It’s difficult to find exact statistics on the percent of women who will have a tear during birth, but the rough estimate is 60-80%.  Of the 90 or so births I’ve attended so far, I’ve observed that the rate of tearing is lowest at home, next lowest when attended by a midwife in the hospital, and highest when attended by an OB.  Similarly, I’ve never seen an episiotomy cut at home, rarely by a midwife or family practitioner, and most often (though still infrequently) by an OB.  Why the difference?

Some factors that make a tear more likely are out of the mother’s and/or the care provider’s control, including: first vaginal birth, a big baby, ethnicity, older maternal age, younger maternal age, and high weight gain in pregnancy (ok, that one may be a little in the mother’s control, but I’m hardly in a position to judge after managing to put on about 55 pounds of luscious with my last pregnancy).  However, those can’t be the only factors when, in my experience, nearly all of the mothers who birthed in the hospital had stitches and maybe a quarter of the homebirths did.  Indeed, the research shows there are several factors that are within the mother’s and/or the provider’s control when it comes to whether there is a tear during birth.

Having a doula

(See how I always work that in there?)  A doula can provide great information before birth on this subject, as well as provide a list of questions/talking points to go over with your care provider.  She is also your best line of defense during the birth as neither you nor your husband/partner will likely be in the best frame of mind to question the hospital staff’s instructions in those last moments before you meet your baby.

Birth position

Most of the women I’ve seen who choose their own birth position end up being on their hands and knees.  A few have preferred side-lying, and another few have chosen to squat. The only time I’ve seen a woman lie on her back or in the lithotomy position (flat on her back with knees pulled back or in stirrups) is when her care provider has directed her to.  Not surprisingly, hands-and-knees and side-lying are both associated with fewer tears than other birth positions.  Squatting can be a great position to starting pushing, but it is associated with a higher risk of tearing, so switching to hands and knees just before the delivery of the head may give you the best of both worlds.

Choosing the most comfortable position to give birth should apply to the mother rather than the care provider, but some providers still “make” their patients assume the lithotomy position for delivery.  When interviewing care providers, be sure to ask about this.  If, at the time of delivery, the provider on call asks you to change positions, ask why: if he or she does not have a valid medical reason, consider ignoring the request (your doula can be very helpful here by prompting you to question your provider or simply asking, “Are you comfortable in the position you’re in now?” or “would you like to stay in this position to birth?”).

Pushing when you feel like it

Often, it seems hospital staff believe a faster birth is a better birth, from liberal use of Pitocin and amniotomy (breaking the bag of waters) to directed, “purple” pushing (“Five, six, seven, keep pushing, nine, ten!!”).  However, for a birth that is progressing normally, letting the mother labor and birth undisturbed has been shown to produce the best outcomes.  Spontaneous pushing allows better oxygen flow to the baby and expends less of mom’s energy.

Let your care provider knows beforehand that you do not want to be told when and how to push.  You might use the phrase “laboring down”, which refers to waiting to push until you have an overwhelming, “I can’t help it!” urge.  Even if you are planning to get an epidural (or if you decide during labor that you would like one), there are still benefits to “laboring down”.  You will likely need help knowing when to push, but you can request that you not begin directed pushing until the baby’s head is visible.

Slow birth of the baby’s head

If mother and baby are both doing fine, letting the tissue stretch over several contractions will help keep the perineum intact.  This requires speaking with your care provider beforehand about your wishes, as well as being clear about this in your chart and/or birth plan in case another provider attends your birth.  A doula is also invaluable here because she can remind you in the moment to slow down, breathe through those last stretching contractions, and even pant to keep yourself from giving in to that urge to GET THAT BABY OUT NOW!  I’ve heard many nurses and doctors tell women to “push through the burn”.  However, that burn is telling you that your skin is near tearing, and it may be beneficial to back off the pushing to give you more time to stretch.

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Now, what about suturing?  Even if you and your provider do everything you can, you may still tear.  Most of these are minor, and may not require any stitches at all.  This actually accounts for a large part of the difference between suture rates at home vs. hospital since homebirth midwives are much less likely to suture minor tears (not surprisingly, when given the option, many women choose to skip the stitches).  Before birth, discuss with your care provider the possibility of not suturing minor tears, particularly small labial tears (these are sometimes called “skid marks” or skin splits).  Small tears in the perineum may also heal up just fine (or even better) without sutures, especially if the tear lines up well and is not bleeding.  In my experience, hospital care providers reach for the needle and thread before they even examine the perineum.  For that reason, it can be very helpful to have your doula on hand to remind you that you would like to have a discussion about whether suturing is necessary.

Caring for your lady parts after birth

Whether you tear or not, or have sutures or not, the tissue will be swollen and at least a little sore.  Try these natural pain relief measures either in the hospital or at home:

1. soaking in a warm tub
2. soaking in a sitz bath —  a portable sitz bath fits inside your toilet seat and is filled with warm water.  You are able to soak your bottom without having to fill up the whole bathtub (very convenient if this is baby #2 or more and you getting in the tub would signal your other child(ren) to climb on the counters in search of cookies and permanent markers).

   

3. soaking in an herb sitz bath — adding herbs to your sitz bath can help relieve inflammation, reduce swelling and speed healing.  There are prepared mixes, or you can buy herbs in bulk to make your own blend (look for a blend that contains shepherd’s purse, uvi ursi, and comfrey leaves, or try this recipe).  Typically, you steep the herbs in boiling water for a couple of hours, then remove the herbs. Add a cup or two of your herbal “tea” to the warm water in your sitz bath.
4. padsicles — get some large maxi-pads, soak them in witch hazel, and freeze.  Place them in your underwear after birth for some cool, soothing relief. Or, instead of witch hazel, soak them in the same herb mixture from your sitz bath.
5. Tylenol — ok, maybe not the most natural remedy, but it works pretty well.  Personally, I turn my nose up at epidurals but believe Tylenol to be a postpartum essential.  I also occasionally eat Lucky Charms with organic milk. If that gets me kicked out of the “Crunchy Families of North Dakota” Facebook group, so be it.