing. Most women instinctually get on hands and knees, squat, or kneel while pushing if no one is directing them and they are following their own instincts. This helps stretch the perineal tissue and gives more space for the baby to come down and out.
DON'T GET AN EPIDURAL. Because an epidural greatly decreases or completely eliminates the sensation to push, women are at the mercy of others telling them when and how to push. They can't self-regulate the pushing as well and more often than not, end up "purple pushing", i.e. holding their breath and pushing as hard as they can when the doctor or nurse tells them to. An epidural also means that her movement is greatly restricted. She is almost always on her back with a lot more pressure on her perineum, though with a lighter epidural she can sometimes get on hands and knees with a lot of assistance. An epidural also increases the use of forceps or a vacuum to help get the baby out, both of which are instruments inserted into the vagina that greatly increase the chance of significant tearing.
BREATHE THROUGH CROWNING. You can ask your husband, provider, doula, or others to help with this if needed. Some women are just naturally strong pushers and have a very strong fetal ejection reflex, their fundus extra efficient at pushing their baby out. When we are able to slow down that crowning a bit and allow the perineum time to stretch, it can greatly reduce your chance of tearing. Breathing techniques like horse lips, humming, blowing through an imaginary straw, or similar can all help in these moments to slow that crowning down. That "ring of fire" moment of crowning can be reframed and instead pictured and talked about as a big stretching and opening sensation.
CONSIDER WARM COMPRESSES. If desired, warm washcloths can be applied to the perineum at crowning to help slow it down a bit but also to give some support and counterpressure to the perineum while the head comes out. This should only be done with the mother's permission, of course.
BIRTH IN THE WATER. Immersion in hot water also acts as a natural counterpressure during crowning. The water can also hydrate the tissues making them more flexible and resilient. The water also makes it easier to get into different positions like hands and knees that are more conducive to not tearing.
KEEP HANDS AND FINGERS OUT OF THE VAGINA. Some providers are VERY handsy as mom pushes. They have fingers and sometimes whole hands inside the mothers vagina, saying they want to "help stretch her out" so the baby can come down. Research and experience show that this actually leads to MORE tearing. Nothing should be going UP and IN while your body is trying to get a baby DOWN and OUT. Since there's a lot more blood and fluid flow into the vaginal canal during birth that "stretching" can actually be what causes damage to that extra sensitive and vulnerable tissue. No one should be "stretching you out" and it should go without saying but this can also obviously be incredibly painful.
HYDRATE AND NOURISH YOURSELF WELL. Make sure you are well hydrated before and during labor so your tissues are resilient. You should be doing this anyway but nourish yourself well all throughout pregnancy with real foods, especially bone broth, collagen, vitamin E, fish oil, and healthy fats. Proper nutrition and nourishment will give you healthier tissue that is more elastic and able to stretch well.
NO EPISIOTOMY. While once very common in medicalized birth, it's become abundantly clear that episiotomies (a cut with scissors intentionally made by the doctor or midwife into the woman's perineum as baby is crowning) INCREASE the rate of complicated tears. Once that tissue is compromised by a cut, it's far easier for it to continue to rip down. Imagine a piece of fabric with a cut in it and how much easier it tears once cut than before. It's also a guaranteed laceration versus a possible one. Thankfully, most providers' episiotomy rates are much lower now than decades ago but there are still many obstetricians out there who use them liberally or without need. Talk clearly with your provider beforehand about their episiotomy rate.
What about perineal massage? A lot of people talk about perineal massage before birth as a way to prevent tearing. There are lots of various methods, all involving inserting fingers or devices into the vagina during the weeks before birth to stretch the tissue. We don't personally recommend it because the research is very mixed on whether it helps or whether it can actually damage the tissue and lead to more tears or even infection. Our bodies are designed to get babies out without having to do painful "massage" techniques or insert devices or fingers to strain that tissue beforehand. Also important to remember that the physiology of labor can't be replicated beforehand and when the time comes, the hormones, blood flow, and elasticity of the tissue are designed to work in those moments of crowning and not before. Sometimes that type of bodywork or "massage" (it's not much like a massage, though!) can help a woman familiarize herself with that part of her body and work on overcoming emotional or mental roadblocks she may have. However, overall it's not recommended as a way to prevent tearing and can sometimes even contribute to a lack of trust in the body and the design of birth.
A little more info on tears:
Tears are ranked in the medical world by "degree" from 1-4.
1st Degree: A more superficial tear involving just the first layer of tissue
2nd Degree: Slightly deeper, extending into the vaginal or perineal muscle
(The vast majority of tearing at birth are 1st or 2nd degree.)
3rd Degree: Extends from the vagina to anus involving injury to the skin and muscular tissue of the perineal area, as well as damage to the anal sphincter muscles
4th Degree: Extends from the vagina, through the perineal area and anal sphincter muscles, and into the rectum. This injury is the most severe type of tear and can lead to longterm complications for the mother.
What if I do tear?
Many 1st and 2nd degree tears need no stitching at all, if the tissue is coming together (or "approximating") well on its own and mom prioritizes rest the first few days, keeping her legs together and being extremely gentle with bathroom wiping (or avoiding it altogether and using just the peribottle). She will likely heal wonderfully well. She will likely be more comfortable without stitches, too, as they can be irritating, itchy, or painful. The process of stitches also contributes to tissue damage and scar tissue developing so avoiding stitches is ideal. However higher degree tears or tears that are continuing to bleed or not approximating well often do need stitches to best heal. When basic stitches are given, providers usually use an injected Lidocaine in the tissue to numb it. However, it may still be very uncomfortable. Extremely complicated tears (like 3rd or 4th degree) may need surgical repair. If in the hospital stitches are usually done within a half hour or so after birth. If at home or birth center, it's usually not as rushed and any stitching is done within the first few hours after birth when mom is ready.
If you do have tearing and/or stitches:
Use a peri-bottle after birth the first few days or weeks when going to the bathroom rather than using toilet paper. Fill the bottle with warm water before you go, squirt the water into the urine stream to dilute it from stinging and use the water to rinse afterward, then pat dry. If you do use toilet paper, pat gently rather than wipe.
Keep your legs together when sitting, changing positions, lying down, etc. Avoid movements and positions that pull that tear or stitches apart.
Be very gentle with bowel movements and avoid straining. Get lots of fiber in to help, even consider aloe juice, extra magnesium, or a stool softener if needed. Avoid foods that generally cause you constipation.
Sit on a soft surface or pillow (or better yet, lie down!).
Change your pad frequently. We recommend organic pads to avoid extra irritation or inflammation from any chemicals or bleaches. Better yet, sit directly on a chux pad or old towel without any underwear or pad. This will keep the area drier and greatly help aid in healing.
Some women find ice packs or spraying witch hazel on the sore tissue very soothing. Soaking in a sitz baths can also help.
Herbal salves, sprays, or baths containing comfrey, calendula, and lavender are also soothing to the tissue and promote healing. (Find some of those items here.)
Continue to hydrate and nourish well!
It's important to remember that, while not ideal, tearing is not necessarily because you did something "wrong". Some babies come out so quickly in precipitous births that mom's tissue doesn't have adequate time to stretch. Sometimes it's in the best interest of the baby to get him or her out more quickly and coached or quicker pushing or instrumental birth (vacuum or forceps) or in very rare cases, even an episiotomy then becomes helpful. Even when tearing happens we can reframe it and remember that our bodies were so generous, so brilliant, so powerful that they could even endure that to help bring our precious babies out into the world.