Tissue Integrity During Birth

Tissue Integrity During Birth

February 29, 2016

When I interview with new clients, possibly the most-asked question with the most furrowed brows is some permutation of, "What about tearing?" While it sounds gruesome and can sometimes be severe, most of the time women will have a moderate - dare I say healthy - tear, and many women will not tear at all. The discussion of tearing involves three parts: Prevention, Repair, and Healing. 

Prevention

There are lots of theories on how to reduce tearing, from the perspective of both the mother and the care provider. In midwifery school, my teacher's take was almost always, "Hands off the perineum!" 

But most midwives I know, including myself, do at least some hands-on techniques as the baby crowns to help protect a mama's perineum. I really think that sometimes counter-pressure and perineal support can at least help a mother feel safer about pushing her baby out, which may actually help her relax and let more blood flow to her tissues.  Could this actually reduce tearing? Possibly. 

Nutrition, general health, and genetics play a role (some of those things you can control, and others you can't). Smoking is definitely contraindicated, and I encourage my clients to eat healthy fats every day - salmon, avocado, walnuts and the like. Some women are just prone to tearing no matter how well they eat. 

Here are some things you can ask your midwife or OB to do to prevent tearing:

  • Ask your care provider ahead of time to help you slow down your pushing as the baby crowns. You will probably want to push like crazy and get that baby out, but there is some evidence that slowing down at that crucial point can give your perineum more time to stretch instead of tear.

  • You can ask your provider to do a little counter-pressure on the baby's to control the descent, or to put some pressure on your perineum, if it's appropriate. Many women will instinctively put their hands on the baby's head to help them ease the baby out. You know your body best, so if that action comes to you easily, go for it.
  • Warm compresses. The literature is mixed, but personally I feel that warm compresses can be comforting to mamas while pushing, and may bring more blood flow to the pelvic floor, to help your tissue expand.
  • Avoid pushing the baby out while you are in a deep squat or on the birth stool. If squatting feels good when the baby is still high, and it is helping baby to descend, great. But before your baby crowns, consider getting on hands and knees or laying on your side or in semi-sit. Squatting and birth stools can distend your perineum, creating less slack for allowing tissue to stretch. Talk about pushing positions with your provider ahead of time and make sure you are both on the same page.
  • I was taught in school that water birth reduces tearing. One of the theories about this is that the water pressure supports the perineum, and that the warmth relaxes the tissues. On the other hand, a new study from Oregon State University of more than 6,500 midwife-attended water births in the United States reports an 11% increase in tearing for women giving birth in the water.  (https://www.sciencedaily.com/releases/2016/01/160121190918.htm) It think it's possible to do all of the techniques described above while mama is in the water, if it's welcomed. 

Repair

And what if you do tear? First of all:  It's not your fault!  Vaginal tearing is a normal part of the birth experience, and midwives believe that your vagina knows exactly how it is supposed to tear to be able to heal well. As with any injury, there are varying degrees of severity, specifically four degrees that we talk about during vaginal birth. (http://www.mayoclinic.org/healthy-lifestyle/labor-and-delivery/multimedia/vaginal-tears/sls-20077129?s=2)  First degree only goes into the skin. Second degree goes into the muscle of the perineum. Third degree tears move into the muscle of the perineum and into the muscle of the anal sphincter. A fourth degree tear goes into the tissue of the rectum. 

Whether or not your tear will need to be sutured (which means getting stitches) is a conversation you can have with your care provider when she checks out your vagina after you give birth. Suturing can help put tissue back together where it belongs and keep it there for the best healing possible, minimizing scar tissue. Typically midwives will be able to suture a first or second degree tear at home or at a freestanding birth center. Some tears, even second degree, hold together so well on their own that as long as they're not bleeding, they may not need to be sutured at all. Third degree and fourth degree tears - which are rare - will always need repair, and we transport women from a home birth to the hospital for those repairs because a surgeon will usually do the best job for a very severe laceration. 

Home birth midwives carry Lidocaine to help numb you if we need to suture. Some freestanding birth centers may even have nitrous oxide to help you relax during suturing.  In the hospital, stronger medications may also be available to you if you have a severe tear that needs repair, including an epidural or general anaesthesia. 

Healing and Pain Management

  • Even if you don't tear, you may have some "papercuts" that sting a lot when you pee. Drink lots of water, which will dilute your urine to reduce the stinging. You can also buy a numbing spray to apply before you use the bathroom. Make sure you use a peribottle with water or brewed sitzbath herbs while you are peeing, which may help dilute your urine. Your midwife or hospital providers will make sure you get a peribottle. Papercuts heal after a couple of days. 

  • A sitzbath basin (http://www.walgreens.com/store/c/nova-sitz-bath-8101/ID=prod6095772-product?ext=gooHome_Health_Care_Solutions_PLA_Toilet_Accessories_prod6095772_pla&adtype=pla&kpid=sku6086102&sst=e328681c-77e4-4415-82a2-5824fc94b925) is available to fill up with warm water or brewed sitz bath. You simply sit in it and pee into the warm water, while the overflow drains out the back into the toilet. So nice.  
  • Several companies make sitz bath herbs that you can make into a tea to put into your peribottle or sitz bath basin. There are lots of wonderful herbs, but my favorites are comfrey and calendula. You can also soak  your bottom in the herbs in your  (very clean) bathtub. Most sitz bath herbs are also great for hemorrhoids!
  • If you're not into the herbs, simply soaking in alternating warm and cold water is meant to promote healing. This is called "hydrotherapy." (Also great for hemorrhoids!)
  • Ice is now contraindicated after 24 hours post-tear, so don't ice for too long. 
  • Acetaminophen and ibuprofen may help pain and swelling in the short term. 
  • Squeeze your butt cheeks and your vagina closed before you sit on the toilet, then relax once you're seated. This will help your perineum to not distend into the toilet, and prevent undue pressure on the wound and on your stitches. 
  • Wound healing requires good nutrition. Ask your care provider if you may be anemic or if you lost a significant amount of blood during birth. If you are anemic, get a good-quality iron supplement on board - one that doesn't constipate you. Anemia reduces oxygen to the tissues, which can impede wound healing. 
  • Take magnesium or over the counter stool softeners to ease bowel movements. You might even reach down and support your perineum with your hand while you have a bowel movement. This may be ultimately unneeded (having a BM shouldn't pop your stitches) but if it helps you relax, do it. 
  • If you believe that your tear is taking longer than expected to heal, or you think it might be infected, talk to your care provider right away. My personal first line of defense for a mildly infected perineum or slow-to-heal wound is a sea salt soak in the sitz bath basin a few times a day. In more severe cases, you may need antibiotics or to have your wound cleaned and re-sutured. 
  • Lots of rest! Avoid climbing the stairs. Please no sex, and no tampons or sex toys. 
  • Keep the wound very clean. You may need want to hop in the shower after a bowel movement if rinsing with the peribottle isn't enough. 
Notice I didn't even mention episiotomy? This is because the evidence is clear that under most conditions, episiotomy is unnecessary and can actually worsen pelvic floor damage. Talk to your care provider about her episiotomy rate before your are in labor. During a normal, non-emergency birth, the extent of your tearing ought to be from natural causes. 
 

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