Your baby’s entrance to the world doesn’t have to leave you with a nasty tear down there. A normal birth can result in a tear to the vagina and its surrounding tissues, but it’s something that can be reduced. Brush up on some of these facts to help lessen any injury on your part and take this knowledge with you when you come in for your next consultation.
What are Perineal tears?
The perineum is the area between the vagina and the anus. It is a strip of soft skin which is prone to tears if it comes under significant pressure, especially during childbirth. This type of injury is referred to as perineal tears, perineal lacerations, or vaginal tears.
A tear occurs due to the pressure of the baby’s head as it passes through the vaginal opening. It could be that the baby’s head is too large for the vagina to stretch or the head is a normal size, but the vaginal opening doesn’t stretch enough.
How common are Perineal tears?
There is a high risk for perineal tears to occur in Asian women because the the skin and connective tissue have less laxity and does not stretch as easily as Caucasian women. The distance between the vagina and the perineum is shorter and this anatomical characteristic also increases the risk of perineal tears to reach the anus. A study showed that asian ethnicity is 2.2 times more likely than western populations to have more severe tears involving the anal sphincter injuries during childbirth and first vaginal deliveries have a 7 times relative risk compared to subsequent deliveries.
Types of vaginal tearing
1st Degree Perineal Tear – It is a shallow tear which involves the perineal skin. It causes mild discomfort and stinging upon urination. It may or may not need stitches because it typically heals within weeks.
2nd Degree Perineal Tear – This involves a tear to the skin and muscle layers of the perineal area. In some cases, it may even extend into the vagina. It will heal better if the tear is repaired with stitches. You can expect this to heal within a few weeks.
3rd Degree Perineal Tear – This tear goes through the perineal muscles and into the ring-shaped muscle that surrounds the anus (the anal sphincter). It is important to surgically repair this to reduce the incidence of flatus or bowel incontinence.
4th Degree Perineal Tear – This tear extends from the anal sphincter all the way to the anal canal or rectum. This type of tearing will require surgical repair. It may take around three months to completely heal or for the area to feel comfortable. 60 to 80% of women have no symptoms at 1 year post delivery after a tear involving the anal sphincter or canal.
What is an episiotomy?
An episiotomy is a small surgical cut made by the doctor during labour to help widen the vaginal opening and assist in the delivery of the baby. Traditionally, it was often performed as it was thought to reduce the incidence of a serious vaginal and perineal tear down to the anus. However, now the evidence that an episiotomy prevents severe 3rd or 4th degree tears is conflicting.
Studies such as those done by Hong et. al. suggest that an episiotomy doesn’t have to be a routine procedure for vaginal deliveries. Make an informed decision by discussing the matter with your doctor. You can even include this detail in your birth plan.
Reasons for an episiotomy
- Forceps or vacuum delivery. It widens the vaginal opening when instruments are used to assist with the delivery. Having a forceps delivery without at episiotomy increases the rate of serious tears by 6.5 times where ares having an episiotomy increases the rate to only 1.3 times.
- A complicated birth. An example is when the baby is positioned with the buttocks or feet first (breech) or when shoulders are trapped (shoulder dystocia) such that there is more space for further maneuvers to be performed.
- To expedite delivery during fetal distress. This is a complication of labour where the baby’s heart rate significantly decreases before birth due to the lack of oxygen (hypoxia). This may be contributed by umbilical cord compression or strong uterine contractions coupled with the mother pushing. The baby must be delivered quickly to prevent the risk of birth hypoxia or stillbirth and performing an episiotomy can help shorten the crowning stage.
Types of episiotomy
- Midline – It involves a vertical downward cut of the perineum that extends towards the anus. It may heal faster than a mediolateral incision.
- Medio-lateral – This is a cut that goes downwards and diagonally. It is usually used for instrumental deliveries and has a lower rate of 3rd or 4th degree tears compared to the midline.
Each type of episiotomy comes with advantages and disadvantages. Only your doctor can make the judgment on which type would be appropriate at the time of delivery. However, you can always have a discussion on this during your antenatal check-ups. You can ask about repair, scarring, post-delivery pain, and healing, among many others.
Stitches for episiotomy or tears
Stitches are usually done soon after the baby is born. It is done under local anaesthesia so that you will not feel any pain. A local anaesthetic may no longer be necessary if you had an epidural because this already numbs the area.
In most cases, the stitches don’t have to be removed since these are dissolvable within 2 weeks. The tear or cut will heal within 3-4 weeks.
Recovering from an episiotomy
To help heal perineal tearing, you may do the following:
- Rest and assume a side-lying position as much as you can.
- Get in and out of bed on your side to reduce any strain on your perineum.
- Keep the tear clean and dry by regularly washing and changing pads (every 4 hours) to prevent infection. You may also be prescribed an anti-septic spray or wash
- Start with pelvic floor exercises 2-3 days after delivering the baby.
- Always wipe from front to back after going to the toilet to avoid infecting your episiotomy site.
- Take pain medications as prescribed by your doctor.
Immediately inform your doctor if you experience any of the following:
- Bleeding from your episiotomy
- Foul-smelling vaginal discharge
- Fever or chills
- Severe perineal pain
How to prevent tearing during childbirth
Since an episiotomy is an option, there are ways for you to avoid tearing or prevent serious ones during childbirth. You can do the following, granted that you are also advised by your doctor:
Nutrition: stay hydrated and drink plenty of water 2.5-3 L a day to ensure the tissues are also well hydrated. Vitamin C, omega 3 fatty acids and zinc are beneficial for skin elasticity and healing so foods like citrus fruit, avocados and nuts are beneficial.
Perineal massage: From 35- 36 weeks of gestation, there is a hormone relaxin that helps to make all the connective tissue stretchy and aids in delivery. Perineal massage during late pregnancy may encourage elasticity and reduce the risk of tearing during chldbirth. The perineum is the area between the vaginal opening and anus. Some women choose to use perineal massage as a way of hopefully reducing their risk of perineal trauma during childbirth. It also helps to accustom the woman to the sensation of stretching that she will feel when the baby’s head is born. Studies have found evidence that regular perineal massage towards the end of the pregnancy can reduce the risk of tearing in first time mothers. This research also identified that the benefits of perineal massage were greatest for women aged over 30 who had not previously given birth. Regular perineal massage during later pregnancy reduced the risk of perineal trauma that required stitches by 5% for first time mothers.
In general, it is advised to perform the massage 2-4 times a week if the woman is comfortable. If she is not comfortable, discontinue the method. It should also not be done if there is a vaginal infection, herpes sore or vaginal/ vulval conditions that may worsen with the massage.
Step 1: Find a quiet, private place to lie down. Use pillows to support your back so that you are in a semi-lying birthing position with your legs open. You may like to turn off the lights, and play some calming music to help you feel relaxed.
Step 2: Apply oil or lubricant to your fingers, thumbs and perineum. The lubrication should prevent discomfort.
Step 3: Next, insert two fingers around 3-4cm deep (2nd knuckle) into your vagina or as close to that as is comfortable. Gently, but firmly, apply pressure against the back wall of the vagina towards your anus. At the same time, gently pull your two fingers apart so that your perineum is being stretched both downwards and outwards. Keep applying pressure until you feel a slight tingling sensation, this is your perineum being gently stretched. This should not hurt, and you should not notice any burning.
Step 4: Imagine that your vaginal opening is a clock face. Next, pull your two fingers down to 6, then stretch them outwards and upwards towards 3 and then 9, applying pressure. The movement is a sort of U shape. Repeat this 20 or 30 times over several minutes. This is what a woman will feel as the baby’s head presses down before it starts to emerge from the birth canal.
Step 5: rub the perineum between the thumb and forefinger, one finger inside the vagina and one finger outside. You can use 1 hand or 2. Then place two fingers just inside the vagina, only to the first knuckle and gently stretch the perineum outward. Massage more with the thumb and forefinger if the tissue feels tight. Remember to consciously relax the muscles, using slow breathing if the sensation feels too intense.
Avoid touching the anus to reduce the risk of bacteria from the anal area entering the vagina. Avoid being too vigorous as it could cause bruising or swelling in these sensitive tissues. Avoid pressure on the urethra anteriorly as it could induce irritation or infection.
This is a device that helps with stretching the perineum especially if the massage is too awkward or uncomfortable. It can be purchased over the internet and is usually delivered in less than a week. http://www.starnbergmed.com.sg/. From 36 weeks onwards, the device which is similar to a balloon connected to a hand pump is used and some mothers report the ability to stretch up to 8-10 cm dilation with use of the device. It also simulates the pressure feeling that occurs when the head is crowning hence users are better able to control their breathing for a slow delivery (read below). A user video can be found below:
From my own anecdotal experience, an estimated 95% of Asian ethnicity first time mothers will tear midline naturally if an episiotomy was not performed. Most of these tears are minor 1st or second degree tears that will heal well. The majority of first time Asian mothers who had an average sized baby and did not tear during delivery had prepared antenatally by either perineal massage or an Epi-No so I do believe that there is some protective effect.
a.) Warm compress: According to some studies, applying a warm washcloth or compress on your perineum continuously in the pushing stage is associated with less tearing.
b.) Perineal Protection: Slow and controlled pushing during the final stage of labour is important to reduce tears. A hands on approach to protecting the perineal appears to have a protective effect on tears in some studies. This includes having the obstetrician guard the perineum with counter pressure whilst the other hand is placed on the fetus head to slow down the descent on crowning. When the head is crowning, it is important not to push but breathe down and have a slow delivery to enable to perineal tissues and skin to stretch. Many patients have a strong pressure feeling that makes them wish to expel the fetus quickly. The head puts pressure on the rectum so they feel like they need to evacuate a bowel movement and hence they use the same muscles to push.
However, this is associated with a poorer outcome. If you can listen to your obstetrician’s instructions to slow down at the crowning phase and try to relax the pelvic floor muscles and breathe instead of push, the chance of a severe tear is minimised. Another helpful tip is to open you mouth to breathe or pant and say ‘ HA… ha….’ during crowning.
Now that you are more aware about perineal tears associated with childbirth and some tips to reduce the incidence, we encourage you to discuss this with your doctor. It is something you must prepare for because it may make things significantly easier and may also affect postpartum recovery.
For your concerns, you may book your consultation with Dr. Pam Tan today.
You may also call us at the following numbers:
Thomson +65 6254 2878
Suntec +65 6804 9580
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