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When it comes to the statistics and science of assessing perineal tears, there is an absence of both information and knowledge. This is the case for a number of reasons. To begin with, there is widespread disagreement and debate in birth circles even as to what would be classified as a first or second degree tear. Simply, every body is different, and vaginas and vulvas are (like everything to do with human bodies and birth, really), highly variable (not only from person to person, but from month-to-month, and day to day), and really quite difficult (impossible) to categorize or quantify. The widespread debate as to how to approach healing after any kind of perineal trauma, goes along with the vastly divergent views on how birth should be undertaken. If you ask a surgeon about perineal tearing and healing, their viewpoint will be highly informed by the kinds of birth they see.
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In many ways, the fact that the subject of perineal tearing (and so many other topics around birth) tends to be ideological (rather than *actually* scientific) makes sense: birth, and our vaginas, are very unscientific. The vagina changes throughout puberty, throughout pregnancy, and certainly it does change during and after birth. Just as it is ridiculous and pointless to “measure” the opening of the cervix (every body is different), it is similarly a bit goofy to “measure” a tear, when women are differently sized, and vaginas range greatly in terms of various folds and parts and dimensions and configurations; they swell up and dry out and leak, just generally do whatever the heck they want at all times.
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It is understandable that many women would be concerned about tearing, especially if you have, in the past, received an episiotomy. An episiotomy will most often leads to a larger tear than would normally occur without an initial cut: imagine a piece of paper, and the integrity that it has, in its intact state. We can pull the paper, and it will hold. But if even a tiny cut is made into the paper, if there is any pulling or “stretching”, the paper readily rips—similarly to what can often happen to the perineum if a preliminary cut is made. And again, contrary to what most people assume, a straight cut may not heal as well as the jagged “natural” tearing that happens sometimes during spontaneous birth. When we add on to the birth process the stress of the hospital environment, the timelines, the managed pushing, etc etc., more serious tears are absolutely more likely to occur in the hospital. According to data gathered from most international colleges of Obstetricians and Gynecologists, the most significant risk factors for tearing include: being a first time mother, induction of labour, epidural, a long second stage, shoulder dystocia, midline episiotomy and forceps delivery.
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Nor is it the case (as many would suggest) that big babies equal tearing. Many women easily birth their 10, 12, 13 pound babies at home with no tears. Other women give birth to their 6 pound babies, and may suffer quite a large tear, especially when under duress. Nutrition and hydration play a very important role in keeping tissues elastic and vital. But more than anything, the way a birth is “managed” (or, ideally, not managed) is the most significant factor. Stress, pressure, and “coaching” are recipes for perineal tearing. I am not a fan of perineal massage in preparation for birth. Women’s perineums do not need to be “prepared” for the work they are designed to do, and there have been some reports of perineal massage causing bruising and discomfort prior to the birth process.
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It is absolutely reasonable, in my view, that a woman who is planning a home birth with non-interventionist support, can assume that her tissues will remain intact, or that she may experience a small tear that will heal beautifully, without stitches.
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For those who are concerned that scar tissue is not as elastic as intact tissue: This is true, and also true that scar tissue is weaker than intact tissues. However, because many many women do tear during their first births—even home births—this means that even if they haven’t received an episiotomy, they may still have scarring—and most of these women will go on to avoid any significant tearing for their second and subsequent children. Everything about home birth can, and should be, completely different front the allopathic approach, which sadly veers wildly away from the fantasy of “evidence-based” care, as well as the simple, observable, normal physiology of mammalian birth.
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Often after an episiotomy, a mother will have received a few too many stitches. Our porniphied cultural obsession with “tight” vaginas and female sexual objectification has contributed significantly to this phenomenon. I have spoken to several mums who were stitched too tightly, and who experienced pain, discomfort and sexual issues stemming from this. Many of these women have said that it was only until after their *second* babies were born at home, and they experienced small natural tears—tears that were unsutured and left to heal naturally—that they finally felt “back to normal” again.
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There are, in my view, distinct advantages to *not* suturing. The vagina is a mucous membrane, similar to the insides of our mouths. It is absolutely designed for the birth process, it is even designed to be able to tolerate tearing, and to heal from it readily. When a mother sustains a first or second-degree tear, the healing process begins immediately, in the same way that our mouths heal so very quickly if we bit the inside of our lip. Receiving stitches means that not only has the mother experienced the initial tissue trauma of the tear, but they are now receiving *additional* trauma from the suturing itself—any object that pierces the skin will lead to inflammation of those tissues. I believe that this can not only be more painful at the time, but that stitches can also increase swelling, bruising, and the potential for infection—probably not in a major way (it’s not terrible or wrong to receive suturing if this is what the mum prefers!), but it might make some difference for the mother’s recovery, and could also distract her from simply being with her baby, and enjoying those first *essential* postpartum hours.
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An interesting study from the University of New Mexico found that: “women with sutured second-degree perineal lacerations used significantly more analgesics during their postpartum stay than women with unsutured lacerations, although pain scores were not different between the sutured and unsutured groups. There were no differences between the sutured and unsutured groups with respect to postpartum sexual activity or function, anal or urinary incontinence, pelvic floor muscle strength, or perineal body or genital hiatus measurements.” So this is good! The study goes on to note that “the postpartum pelvic examination at 6 weeks revealed weaker pelvic floor muscle strength in the women with second-degree lacerations compared with women with an intact perineum; however, in women with second-degree lacerations, there was no difference in pelvic floor muscle strength between the sutured versus unsutured groups (Table 3). Groups did not differ in the proportion of women with a lengthened genital hiatus or shortened perineal body. The proportion of women with subjectively gaping asymmetrical or open perineal wounds was similar at 6 weeks between the groups.”
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So basically, yes, tearing will have a (short-term, I think) impact on pelvic floor strength…but this is the same for the sutured and unsutured group. (Also keep in mind that these studies were done in a clinical institutional setting, and does not represent a sample of women who have all experienced similar spontaneous physiological birth processes).
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This study *did* find however, that “The sutured group was more likely to use analgesics (52%) than the unsutured (35%) or intact (23%) groups at time of hospital discharge (P < .002),” And, I have read in several places that women who are sutured (vs. unsutured) tend to have more breastfeeding issues than women who are unsutured (which seems self-evident to me).
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What this data really tells me, is that one of the strong benefits of leaving a minor tear alone, is that A) there is no detriment to healing, sexuality, etc., and B) the mother tends to feel much less like an invalid, more capable, more confident, when she is not dealing with the additional trauma, pain, and discomfort that stitching can *add* to the minor discomfort of a small tear. Historically, natural tears, and episiotomy wounds were sutured by men, for men (i.e.: the “husband” stitch, that I referred to above). I think the “trend” (ha!) towards a) birthing where tearing and trauma is going to be unlikely, and b) leaving tears to heal naturally, has to do with reclaiming our bodies as our own, and as fully functional. Most mothers, after they have had a totally ecstatic, glorious home birth, feel amazing—and even when, prior to the birth, they might have been worried about tearing, and even if they *did* sustain tearing, the very last thing on their minds is asking someone to go down there with a needle. Unfortunately, it is common, after hospital birth or institutionalized home birth, for doctors and registered midwives to tend to want to sew women right up–to fix, and fuss, and to make use of all those years of medical school. I think this propensity for erring on the side of suturing serves more to reinforce the authority of professionals, and a woman’s dependence on the system. The medicalization of birth so very effectively creates customers for life.
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My own first birth involved a 3rd degree tear: essentially my inner labia tore in half, sideways, and into my vagina. (So if you can picture it, I now have 3 labia—one side is normal, and then the other has 2 pieces, one on the top and one on the bottom that dangles down. Strange, I know 🙂 The first week, it was *excruciating* to pee…But I never received any stitching, and I’m actually really glad about that. The part of the tear that actually went into my vagina healed right away on it’s own, and now I have the funny outer part. My vagina is a little bit different, for sure, but I sincerely love it the way it is.
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With all my subsequent births, I didn’t experience any tearing at all. I should also say, that everything “works” really well down there, in all ways. (To be clear, closing up the vaginal opening has *nothing* to do with sexual function—it is the inner muscles of the vagina that have to do with sexuality, not the opening itself. I can attest to the fact that everything works really well, even after 5 natural births—this is a big fear that many women have, so I usually share my experience so that everyone can breathe a sigh of relief 🙂
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What should be the “standard of care”, for every woman, is gentleness: her care provider should be gently, and lovingly guiding the mother to slowly move her baby into the world with the very minimum of trauma to her body as is possible. She should never be yelled at to push or not push, or advised or urged to do anything that she doesn’t want to do. She should never be “coached” or pressured. She should be given the message that she has time, and space, and that her body possesses the inherent knowledge and power to do the work it was made to do.
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Often during a birth, I might gently and quiet remind a mother who is entering the pushing stage, that she can take her time, breathe her baby out, that she is safe, and that her body is opening beautifully.
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Letting your baby emerge slowly is a really good way to minimize tearing, and sometimes mothers appreciate some guidance as baby is emerging. If you do tear, it will be at the moment that your perineum is stretched taut. During this part of the birth, your entire perineal area has become numb (another one of nature’s amazing ways of protecting you, and making birth work) and you won’t feel anything at all at that moment.
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Another thing to remember is that it is *so important* for all aspects of healing postpartum, for the mum to stay in bed, skin to skin with baby for as long as she possibly can. This will reduce postpartum bleeding, enable breastfeeding, and help to avoid mastitis and any breast infections. Everything, everything is helped by a calm, peaceful postpartum.
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Ultimately, gentle mother, I know you are going to be amazed by your body’s genius, and the way it will move in its wisdom, to birth your baby perfectly into the world <3
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Here are a few more links on tearing that might be of interest:
http://www.glorialemay.com/blog/?p=66 (just a note: Gloria is my friend, mentor and teacher, and I adore her—she was the birth attendant during my first birth, when I tore so significantly: It’s not her, and it’s not me—it’s just that sometimes tearing does happen, and it’s ok 🙂 So much more common during first births than subsequent. You’re going to be fine.)
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