Your perineum is the area of tissue between your vagina and your back passage. When your baby’s being born, this tissue gets stretched and very thin – sometimes so thin that it tears. The more stretchy and elastic the tissue is, though, the less likely it may be to tear.
The thought of tearing or having an episiotomy in labour is what worries many women, but reassuringly the thought of it is far worse than the reality. Understanding a bit more about tearing and episiotomies before it actually happens may help ease your worries.
There is research that’s shown that doing perineal massage in the last six weeks of pregnancy can help to reduce the incidence of tears as well as of an episiotomy being needed. What perineal massage involves is gently rubbing your perineum with a mild vegetable-based oil such as wheatgerm, almond (if you’re not allergic to nuts), olive, grapeseed or Vitamin E oil (look in health food shops).
All you do is put your thumb inside your vagina against the back wall (make sure your hands are clean and your nails are short!) and your forefinger on your perineum and massage the perineal issue between your thumb and forefinger for a few minutes (say five), pressing downwards and up each side of your vagina (so you’re making a U-shaped movement) with your thumb. You can use both thumbs if you want to, one each side. You can also try gently stretching the opening of your vagina (it’ll feel like when you pull the corners of your mouth). You can do this massage for yourself, or get your partner to do it for you (it may not be easy to reach yourself!).
Avoiding an episiotomy/tear
Although there are no guarantees, the following may help avoid a tear or the need for an episiotomy arising:
- Using upright positions in second stage
- Not pushing or straining too hard in second stage
- Not holding your breath for too long during contractions in second stage
- Allowing your baby’s head to be born slowly. Your midwife will help you with this by telling you when not to push (she may tell you to pant). If the head is coming quickly, getting onto all fours may help slow it down
- Relaxing and letting your body open up rather than resisting it
- Giving birth in water has shown to reduce the likelihood of tearing as the warm water helps relax the pelvic floor muscles and it also helps soften the perineum.
- Doing perineal massage during pregnancy
- Doing pelvic floor exercises and learning to relax your pelvic floor during pregnancy
If you’re particularly anxious to avoid an episiotomy, make sure the midwife knows this by including it in your birth plan.
As your perineum thins and stretches over your baby’s head, it’s possible for it to tear. You’re likely to feel a burning sensation as your baby’s head crowns, but your perineum will be so numb and stretched that if you do tear, you probably won’t feel it.
Not every women will tear giving birth, but it is more likely if it’s your first labour (about one-third of first time mums). About 10% tear delivering their second and subsequent babies.
Tears can be relatively minor and not need any treatment (1st degree), or they can be slightly more extensive and perhaps need a few stitches (2nd degree). The most serious can go through to your back passage (3rd and 4th degree), and will need careful surgical repair in theatre. This is quite rare, though.
An episiotomy is a small cut in the back wall of your vagina and into your perineum (the area between your vagina and your back passage) which is made by the midwife or doctor using a special type of scissors. It’s usually done for one of two reasons, either to enlarge the opening of your vagina to help your baby to be born more easily, or to prevent your perineum from tearing seriously.
If you have an episiotomy, it’ll need to be stitched, and your perineum is likely to be sore for several days. Some women find that it takes a lot longer than that for their perineum to heal.
Having an episiotomy doesn’t affect all women in the same way. While most women would probably prefer to avoid one, not all of those who have one are troubled by it. Some women, though, find that it changes the way they feel about themselves, while others are worried about the effect it might have on their sex life. A few are very traumatised by it.
The chances of having an episiotomy during birth is much less than it was a few years ago because numerous studies have concluded that episiotomies should not be done without good medical reason so your midwife or doctor will only suggest an episiotomy if she feels that it’s entirely necessary. She’ll ask for your permission before she does one, and will give you a local anaesthetic before carrying it out.
Helping the baby out
These are some of the reasons an episiotomy might be suggested to help your baby be born more easily:
- There are signs that your baby is compromised and needs to be born quickly
- Your baby’s shoulder is stuck (shoulder dystocia)
- The opening of your vagina won’t stretch enough to allow your baby to be born
- Forceps or ventouse are being used to help your baby to be born
Episiotomy vs. a tear
Your midwife may suggest an episiotomy if she thinks you’re at risk of a serious tear, in order to prevent this from happening. This is, of course, a judgement call on her part. Because the risk of a serious tear is small, women who strongly wish to avoid an episiotomy may choose to take the risk.
Occasionally, an episiotomy can extend into a more serious tear.
An episiotomy may be easier to stitch than a tear, but a tear may heal more easily and research shows that tears are less painful for women than episiotomies.
Caring for your perineum after an episiotomy or tear
- It is important to practise your pelvic floor exercises – even if the area is numb, this will help the blood flow and aid healing
- Keep your perineum clean and dry by having regular baths or showers, using a bidet, or bottle of water to squirt on the area and regularly changing pads
- Homeopathic remedies like arnica are good for bruising – check with your local homeopath or natural health shop
- Ice packs can offer comfort because they will help reduce swelling. Make sure you cover the pack and only use it for 5 minutes at a time because the intense cold can hinder blood flow after a time.
- Sit on a ‘V’ pillow which helps relieves pressure in this area and will help you to sit more comfortably!
- Avoid constipation by keeping your fibre intake up and drinking plenty of water. Eating a balanced diet can also aid healing
- Many women worry their stitches will burst when they have a poo. This will not happen. Try holding a sanitary towel or a pad of toilet paper firmly over your wound while you have a poo if you are worried.
Your midwife will check any stitches to ensure the area is healing. Usually stitches dissolve on their own – this can take 2 -12 weeks depending on the make of stitching used. If they are causing problems (for example feeling very tight) the midwife may remove them if it appears to have healed well.