Prepare To Tear: The Before, During & After Of Perineal Tears In Childbirth

Sometimes it’s hard to be a woman… the words of Dolly Parton came to mind as I lay on my bed, wearing only a towel, diligently pumping up a rubber balloon inserted into my vagina while attempting to breathe in a relaxed, yogic manner. Towards the end of my second pregnancy, having incurred second-degree tears during my first labour, I’d become obsessed with tearing – and how to avoid it, hence the rubber balloon, a.k.a. the Epi-No.

Many women experience tears to some extent during childbirth as the baby stretches the vagina. Most occur in the perineum (the area between the vagina and anus). We’ve all read horror stories about birth, but this piece isn’t one of those, it’s about how to prepare for and recover from a vaginal birth, and what I wish I’d known before mine.

Tears or lacerations are classified from first-degree (to the skin of the vagina and perineum, which heal naturally) to second-degree (to the skin and muscle beneath, which may require stitches), and third- and fourth-degree (all the way to the anus and muscles beneath).

To learn more, I spoke to obstetrics and gynaecology registrar Dr Emma Bredaki, who started by explaining that tears are normal. "Perineal tears are a frequent consequence of birth," she said. "Over 85% of women in the UK who deliver vaginally sustain some degree of perineal trauma, many requiring suturing (stitches)."

There are multiple possible causes of tears, mainly to do with the size, position and speed of the baby coming out, which are out of the mother’s control. However, Dr Bredaki outlines three ways to prevent or mitigate tears.

1. "Your midwife or obstetrician can protect the perineum by pressing on it – or alternatively, apply a warm compress as your baby’s head is delivering, known as 'hands-on'. This can be discussed and added to your birth plan."

2. "If forceps are needed, an episiotomy [when the doctor or midwife makes a deliberate cut before you tear] makes a third- or fourth-degree tear less likely."

3. Additionally, "Perineal massage towards the end of pregnancy is shown by studies to reduce tearing."

What about the Epi-No birth trainer I invested time and £100 in to prepare the perineum by inflating the balloon to a larger circumference over a period of weeks? "No formal research has been completed yet," Dr Bredaki answers, "but clinicians are discussing it. It’s gaining in popularity and independent midwives recommend it, though it’s too expensive to be tested by the NHS. The theory behind it is good, and anything that starts the conversation about birth and the perineum, to normalise tears and challenge the notion of them as a failure, is worthwhile."

Severe, or third- and fourth-degree, tears are rare, midwife Dionne Goldson reassures me. "The overall rate is 2.9% in the UK, slightly higher in first-time mothers. Recovery includes pain management like paracetamol and ibuprofen, arnica tablets that can help reduce swelling, antibiotics to prevent infections, and post-operative laxatives. Storing sanitary pads in the fridge can also provide some relief. Women with third- or fourth-degree tears should be referred to a physiotherapist for pelvic floor exercises to heal and strengthen the muscles affected. Pelvic floor exercises are vitally important to every woman postnatally, regardless of type of delivery or degree of tear. Another referral should be to a specialist gynaecologist or colorectal surgeon, if they are still unable to control bowel or bladder movements after six to 12 weeks."

Additional to the physical recovery, Goldson says it’s important to have "an opportunity to discuss the birth story with the midwife or obstetrician, and receive information. This can provide an opportunity for the woman to debrief which can be vital for emotional recovery, preventing feelings of disempowerment or future psycho-sexual issues."

So, aside from the worst-case scenario, what can you expect from your vaginal birth?

Goldson says: "When I care for women I bring up perineal massage around 34 weeks. I encourage women to locate their perineum (get a mirror if necessary) and massage externally for around five to 10 minutes, twice a week. After 37 weeks the woman can use internal stretching massages, to train the muscles to reach their stretched potential."

Try the Epi-No if you have the budget. It comes with instructions, online video tutorials and the company says they will answer questions if you contact them.

If you tear giving birth, you probably won’t feel it happen – as contractions and the baby crowning are pretty intense sensations. If you have an episiotomy, your midwife or doctor will discuss it with you. If you have stitches, local anaesthetic means you won’t feel them going in. If you have small tears you might not need sutures, as the midwife pressing on the wound with a pad can stem the bleeding.

Recovery happens in several stages. While stitches are fresh, everything hurts; you can’t do a poo without crying and walking can be a challenge. Washing yourself with water after the loo can help keep it clean.

After the wound has officially healed, the journey to normality isn’t over, in my experience, until you’re able to walk comfortably, exercise, and eventually have sex pain-free. All this could take a few months, so be patient.

Melissa, 28, who had her first baby 11 months ago, experienced complications recovering from her episiotomy and had to be patient. "My recovery from a forceps delivery was extremely painful, and took four months," she told me. "I couldn't sit upright or walk properly for a few weeks, and I developed an infection. I had to have surgery to correct the damage that had been caused by the infection. Three weeks after surgery, I’d largely recovered. My vagina has now gone back to normal, thankfully. I’ve no further physical issues but emotionally, I’m terrified of having a similarly awful recovery if I have a second baby."

Reflecting on the experience, she added: "I don’t think trauma from vaginal birth is discussed enough or even acknowledged. We believe that having a baby vaginally is the best way and that a C-section is major surgery. While both of those statements may be true, there is a huge area in between."

Dawn, 35, who had her son 14 months ago, was disappointed to have had an episiotomy. "I didn’t want one, but was told I had to," she said, "the thought of it made me queasy. It took about four weeks to heal. It was something I wished I wasn't having to deal with at the time. I felt normal after four or five months, once I had had sex that felt good and enjoyable rather than a test to see if everything was okay."

Several others I spoke to said they had recovered well and put the experience behind them, although a common factor was not knowing the likelihood of a tear, being too squeamish or afraid to research it, and then reality coming as a shock.

As for me? My first baby emerged with his hand on his head, and my second was back to back, so I didn’t manage to avoid another tear. But I don’t regret using perineal massage or the Epi-No – if anything, they might have helped me avoid a worse outcome.

Recovering from birth can be as hard as giving birth. You need looking after, as well as your baby. Avoid nasty surprises by asking questions at your appointments, and if something’s not right, keep going back or request a referral if necessary. Be pushy, so to speak. Goldson’s point that psychological help is available for birth trauma is worth remembering.

So is this: You will go back to normal. According to my anecdotal research, the timescale may be longer than stated but in time, you will get your vagina back.