If you’re pregnant or planning to be pregnant, chances are you’ve heard stories about what might happen to your nether regions during a vaginal birth. Perhaps you’ve heard about tearing during delivery or even heard the term episiotomy.
Tearing naturally during labor is super common (over 80% of women will experience tearing to some degree). Less common, but still in practice, episiotomy (also called perineotomy) used to be done on the regular.
Even though the American Congress of Obstetricians and Gynecologists (ACOG) recommended doing away with the routine practice of episiotomies in 2006, the rate in the US in 2014 was still 12%. Perhaps more important, the number can vary widely depending on the hospital where you give birth—from under 3% to over 35%!
Is tearing inevitable? Why are episiotomies still practiced today and how can you avoid one? We talked to experts to get the information you need to make the best decision for you and your baby.
During an episiotomy, an incision is made in the perineum, the tissue between the vagina and the anus. Episiotomies were thought to facilitate an easier labor in cases when the vaginal opening didn’t stretch enough for the baby’s head and body to emerge. They were also believed to prevent dramatic vaginal tearing during birth, as well as preserve the pelvic floor muscles, which can be compromised during labor and delivery.
But, today, they are not recommended as the first resort for a normal vaginal birth:
There are reasons your doctor might decide an episiotomy is necessary — if your baby’s shoulder is stuck behind your pelvic bone (known as shoulder dystocia), your baby’s heartbeat is abnormal (or other situations of fetal distress when the baby isn’t getting enough oxygen), or you need to have a quick surgical delivery, involving suction or forceps.
While in labor with her daughter, Emily had an episiotomy when the umbilical cord wrapped around the baby’s head and her heart rate began dropping. “They wanted to get her out quickly,” Emily said. “I was really hoping to avoid tearing, let alone an episiotomy.” Emily’s recovery was tough – sitting was painful, she couldn’t walk normally for about 2 weeks after giving birth, and she was slightly incontinent of both urine and gas – “the latter of which was possibly the worst part.”
Today, episiotomies are not recommended as the first resort for a normal vaginal birth.
An episiotomy can have intense complications: bleeding, infection, painful sex, and tearing in the rectal tissue and in the anal sphincter that can impact your ability to pass stool. It’s no wonder ACOG recommends against it’s routine use.
How to avoid an episiotomy
Communication, between you and your provider, can go a long way.
If you’re currently pregnant and thinking about your birth plan, consider factoring in your wishes to avoid episiotomy and/or receive perineal support. Remember that your birth plan is a guide for your labor and delivery, not a guarantee of how things will go, but can be a valuable way to openly communicate with your partner and health care provider about your concerns in regard to labor and delivery. Don’t hesitate to change providers if you feel like you can’t do that or that something isn’t right. (Follow your instincts!)
In terms of the nitty gritty, Dr. Segura suggests getting acquainted with Lamaze or other birth education resources. “Often, patients do better whether they take a class or look at online videos- where they can learn and later incorporate breathing techniques, along with how to push.” She also recommends doing squats and other low impact exercises to strengthen those perineal muscles. Choosing to go with a midwife can also help avoid tearing and the likelihood of an episiotomy since less intervention and patience in labor and delivery can give your perineal tissue time to stretch.
Don’t hesitate to change providers if you feel like you can’t discuss your concerns about labor and delivery or feel like something isn’t right. Follow your instincts!
Dr. Segura also encourages patients to ask providers what they should do to help themselves not tear and to keep in mind that communication should also go both ways. “Listen to the health care provider who’s delivering you,” she advises. “When to push, when to stop and give little grunts. This way it increases your chance of having a well-controlled delivery decreasing the chance or severity of laceration.”
If you know you don’t want interventions like an episiotomy, make sure your health care provider is aware of that, but also, keep in mind that sometimes unforeseen circumstances dictate otherwise. “It’s best to discuss scenarios with your physician to have a realistic expectation of what may occur— such as fetal distress, hemorrhage, failure to progress in labor, etc— all things which cannot be predicted, but your health provider has to be prepared for—to afford a safe delivery for you and your baby.”
An episiotomy is a cut made by a medical professional, but you can tear naturally in labor and many women do — 80% of women will tear to some degree, with 50% of those tears requiring suturing. Whether or not you will tear during delivery may depends on several factors, says. Dr. Segura, such as the length of your perineum as it relates to the sphincter, and how quickly your labor goes — if your delivery is super fast, it doesn’t given enough time for your perineum tissue to stretch and accommodate the passage of the fetus and can result in a tear.
Not all tears are created equal. Most women will experience a first degree vaginal tear, the least serious kind. It involves the skin between the vaginal opening and the rectum and the tissue right beneath the skin. If you have a first degree tear, you probably won’t need stitches and should heal within a few weeks. As you heal, you can expect mild pain or stinging when you pee.
80% of women will tear to some degree. Most women will experience a first degree vaginal tear, the least serious kind, which might not even require stitches and should heal in a few weeks.
Second degree vaginal tears can extend into the vagina and involve the skin and muscle of the perineum. If you have a second degree tear, it will require stitches and healing could take a few weeks.
Third degree and fourth degree tears are more serious but also far more rare (less than 2% of deliveries). If you experience a major tear in these categories, you’ll likely be taken to an operating room to repair it in a procedure requiring anesthesia. Both third and fourth degree tears can result in painful intercourse and fecal incontinence.
Joanna tore naturally while delivering her son with the help of a midwife. She describes hers as a “really standard tear with good healing.” Prior to her own birth experience, he she didn’t realize that “standard” tears were possible—she’d only ever heard of bad tears that could be be devastating to her bowels and sex life,. Even with her standard tear, healing was long — about 3 months. “I was not prepared for how patient I would need to be, even though everything totally healed up and i have normal bowel and sexual function,” she said. “I’m not saying, ‘it was great, can’t wait to do it again!,’ but i am saying, it was a lot more manageable than I thought it could be.”
How to avoid tearing
Ruth Underhill, an OB nurse currently based in Alaska, says there is a lot that can be done during labor to help a woman not tear. Among them are “controlled” pushing, meaning the woman pushes slowly and steadily, medical professionals keeping their hands out of the woman’s vagina while she pushes (hands can dry out the natural moisture and cause swelling), and applying warm compresses to the perineum during labor to coax the tissue and skin into stretching naturally and accommodating the emergence of the baby’s head. She cites ACOG’s latest recommendations, which advise doing the least amount of intervention possible for low risk deliveries, which include not breaking a laboring woman’s water unless it’s medically necessary.
“Listen to the health care provider who’s delivering you. When to push, when to stop and give little grunts. This way it increases your chance of having a well-controlled delivery decreasing the chance or severity of laceration.”
Dr. Kecia Gaither is the Director of Perinatal Services at NYC Health + Hospitals/Lincoln. “Some women may elect to prepare their perineum beforehand by gentle stretching with a lubricant months prior to the delivery in the hopes that it will make the skin in that region more malleable to delivering the fetal head without tearing— this technique is called ‘perineal massage’, or birth canal widening— it’s an age old practice,” she says. If this is going to work, she adds, you should not have any infections in the genital area (herpes, for example), and you should absolutely have clean hands and use a warm lubricant.
Dr. Segura encourages patients to ask providers what they should do to help themselves not tear and to keep in mind that communication should also go both ways. “Listen to the health care provider who’s delivering you,” she advises. “When to push, when to stop and give little grunts. This way it increases your chance of having a well-controlled delivery decreasing the chance or severity of laceration.”
Good old fashioned patience may play a role as well. A 2011 study of Swedish home births also indicated that women who were not rushed during labor and were supported emotionally as well as physically were less likely to tear.
And as with episiotomy, your choice in a care provider may impact your outcome. Midwives tend to have decreased rates of tearing which may be tied to the range of birth positions they support and their partnership with the birthing mother.
Take home message
Ultimately, of course, there’s no guarantee of how things will go during your labor, but establishing good communication with your health care provider ahead of time, and learning all you can about your options can provide you with sense of empowerment as you move forward.