Articles

Key takeaways

• Perineal tears are common in vaginal birth, especially for first-time mothers.
• Perineal massage during pregnancy can help reduce the risk of tears.
• Birthing positions and controlled pushing can help protect your perineum.
• An episiotomy is a surgical cut, not a tear that happens on its own.

Understanding perineal tears

Your perineum is the area of skin and muscle between your vaginal opening and your anus (your back passage). Tears can happen here as your vagina and perineum stretch during your baby's birth. Tears can also occur inside the vagina or on other parts of the vulva, such as the labia.

Up to 9 in 10 people having a vaginal birth for the first time will experience some type of tear, graze, or an episiotomy. Most of these tears are minor and heal quickly. They are not likely to cause long-term problems, but they can be very sore.

Types of perineal tears

There are different degrees of perineal tears:

• First-degree tears – These are small and only affect the skin. They usually heal quickly without treatment.
• Second-degree tears – These are deeper and affect the muscle of the perineum and the skin. They often need stitches.
• Third-degree tears – These extend into the muscle that controls the anus (the anal sphincter).
• Fourth-degree tears – These extend further into the lining of the anus or rectum.

Around 6 out of 100 people having a vaginal birth for the first time will have a third-degree or fourth-degree tear. These deeper tears are usually repaired with stitches in an operating theatre to help them heal properly.

Rarely, a hole can form between the back passage and the vagina without the muscle that controls the anus (the anal sphincter) tearing. This is called a rectal buttonhole.

Why tears happen

Your vagina stretches during birth, but sometimes it cannot stretch enough. Tears are often unexpected, and it is hard to predict if you will tear.

Some factors can make a tear more likely:

• It is your first vaginal birth.
• Your baby is over 4kg (9lb).
• You have a long second stage of labour (also known as the pushing stage).
• Your midwife or doctor may need to do an assisted birth to deliver your baby. This involves using forceps or a vacuum cup (ventouse).
• Your baby's shoulder gets stuck (shoulder dystocia).
• Your baby is facing with their back to your back (an occipito-posterior position).
• Your baby is coming feet or bottom first (a breech position).
• You are of Asian ethnicity.
• Having a very quick labour (a precipitous birth).

Prevention strategies during pregnancy and labour

There are steps you can take to help reduce the risk of tearing during birth. These include techniques you can use during pregnancy and strategies during labour.

During pregnancy: perineal massage

From 35 weeks of pregnancy onwards, you can try perineal massage until your baby is born. This has been shown to reduce the risk of tears, especially for people giving birth for the first time. You may wish to ask your partner to help you with this.

How to do perineal massage:

1. Use a lubricant like vitamin E oil, almond oil, or olive oil.
2. Hold one or both of your thumbs in the lower part of your vagina for about one minute. You will feel a stretching sensation.
3. Gently massage the lower half of your vagina using a U-shaped movement for 2 to 3 minutes.
4. Repeat this 2 to 3 times.
5. Repeat the massage daily or as often as possible.

During labour: techniques to help

Your midwife can help reduce the risk of a tear during labour. There are several strategies that can be used as your baby is being born.

• Warm compress – Your midwife or doctor may gently place a warm compress on your perineum as your baby's head comes out. This may not stop tearing but could reduce how much you tear.
• Birthing positions – Positions that may reduce tearing include kneeling, being on all fours, or lying on your side.
• Controlled pushing – When your baby's head is almost ready, your midwife will ask you to stop pushing. Pant or puff short breaths to help the head emerge slowly, allowing your perineum to stretch without tearing.

The role of an episiotomy

An episiotomy is a cut a doctor or midwife makes in your perineum during childbirth. This cut makes the opening of the vagina wider. It allows the baby to come through more easily.

About 1 in every 6 people giving birth will have an episiotomy. Episiotomies are not done routinely in England. They are only done with your agreement (consent).

When an episiotomy might be recommended

• Your baby shows signs of stress and needs to be born quickly. This can happen if their heart rate changes, suggesting they are not getting enough oxygen.
• Instruments may be needed to help with the birth, such as forceps or a ventouse (a vacuum cup). This may be necessary if you are tired after pushing for several hours, or if your baby is showing signs of stress as above.
• There is a risk of a severe tear to the anus (a third-degree or fourth-degree tear). Research suggests an episiotomy can prevent these tears, especially during forceps deliveries.
• You are having a breech birth. This is when the baby is born bottom or feet first.
• You have a serious health condition, such as heart disease. A quicker delivery may be recommended to reduce further health risks.

A doctor or midwife will only do an episiotomy when they can see your baby's head coming out of the birth canal (crowning).

Episiotomy versus a natural tear

A tear happens on its own as the baby stretches the vagina during birth. An episiotomy is a planned cut made by a midwife or doctor.

The cut is made into the perineum and vaginal wall to create more space for your baby. Sometimes, an episiotomy may extend and become a deeper tear.

What to expect if you do tear

If you experience a perineal tear, your midwife or doctor will discuss the healing process with you.

• First-degree tears often heal naturally.
• Second-degree tears usually need stitches.
• Third-degree and fourth-degree tears are deeper and usually repaired with stitches. This is done in an operating theatre.

After a third- or fourth-degree tear is repaired, your bowel control may not be as good as before you had your baby for the first few days. It is important to eat well and drink plenty of water to help avoid constipation. You should drink at least 2 litres of water every day.

Eat a healthy, balanced diet. Include fruit, vegetables, and wholemeal bread. Opening your bowels should not affect your stitches.