“Tearing” During Birth: What Does It Actually Mean?

In order to understand what tearing during birth really means, we need to first understand our anatomy.

The perineum is a diamond shaped muscle that divides your vagina and anus. It is a thick muscle that stretches during crowning and childbirth to allow the baby's head and body to come through the pelvis. It also connects almost all of your pelvic floor muscles! Most, perineal trauma occurs downward, toward the back vaginal wall, extending towards the anus*.

More than 85% of women who deliver vaginally will have some degree of perineal tearing.*

Although it is common to experience some degree of perineal trauma during a vaginal delivery, some tears are more severe than others and may require more postpartum care and recovery time.

How we grade the severity of tears:

Grade 1 : Superficial: involving just the skin of the perineum

Grade 2 : Involves the skin and muscle of the perineum

Grade 3: Involves skin, muscle and part of the anal sphincter (partial)

Grade 4: Involves the skin, muscle and through the anal sphincter (Complete) and mucosa

As you can imagine, recovering from a complete tear, through the anal sphincter (grade 4) is usually going to involve more time, care and consideration than a grade 1. Talking about perineal tearing can seem scary, especially when you start to learn about more severe tearing (such as a grade 3 or 4). But, it should also be noted that incidence of those severe tears (grade 3 and 4) occur in 4-6% of births* Grade 3 and Grade 4 tears are also commonly referred to as Obstetrical Anal Sphincter Injuries and it is recommended that any woman who has experienced one of these more severe perineal tears, be referred to a pelvic floor physiotherapist because they are associated with an increased risk of both urinary and fecal incontinence.

Interventions to Prevent Severe Tearing:

There are some measures that your healthcare provider can take to help minimize the risk of severe perineal trauma during delivery.

Some of the known strategies include:

• Slowing the fetal head at delivery

Your healthcare provider may ask you to slow down as the baby's head is crowning, to allow more time for the tissue to stretch and adapt. In some studies this has shown to reduce the risk of severe tears by up to 50%

• *Perineal Support

Your healthcare provider can also use warm compresses on the perineum during birth as well as pressure on the perineum to help reduce the likelihood of tears. Perineal stretching during birth has also shown to reduce the risk of severe trauma.

• Delivery position

During the active pushing phase of labour, which position you are birthing in may have an effect on the risk of severe perineal trauma.

Although the research is still mixed on what the “best” or most optimal position for birth is, there is some evidence to support that the lithotomy position( lying on your back or semi-reclined) during birth, can increase your risk of perineal trauma and tearing.

Some common alternative positions include side-lying, four-point kneeling, squatting or a birth stool. Knowing that you have options when it comes to birth positions is extremely important and valuable.

Tips for the first few days & weeks:

It’s always a great idea when planning for birth, to also include strategies to help optimize your postpartum recovery. I always recommend women have a few things at the ready, either in their hospital bags or at home that will help minimize discomfort should they experience tearing.

Sitz Bath

This is essentially a little bowl that you place on top of your toilet, with warm water to help soothe your perineum after birth.

Padsicles

Padiscles are typically a large pad soaked in witch hazel and then placed in the freezer. You would take the padsicle out and place it in your underwear for a few minutes at a time to help soothe swelling and pain in those first few days after birth.

Peri Bottle

A peri bottle is a small squirt bottle that you fill with warm water and aim at your perineum during urination. Because urine is acidic, when it hits or runs over your incision, it can sting and be uncomfortable and the warm water from the bottle will help neutralize the urine and make going to the washroom more comfortable in those first few days.

Postpartum Undies

Supportive undergarments can really ensure that you’re comfortable in those first few days and weeks. You want something that is stretchy and comfortable and that doesn’t put too much pressure on your perineum.

Tips for long-term recovery (6+ weeks)

After that acute phase of healing, your body has formed scar tissue at the site of injury (where you experienced your tear). This is 100% necessary for that tissue to heal. However, scar tissue is more rigid (less flexible) then your normal tissue and this lack of mobility can be associated with feelings of pain and sensitivity (especially with intercourse).

We want to restore as much mobility as we can to the perineum and the scar tissue. A great way to do this is with targetted scar massage and stretching. Below I walk you through how to start, as well as how to progress. Remember to use gentle pressure to start. It may be uncomfortable but it should not be painful. Make sure to trim your fingernails and use lubrication.

Considerations before starting:. Minimum 6 weeks postpartum with no signs of infection. Please speak to your healthcare provider to ensure the tissue is fully healed before beginning.

I hope you found this information helpful! As always, if you have any questions about the content above please reach out!

References:*Perineal Tears: A review. Goh et al, AJGP. 2018.*Obstetrical Anal Sphincter Injuries (OASIS): Prevention, Recognition, and Repair. Harvey et al, JOCG 2015.