Will I tear pushing my baby out?

This is one of the most common anxieties surrounding vaginal birth that I come across as a midwife. As soon as I start talking about this topic in antenatal class I see a roomful of people wince and cross their legs, and I totally get it, I do. But, what if we reframed the question? How about: will my perineum and tissues stretch to allow my baby to be born? The answer to that is a big fat YES!

Just a reminder: the perineum is the area between the vaginal opening and the anus. This is the area that stretches as your baby is born. The baby’s head descends into the vagina and sits behind the perineum as it gradually thins and stretches. Try to remember: your body is designed to birth a baby, it has primed itself throughout pregnancy to be ready to do the job. The hormone relaxin will enable the perineum to soften and stretch before and during labour. And there are lots of other factors at play that influence the occurrence of injury to the perineum.

Photographs showing the perineum stretching.

But, I am going to be real here. For the majority of births (80%) there will be some degree of ‘trauma’ to the vagina and/or perineum. This is a completely normal part of birth and does not mean your vagina will be left unrecognisable to you. Trauma sounds scary and extreme, but can simply be superficial grazes to the skin around the labia, which heal easily with no intervention needed. Commonly, you may have a first or second-degree tear. A first-degree tear involves just the skin of the perineum, and a second-degree tear involves some of the vaginal and perineal muscle. This will often require some stitches, but sometimes can be left to heal by itself. ‘Suturing’ as it is called can be performed by a midwife or doctor. Usually this is done shortly after the birth, in the room where you had your baby and with effective local anaesthetic.

Rarely, more severe tearing can occur that extend into the anal sphincter (around 1-4% of births). This is known as a third or fourth degree tear. I often feel conflicted about whether to share this information as know it can cause further anxiety. But I also don’t feel that I can just leave it out. My main takeaway messages are: it is very rare, and there are things you can do to prevent it.

I think we can fall into tricky waters if we claim that an ‘intact’ perineum (no tears) is a badge of honour to hold. You have not failed or done anything ‘wrong’ if you tear or need some stitches. However, research shows that women with an intact perineum:

  • Experience less pain after having a baby
  • Are less likely to have problems passing urine
  • Are more likely to resume sexual intercourse earlier
  • Report less pain with first and subsequent sexual intercourse after giving birth
  • Report greater satisfaction with sexual experience
  • Report greater sexual sensation and likelihood of orgasm at six months postpartum

So, aiming to reduce the degree of trauma as much as possible is hugely important for your ongoing physical and sexual health, and psychological wellbeing. You are more likely to experience symptoms described above with 3rd or 4th degree tears, which as I mentioned before are very rare.

Top tips for letting your perineum do its job:

  • Communication – Having good communication with those present at your birth can really help you to focus on the job of pushing your baby out. You will most likely have an uncontrollable urge to push when your baby is low down and ready to come (this can vary depending on if you are using pain relief and what type). For most people, this is experienced intensely as an urge to poo, as the baby is pressing on your bowel and rectum. Trusting your body and going with these natural sensations and urges is important, but there will come a point when it is preferable to breathe and slow down as much as possible as the baby’s head is being born, known as ‘crowning’. The sensation at this moment is referred to as the ‘ring of fire’, as the skin and tissues are stretching to their maximum. But remember that relaxin is working to help the skin stretch, and the body is also clever enough to release endorphins which are natural painkillers. It may feel like you want to push with all your might at this point to put an end to this intense sensation, but keeping as calm as possible and breathing with the support of your birth partner/midwife will help your baby come gently and give your perineum time to stretch as nature intended.
  • Position – the position you are in when you birth your baby is also really important. Kneeling, all-fours, lying on your left side or resting in a semi-recumbent position are all fantastic for helping your baby as much as possible to navigate their way out. Deep squats, standing and ‘lithotomy’ (legs up in stirrups) are associated with greater degrees of tearing, as these positions can put intense pressure on the perineum as the baby is being born. This doesn’t mean that these positions are ruled out if they are what you find comfortable. Your own comfort is the most important factor. Every labour and birth is different and it is about finding what works for you. I have observed that women will instinctively adopt positions that help their baby descend through the birth canal as they push, and then move into a ‘preferred’ position such as kneeling when they feel the baby’s head crowning. This is because the body intuitively knows what to do when birth is as undisturbed as possible and physiological processes are nurtured.
  • Warm compresses and immersion in water – Research has shown that one of the few interventions that really make a difference is applying warm compresses to the perineum as it stretches when the baby is being born. Giving birth to your baby in a birthing pool or bath has been shown to have similar outcomes to birthing on land and reduce overall perineal trauma. This is thought to be due to the warm water helping the skin to stretch and the counter-pressure of water against the perineum as support.

I hope this post has given some practical and useful information rather than causing further anxiety or fear. In my next blog post I will be talking about perineal massage and how this can be done in pregnancy to help increase the perineum’s ability to stretch.

 

 

Researchy bits:

http://www.cochrane.org/CD006672/PREG_perineal-techniques-during-second-stage-labour-reducing-perineal-trauma

Stats (UK based):

https://patient.info/doctor/episiotomy-and-tears

Water birth:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3982045/

https://www.ncbi.nlm.nih.gov/pubmed/12708093

 

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