Vaginal tearing is a common occurrence for women during vaginal delivery. Most of us would like to avoid tearing during delivery, but in some instances, this may be unavoidable.
Is there anything we can do to reduce our risk of tearing during vaginal delivery? What if we have had tears in previous deliveries, are we more likely to tear again? Let’s look at what research states, and then explore some options that may help to reduce our risk of tearing.
Why do we tear? What increases our risk of tearing?
There are several factors that may contribute towards vaginal tearing during childbirth:
The Baby: Size and/or Position
Epidural (theory is that you can’t feel as much, and may push through points that an unmedicated mother would pause to allow for tissues to stretch instead of tear)
Labor augmentation (could be that labor augmentation has a higher occurrence of the use of an epidural though)
Use of pushing interventions (forceps, vacuum, or episiotomy)
Speed of delivery
If I had a 3rd or 4th-degree tear, will I tear again?
If you had a 3rd or 4th-degree tear, the likelihood of having a 3rd or 4th-degree tear again is 6.6% according to a decade-long study in Scotland. The occurrence was higher when compared to women who did not tear (their risk was about 1%), so you may hear statistics like, “you’re 4 times more likely to tear again!” which is not necessarily an accurate way to explain your risk.
But the study does state that a focus on pushing technique and other interventions such as perineal massage may help to reduce this risk even more. In sum, no, you may not tear again in a subsequent delivery!
What may reduce the risk of tearing? And what has no real effect on reducing our risk of tearing?
Warm Compresses
A warm compress is a warm washcloth that the provider can place on your perineum. The thought is that the warm compress helps the tissues stretch easier. Similar to how it’s easier to stretch if we are warmed up compared to trying to stretch cold.
There is limited research that supports that warm compresses will actually reduce your risk of tearing. There was no difference between women that received warm compresses and women that did not when we compare tears. There may be some evidence that supports it could reduce your risk of a third- or fourth-degree tear, but it’s inconclusive.
So in sum, warm compresses may not actually help reduce your risk of tearing.
Perineum Massage During Pregnancy
Perineal massage may reduce the likelihood of tearing during delivery, but doesn’t take it all away.
In one study, they found that 24.3% of women from the perineum massage group and 15.1% of women in the control group that did not perform massage had an intact perineum at birth, or did not tear at all.
Although, there didn’t seem to be much difference in women have had a previous vaginal delivery; so, the perineal massage only really seemed to benefit first-time moms.
Doing perineal massage during pregnancy may reduce your likelihood of tearing during a vaginal delivery if you’re a first-time mom or it is your first vaginal delivery.
Learn more about perineal massage techniques in our prepare your pelvic floor for birth course!
Perineum Massage During Pushing
There was no difference in the occurrence of tearing whether your provider performed massage during pushing or did not. What this means is that your provider massaging your perineum does not increase or decrease your risk of tearing; so, it doesn’t really do much good for you, but it also doesn’t hurt you.
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Pushing Strategy or Technique
This is where we may see a difference! Spontaneous pushing and allowing the mother to choose her own pushing position have been associated with a decreased risk of perineum tears.
The positions that have been associated with a decreased risk of tearing all allow space for the sacrum to move, thus opening the pelvic outlet more. Positions such as: standing, kneeling, all-fours, side lying, or sitting on a birthing stool all allow space for the sacrum to move when compared to lying flat on your back.
In addition, internal rotation of the femurs, or knees in, ankles out, opens the outlet more side to side by moving the ischial tuberosities (sitz bones) laterally. The combination of both allowing for space for the sacrum to move and internal rotation of the femur opens the pelvic outlet and creates more space for baby to descend.
Breathing techniques while pushing did not have a correlation to decrease tearing, but could decrease the length of pushing. Valsalva breathing, closed glottis pushing, or purple pushing (all where the mother holds her breath and bears down) have been shown to increase the length of pushing, and in some studies increase fetal distress and de-oxygenation of both mother and baby. This method of breathing can also be fairly fatiguing on the mother.
Gentle pushing or open glottis pushing (where the mother exhales as she bears down) has been shown to decrease the length of pushing, and in some studies have less stress on both mom and baby. Most studies agree that mothers should choose the breathing style that feels more comfortable for them, with little direction. A combination of both breathing styles could be effective, as opposed to an all or none strategy.
In the study by Edqvist et al, the group of midwives that used this management technique compared to the control group, had a lower risk of tearing. But it is important to note that this could be even higher, since the control group also used spontaneous pushing and pushing positions that allows the sacrum to move. Essentially, some of the midwives in the control group were using the pushing strategy that minimized tearing, so we could theorize that the decrease in the risk of tearing could be even greater with a more optimal pushing strategy!
The pushing strategy that allows a mother to choose her own position, push when she wants to push, and breath the way she wants to breath seems to decrease the risk of tearing.
Learn more in depth pushing techniques and ways to reduce your risk of tearing in our childbirth education courses or check out our upcoming live, webinars all about pushing and preparing your pelvic floor for birth!