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Nyssa's Mia Clarke speaks to Dr. Laura Laursen, an OB-GYN with Rush University Medical Center in Chicago about the realities of vaginal and perineal tearing in childbirth. Dr. Laursen provides straightforward information about the anatomical impact of tearing and strategies to help minimize tearing and encourage a positive physical recovery.
This transcript has been edited for length and clarity.
MC: Before we get started, could you share a little bit about yourself?
LL: My name is Laura Laursen. I am an OB-GYN in Chicago practicing full spectrum OB-GYN care. I am also a fellow of the American College of Obstetrics and Gynecology with a focus on inpatient obstetrics, trying to improve birth outcomes for women and all patients.
MC: Today we're going to be talking about vaginal and perineal tearing as it relates to delivery of a baby. What is a perineum and what causes it to tear?
LL: I feel like the perineum is this mysterious thing that no one really thinks about until they have a baby and then you hear about these perineal tears.
If you think about your anatomy, there is the urogenital area and the anorectal area, basically the vagina and the anus. Then there is a muscular layer between the vagina and the anus that supports your pelvic floor and that is the perineum.
When a baby is delivered it goes through the birth canal and the vagina expands. The body is made to do that. The muscles of the perineum expand and stretch as well in order to allow passage of the baby's head. In that process they can expand a little too much and this can lead to these tears.
MC: There are different degrees of tearing. Could you talk through those?
LL: We talk about these tears as first degree through fourth degree. That is the medical terminology that we use to keep everything standardized. A first-degree tear is a tear that's just in the vagina. It's not going through any muscles - it's in what we call the vaginal mucosa.
A second-degree tear is going to be that vaginal mucosa and also some muscles in the perineum. Then we get to the third- and fourth-degree tears which are the more complex.
These tears are much more rare, and we'll get to that a little bit later, but a third degree tear actually goes into the sphincter of the anus. The anus is actually made of an internal anal sphincter and an external anal sphincter. The external anal sphincter is what you control and that controls continence of stool and flatus. The internal anal sphincter is under involuntary control so the body is controlling that completely on its own and you don't have any control over that. Then the fourth-degree tear again tears through the vaginal mucosa, the muscles of the perineum, the sphincter, and then it also goes into the rectal mucosa, so into the rectum itself.
MC: Tearing during childbirth is actually quite common. Could you talk a little bit about that and the degrees of tears that are generally more commonly seen?
LL: Yes. 70% of people who give birth are going to have a tear. It's much more common in first time birthing people than it is with people who've had multiple deliveries. There are some strategies that we can do to help, but it's very common. The vast majority of these are first and second–degree tears. Third and fourth-degree tears happen in only about three percent of birthing people so they are very rare, but overall there is a high rate of the lesser tears.
MC: When I gave birth to my daughter, I had had a 3.5-degree tear. Is that something that you hear a lot, as well as the three and four degrees?
LL: Yes, definitely. We can actually subdivide third degree into a 3a, 3b and, 3c — that's what I was getting at with the internal versus the external anal sphincter. A 3a is going to tear less than 50 of the external sphincter, a 3b is going to do more than 50 of the external sphincter and then a 3c is going to tear both the external and internal anal sphincter. So 3.5, I would assume [for you] meant a 3a or 3b.
MC: What are some of the risk factors that can increase somebody's chances of having a laceration?
LL: The biggest risk factors are the following: how big the baby is--if the baby is over nine pounds you're more likely to have a laceration or a larger laceration.
Next, is the use of an instrument in delivery, which is one of the many reasons why, if we can avoid it, we try not to use forceps or vacuums. Obviously there are indications when their use is necessary.
Another factor is a long second stage of labor, so, long pushing time. First stage of labor is from start of labor to 10 centimeters dilated and second stage is from 10 centimeters to having the baby. The longer you push, the more likely you are to have a tear.
MC:What would you say is a long pushing time for you in your practice?
LL: It again varies a lot between people who've had multiple deliveries. The average amount of pushing for a first-time parent is around one to two hours and for a second
time parent it's closer to 30 minutes. But anything up to three to four hours is actually within the range of normal and as long as the baby is looking good and the mom isn't too exhausted it’s something we can definitely work with.
But, if you do get closer to those three or four hour pushing times, although it's as I said within the realm of normal and definitely something that's recommended over a c-section, it does lead to a higher rate of these lacerations. Another factor is that while most babies come out with the head facing down, which is called occiput anterior, occasionally the baby comes out the other way, known colloquially as a sunny side up baby, and so those make it harder to push the baby out. You could definitely have a vaginal delivery but those parents definitely can push for longer. In those instances, because of the way the baby's head is, it can lead to larger tears.
Then some of the other factors are, like I said, if it's your first delivery you're more likely to [tear] and then the last risk is something called shoulder dystocia, which in rare instances the baby's head will deliver but the shoulders will get stuck, because it's head first and then the shoulders have to go through the birth canal (laughing) so you’re like a little shimmy out…
MC: (laughing) Yeah, exactly a little shimmy.
LL: So as the shoulders go through, sometimes if those get stuck and we have to do maneuvers to get the shoulders out, that can lead to more lacerations as well.
MC: And is it generally with a higher birth weight baby that one might see the risk factors for shoulder dystocia?
LL: Generally, that is one of the risk factors for shoulder dystocia. Some of the other risk factors for shoulder dystocia are patients who have diabetes and some of it is really unexplained and we have had it with smaller babies as well. But yes, those are the main risk factors.
MC: Why is it with patients with diabetes? Is that again just because they might have a larger baby because the proportions are slightly different.
LL: It's actually proportions. Patients with diabetes are more likely to have larger babies. So that's one factor. But even if the baby is not as large as another baby without diabetes their proportions are different. They collect more of their weight in their shoulders than they do in other parts of their bodies. They're kind of built like linebackers.
LL: There are definitely a few things that can be done. In the third trimester, before labor, one of the things that you can start with is perineal massage. You can either do this or you can have your partner help you with this, but basically you just place two thumbs into the bottom of the vaginal canal and press downwards towards the anus into the sides of the vaginal walls.
So you're going to press that way, in that direction and hold it there for a minute. You're going to feel a stretching sensation which may be a little painful but if you breathe into it, you'll feel those muscles stretch and then you can continue by actually massaging that area up, kind of in a u-shape for about two to three minutes. If you repeat this two to three times a day in your third trimester, some studies have shown that it can decrease the rate of higher order lacerations.
MC: What about during labor? Does position that you're laboring in make a difference?
MC: What about during labor? Does position that you're laboring in make a difference?
LL: There are a few things you can do. One is using a warm compress, asking either your midwife or your OB to place a warm compress on the perineum as you're pushing. Or, you don't have to do it the whole time you're pushing but as you're crowning can help a lot. Having the healthcare provider support your perineum as you deliver can also really help. During delivery you often see the delivery provider really holding pressure on the perineum as the head and the shoulders deliver and that we're trying to kind of hold the muscles together and support them.
MC: Do you recommend if somebody felt that that wasn't happening would you recommend speaking up in that moment asking the healthcare provider to
provide some support there?
LL: Yes, definitely because that's probably the biggest thing that has been shown to make a difference out of all of these things that we're discussing. Then the other thing that is helpful, but depending on whether you have a medicated or unmedicated birth which may be more difficult, is having controlled pushing towards the end, instead of you pushing really hard.
I know, I know, you've been pushing for a long period of time you're ready to meet your baby, but at the end during that expulsion phase, really listening to the provider's voice, really dialing it in, and doing small short pushes instead of a large explosive effort, can help stretch the perineum and lead to less tearing as well.
MC: That's really good to know. What is an episiotomy and how is that different to a tear?
LL:Episiotomies, luckily, are becoming more and more of a historical thing than they are becoming a standard part of practice. I probably have done one or two episiotomies in my entire career and that's generally standard for most providers at this point.
An episiotomy is actually a controlled cutting of the perineum. You can either cut straight down in the middle down towards the anus, you know not going all the way to the anus, or you can go kind of off to the side to try to avoid the anus.
The thought process behind the episiotomy was twofold. One is it would give the baby more room to deliver and two by doing a controlled cut you would decrease the risk of having larger order tears, that were tears in multiple places that weren't as controlled. Data has really borne out that those things are not true and episiotomies actually lead to higher order tears, some more third- and fourth-degree lacerations, and don't assist with delivery at all.
That's not to say that there is absolutely no indication for episiotomy. I have had instances, like I said, where I’m at with the shoulder dystocia when I need more room to get the shoulders out and it's an emergency or the patient is really, really close to delivery and it's just not right there or I have an informed consent discussion because the baby's heart tones aren't looking reassuring. So things like that. It is possible but as a standard practice it's definitely not recommended anymore.
MC: What is the general process for treating more minor and common tears versus the third- and fourth-degree lacerations which are more complex to repair? When you're in that situation and you're delivering a baby what's your standard process?
LL: First step, baby's delivered, then we go ahead and we deliver the placenta and once we make sure that the bleeding's okay and the placenta is delivered, then we inspect the perineum and the entire vagina to check for lacerations.
The biggest thing with that is, if there is a laceration, I’m going to first check with the patient to make sure they have adequate pain control. If they had an epidural the epidural will still be working and that's definitely an option. If the patient does not have an epidural, I will give them lidocaine in the area that I’m repairing to numb it and I’ll make sure the lidocaine's working before I go ahead and repair the laceration.
Another option for patients who had an unmedicated birth is that you can give them some IV narcotics at that point in time, especially for the higher order lacerations, if the lidocaine just isn't cutting it and someone needs something a little bit more. So that's definitely something you can ask for as well.
Then, once I’ve decided it's a first or second-degree laceration, we just use actually one running stitch. Oftentimes a question I will get is, ‘well how many stitches are you putting in me?’ It's not like I’m doing individual stitches and then tying each one. I get one long piece of suture and I’m kind of running it down to repair the laceration and then tying it.
Generally, with first- and second-degree lacerations it can be done in the labor and delivery room. It takes about five, maybe ten minutes. It should be generally very quick and we're just using some suture to bring everything back together.
MC: And will it dissolve on its own?
LL: Yes the suture will dissolve. We like to say that the vagina itself is pretty forgiving. We'll talk about the third and fourth degrees a little later, but with the first and second degrees there's so much blood flow, especially after childbirth, to the vagina and the perineum that once we close them up they heal very well.
MC: What would you recommend for somebody in those early days of postpartum if they have a tear or an episiotomy?
LL: The biggest things are going to be a combination of either warm or cold packs. Something likethe Nyssa underwear is really wonderful. You can actually put the cold pack there and that helps a lot.
Using witch hazel really helps with the burning and then using Dermaplast, or the equivalent of, which is a numbing spray to numb that area really helps as well.
Some of the most pain people feel is actually while they're urinating. While you're urinating it often helps to use a squeeze bottle with water in it to dilute the urine so therefore you're not having that stinging. That's probably the biggest thing. And then, just giving it some time to heal.
MC: How does the management differ depending on the degrees? For example, as I mentioned I had a pretty severe third-degree tear and I couldn't sit down. So I had to have one of those inflatable donuts. How would care differ if you had a more severe tear?
LL: Unfortunately, with the third or fourth degrees the recovery process is more challenging. And it's really unfortunate because you're home with the baby and you're going through all the postpartum stuff and now you have this. So, getting back to the repair, some is the same where I use that running suture to repair, because if you think about it there's a second degree plus the areas of the anus that we have to repair.
The difference is with the third and fourth degree tears is that I actually tease out the anal sphincter so I am grabbing with my instruments the anal sphincter and making sure that I see all of it before I repair anything and then once I see the entire external internal anal sphincter, I actually repair the external and internal separately, putting four individual stitches in each of those to make sure that they're truly coming back together and it's really really reinforced. That process does take a little bit longer.
Again, a vast majority of the time it can be done in the labor room. In very rare instances would you have to go to the operating room just because of visualization, or if the patient's pain control wasn't able to be managed. That's actually never happened to me but it can happen. Then afterwards the pain is more difficult. The doughnut does help a lot. Sitz baths are really helpful. Just a shallow bath that you can sit in really calms that area.
And then stool softeners are most important. We don't want any straining, as you can imagine, if there's been any issues with the anus. We give patients multiple stool softeners and we want the stool to kind of be ( I don't mean to be graphic) but to be just like frozen yogurt you know like a soft-serve kind of consistency so that it comes out without any straining and we want that for about four to six weeks. While things are really healing we don't want people to put strain on that for quite a while and so stool softeners are going to be really important.
Pain control like Tylenol and ibuprofen are generally fine, but again with these third and fourth degrees they can be extremely painful so sometimes a short course of narcotic pain medications are needed.
If you feel like your pain is not being controlled with the standard ibuprofen and Tylenol that your provider is giving you, please let them know and they should give you a short course of narcotics. In short courses we're not worried about addiction potential or anything like that. We want to make sure that your pain is controlled.
MC: What would you recommend for follow-up care with a medical provider, regardless of what degree of tear you've experienced? Should you be trying to have a follow-up with your OB-GYN or have pelvic floor therapy, things like that? How can that help?
LL: With all tears you're going to want to see your OB-GYN by six weeks. With a third and fourth degree you often want to see your OB-GYN even earlier, closer to three to four weeks just to make sure things are healing okay. In our practice we actually send everyone with a third-and fourth-degree laceration to our urogynecologist.
Urogynecologists are doctors that specialize in the combination of gynecology and urology and then a little bit of colorectal as well. So we actually have all of our patients follow up with them so that they can inspect the tear and make sure that it's healing well because they're really the experts in this. They can actually help you also if you are having any side effects like leakage or incontinence. They can work with you and see if you need additional surgery or anything over time. It's very rare that is needed, but it's important to have contact with those doctors early on so you're not worried about it if and when it happens.
Pelvic floor physical therapy I am a huge proponent of — ideally every single patient who has a baby would go to pelvic floor physical therapy. No matter what your laceration is, no matter if you've had no laceration your pelvic floor has gone through a workout and it needs some help, but definitely people with third-and fourth-degree lacerations. Pelvic floor physical therapists can see you as early as two to three weeks afterwards to just start working on things.
People talk a lot about Kegels, but it's really hard to do a Kegel on your own without having a physical therapist show you the right way to do that and to give you some feedback and then it's also a lot more than Kegels. It's a combination of strengthening those areas, but also relaxing. A lot of people don't realize this. When we repair, even after delivery, your muscles are kind of traumatized so they tense up – they're not strong, but they're very tense. The goal is to calm it all down, relax the pelvic floor and then build up that strength again.
MC: That makes sense. What are some of the long-term issues that somebody might experience if they've had a tear?
LL: There are long term and short-term issues. I think you know what some of the short-term issues are. Like you said, pain is the biggest one. Pain with intercourse is something that people really don't talk about, but I think is something that's much more common then people think, and something that we really should be talking about a lot more.
Often, people go to their OB at their six-week visit and are told everything looks good. You can have sex now. And it's like, okay, well first of all I don't know if I want to have sex, and then even if you do want to have sex it can really hurt and a tear can can make sex a lot more painful. That, in combination with not having as much lubrication in the postpartum period because you've lost so much estrogen, can make sex a really painful experience. I always tell my patients to go slow. Only do what's comfortable, use lubrication, and if it's not getting better come back to me or go to pelvic floor pt because in just a few short sessions they can work to make that a lot better.
Long term effects, and again these are rare, but some of the long-term things to look out for are incontinence of stool, flatus or gas, and urine. Chronic pelvic pain is possible, or needing a repeat repair if you've had a third- or fourth-degree tear if it breaks down or doesn't heal very well.
Then, in that same vein about next pregnancy,only about five to six percent of people who have a third or fourth-degree tear get another third or fourth degree in their next pregnancy.
MC: Can you talk a little bit more about that? I have my own personal interest in being concerned about that, because it's like, okay you know you've had a big tear, you know time has passed, things have healed, but I suppose my instinct would be now that area is weakened.
LL: Because it's the second or third baby the muscles have stretched enough that they haven't really gone back all the way so there's already more room in the birth canal. That being said, I think it really depends on the patient and what they've gone through and how terrible their recovery has been. Some of my patients tell me I will never ever want to go through that again, please let's do a c-section and that is a totally acceptable thing.
I think especially if someone had to get a repair or had to go to urogynecology that might be something that is totally reasonable. American College of Obstetrics & Gynecology says that we should offer anyone who's had a third to fourth-degree tear a c-section next time around and that's totally something we offer. Other patients are like, I’d really like to avoid a c-section at all costs and I’ll take that five or six percent risk and do it again.
I think for those patients seeing physical therapy in pregnancy will be really helpful because they can help with the perineal massage we were talking about and prepare you for childbirth for sure.
MC: Great point. As an OB-GYN what do you wish more people knew about when itcomes to vaginal tearing? Is there anything you'd like to see changed in the medical community in terms of treatment and also just in our culture at large because I think this is something that I’ve struggled with. As you said at the very beginning, a very large percentage of people experience a tear of some kind, most commonly first or second, but I didn't know that before I gave birth and I wish this would just be talked about, that I was a little more informed about the risk factors. What is your personal opinion on that?
LL: The number one thing is that I wish everyone knew how common tearing is. It’s the first question I get from most of my patients after they deliver, did I tear? And they really didn't want to tear. I wish that we would have had that conversation. With my patients, I try to [speak about this] much earlier on in pregnancy. That is part of the pre-health care to let them know that this is a normal part of childbirth, this is what's to be expected. Talking them through the normal things like a first and second degree, but also preparing them for the possibility of a third and fourth degree.
I think pregnant women get babied sometimes. People don't want to have them worry about a third- or fourth-degree tear because they feel “it's just one more thing for them to worry about and it's probably not going to happen to them.” But I think a lot of patients are very worried about tearing and I think addressing that head-on before they have the baby and answering those questions will actually make people a lot less worried a) knowing how uncommon a third or fourth degree is and b) just knowing how common a first and second degree is and how it's probably not going to lead to much long-term sequelae.
The biggest thing I’d love to change in the healthcare community is postpartum care. Really making sure that all patients can get into physical therapy, not waiting till the six week visit to follow up with these patients, making sure that everyone's pain is well controlled.
I think people do a fine job during delivery repairing these and that's all done okay, but I think a lot is lost in the postpartum period and that's what I really would like the medical community to focus on.
MC: Work culture too. I went back to work three months after having my daughter and I definitely was not healed. It actually took me a very, very long time to heal but, again because there's a lot of shame around talking about things like this, especially at that time, and I just feel if I had a more supportive work environment, I may have been able to continue to do the pelvic floor therapy for longer.
LL: Yes, for sure. You know it’s like you're back and everything is great. But, no, no, no, not with everything that's going on. Your body isn't yet healed. Many times you're still breastfeeding and even if you're not breastfeeding you still have an infant and trying to figure out all those things. The expectation that you go back to 100% like nothing's changed is really unsustainable.
MC: Thank you for sharing your knowledge about all of this and I hope anyone watching and listening finds it helpful. Thank you so much.
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