Vaginal tears during delivery: what are the grades and how to reduce your risk of a severe tear.
Pelvic floor physical therapist and birth educators aim to reduce the risk of the 3rd or 4th degree tears with a variety of birth prep exercises and birthing techniques. In this blog post I will explain what the different types of perineal tears are and how YOU CAN REDUCE YOUR RISK OF A SEVERE TEAR with vaginal delivery.
First what even is a perineal tear? A perineal tear is a tear that can occur during a vaginal delivery in the perineum (the space between the vaginal and rectal opening). The tears are broken down into 4 grades. 1st, 2nd, 3rd, and 4th degree. A 3rd or 4th degree tear are considered severe tears because they are more commonly associated with pelvic floor dysfunction such as fecal and/or urinary incontinence and pelvic pain, including pain with intercourse.
Types of tears:
A grade 1 tear is mild and often does not even require stitches. It extends into the superficial skin of the vaginal canal.
A 2nd degree tear tears through the superficial muscle, but not into the perineum and may a require a couple stitches.
A 3rd degree tear extends into the perineum and towards the external anal sphincter, requiring multiple stitches.
A 4th degree tear extends all the way through the perineum, through the external anal sphincter and into the external mucosa, also requires multiple stitches.
An episiotomy is when the obstetrician creates a surgical cut into the perineum to create more space for the outlet of the baby. In emergency situations, this may be necessary but often the episiotomy will extend into a 3rd or 4th degree tear at a higher rate than just allowing someone to tear themselves naturally.
Labial tears are not graded 1-4th degrees, graded tears are only considered with tears that extend downward into the perineum and towards the anus.
How to reduce your risk of vaginal tears during childbirth.
I am going to break this up into two parts.
Part 1- what can you do during the later stages of pregnancy to prepare for vaginal delivery and
Part 2- what can you do during the actual labor and delivery to help reduce your risk of vaginal tears.
PART 1 During pregnancy
1. Relaxation stretches
Around 34 weeks of pregnancy I recommend including down training or relaxation techniques into your routine if you are not already doing so. This is because VAGINAL DELIVER IS NOT ABOUT HOW STRONG YOU ARE ABLE TO PUSH OUT A BABY, BUT HOW WELL YOU CAN LENGTHEN YOUR MUSCLES. This means that strengthening is great overall during pregnancy but when you are preparing for labor your focus should start to aim towards lengthening and flexibility. My favorite example are yoga type movements where you are literally aiming at stretching/ lengthening the muscles in and around the pelvis.
This might mean you go to a yoga class, you find a YouTube video, or you make sure you do some stretches after all your workouts.
Some of my favorite birth prep exercises include:
1. Happy baby pose
2. Malasana (deep squat)
3. Childs pose.
4. Pigeon pose or modified pigeon pose
5. Cat cow
Get into these poses and remain for at least 2-5 minutes and include your diaphragmatic breathing.
2. Breathing
Diaphragmatic breathing means to breath with diaphragm, allowing ribcage and belly movement. As you inhale, imagine your body expands and your pelvic floor lengthens.
Breathing techniques can help allow muscles to release any tension (which is what you want in birth prep), it can help calm your nervous system (which you want during this stage pregnancy), and be used during actual labor.
3. Perineal massage
A perineal massage is when you use your finger (your thumb) to release tension around the vaginal opening. I personally do NOT teach this to be performed to the point of feeling a burning pain (otherwise you won’t continue doing this). Instead, you insert your thumb and press downwards just until you feel a stretch and then take a few diaphragmatic breaths focusing on lengthening the muscles. Then move to the next location.
Think of perineal massage as helping to release the tension around the perineum so it is more accommodating to a stretch during a vaginal delivery. It is not actually stretching the vaginal opening or changing it.
4. Make sure you are aware of how to lengthen your pelvic floor. You want to make sure it is not doing a kegel. You can use a mirror to check yourself. Pelvic floor PT can help with this if you are still unsure (I encounter this all the time).
5. Hire a doula
There is tons of research supporting the link between better birth outcomes with a doula. Likely because they help with birth brep, birth education, but also help advocate for you and your desires during your delivery. If you this isn’t an option, make sure your partner or whoever is in the room with you knows your birth plan and is willing to help you with all the comfort measures.
PART 2: During labor and delivery
Research shows that allowing your body to go into spontaneous labor with the least number of interventions, reduce risk of vaginal tears. I understand that is not always the best option, so I am going to present the evidence as such.
1. Movement during labor to progress your labor.
Get your pelvis moving. If you can tolerate walking, go for it or just get into the yoga poses listed above. You can even sit and bounce on your birth ball to help encourage baby to descend down into the pelvis.
BIOMEHCANICS OF BABY MOVING THROUGH PELVIS
To encourage baby to get into the top portion of the pelvis (the inlet), get into positions of hip external rotation like deep squat or child’s pose.
To encourage baby to get through the outlet during second stage of labor, bring hip into internal rotation. Lye on side with a peanut ball with the knee into the narrow portion and foot on the larger portion.
2. If you can and it is appropriate, try not to go to the hospital too soon, unless medically indicated, as they often start interventions bring you to a room and place you in bed where movement is limited (especially because of fetal monitoring).
3. Birth positions
Global evidence shows that allowing the birthing woman to get into whatever position that she is most comfortable in is the best to improve her outcomes and reduce risk of perineal tears. This means that if she wants to be standing, she should, all fours? go for it. Whatever feel innately right.
As a physical therapist and understanding the biomechanics of the pelvis, I would encourage a position that allows movement of the tailbone. Basically, any position except lying on your back. If you do choose to lie on your back, you can fold up a towel and place it under your sacrum so there is space for your tailbone to extend during delivery.
Positions that women can and should be allowed to deliver in if they choose include: all fours, sidelying, squatting, and kneeling.
4. Epidural - even if you are planning to have an epidural you can have your nurse, doula, partner, or anyone help position you in one of these positions with use of a peanut ball for support, especially in side lying. Some hospitals have what they call a “walking epidural” which just means it’s at a lower dose. In these situations, more movement can be tolerated.
5. DO NOT HOLD YOUR BREATH DURING THE “PUSHING PHASE.” Often women are encouraged to hold their breath for 10 seconds during the contraction and push down to deliver the baby. This puts an insane about of forceful pelvic pressure on the perineum. Instead try open glottis breathing which basically means to breath during the delivery phase. There are many techniques here but simply try to exhale as you lengthen pelvic floor to deliver the baby.
6. Reduce use of additional interventions such as vacuum assist, forceps, and episiotomy unless it is a emergency situation of course. I recommend having this discussion with your provider beforehand. You can tell them you prefer not to utilize these interventions. You can ask them how often they use these interventions or even what their episiotomy rate is.
I believe knowledge is power and simply knowing this information so that you aren’t blindsided can improve your birth story. You have options, it is your birth story. Please know there are many professionals that want to support you in every way that we can.
Disclaimer. This blog is not intended to be medical advice and should not be considered a replacement evaluation and treatment by a licensed healthcare provider. If you are concerned with your birth, talk with your medical providers. You would likely benefit from seeing a pelvic floor physical therapist or pelvic floor occupational therapist.
