During the birth, your baby’s head will stretch the opening of your vagina in order to make his way into the world. And while the skin often copes well with this stretching, it sometimes tears. Alternatively, your midwife may decide to help your baby out with a deliberate cut, called an episiotomy.
The good news, however, is that far fewer episiotomies are carried out than ever before. About just 12% of women in England now have a cut, compared with when rates peaked at 90% 30 years ago. Your midwife will minimise the chance of either, but if it does happen, take heart that most mums report it’s much worse in theory than in practice. ‘If a tear happens, it is often quite small,’ adds Gail Johnson from the Royal College of Midwives, ‘and if there is a need for an episiotomy the skin will heal well.’
Why might I tear?
When you are pushing your baby out, your perineum (the skin and muscle between your vagina and back passage) is put under a lot of strain. It’s quite common to tear – it’s estimated that around a third of women in the UK have a tear large enough to need stitches – and this usually happens when the largest part of the baby comes out – his head and shoulders.
Why might I need an episiotomy?
These days, episiotomies are used only if a baby is in distress and needs to be delivered quickly or with the aid of forceps, or to limit the damage if it looks like you’ll tear badly. Sometimes it’s simply the best option to keep both of you safe and healthy.
How is it done?
A cut is made to your perineum to make the opening of your vagina bigger, usually by your midwife. You’ll have an injection to make the area numb, or if you’ve had an epidural this may be topped up. The cut (called a medio-lateral incision) is made at the back of the vagina, going diagonally down and outward. Occasionally the cut is made directly down, but the first type is thought to reduce the risk of further tearing.
Will it hurt?
You won’t feel much at all – the cut is really straightforward, and you’ll have had a local anaesthetic. Similarly, by the time you get to the pushing stage of labour you may not even be aware that you are tearing.
What might increase my chances of having a tear or a cut?
If your baby is big or in an unusual position, or you have a previous birth tear which shows signs of splitting, you may be more at risk. A previous pelvic floor injury or an unusually short perineum can also increase your chances.
Is there anything I can do to minimise the risks?
Choosing a different position during delivery, such as kneeling, lying on one side or on all fours, can help to make the baby’s passage easier, while research also shows that using a birth pool may help your perineum.
You should avoid extreme pushing in the last stage of labour, and just try to relax.
You could also try talking to your midwife about her delivery style: research shows that if she adopts the ‘hands poised’ approach, where she doesn’t touch the perineum and lets the shoulders of the baby deliver themselves, you have a better chance of staying intact. The downside of this is a slightly more painful recovery following the birth.
Some midwives also advocate perineal massage as a way of reducing the likelihood of episiotomy.
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Will I need stitches?
If you tore, your midwife will decide whether you need stitches or if the wound will heal on its own. If you had an episiotomy, you’ll need stitches. For bigger tears your midwife will offer you a local anaesthetic to numb the area first, and she’ll use dissolving stitches so there is no need to worry about having to have them removed later.
Will it hurt afterwards?
You will probably feel a bit battered and bruised. Taking painkillers will help, and if it’s uncomfortable to sit down you might want to invest in a cushion or rubber ring.
How will I go to the loo/wash?
It’s important to keep your stitches clean to avoid infection – use a bidet or spritz the area with a water spray, and change pads regularly. When you pee, remember to wipe from front to back. It’s really common to worry that your stitches might burst when you go to the loo, but this is very, very unlikely. For peace of mind, it can help to hold a sanitary pad over the stitches the first few times nature calls.
How long will it take to heal?
The worst will be over in less than a week, and any stitches will dissolve after about 10 days. You may feel a bit tender, but within three to four weeks you should be completely healed. What’s more, many women who have had an episiotomy or tear first time round won’t need stitches at subsequent births.
What about complications?
A small number of women experience some incontinence following an episiotomy – this should disappear once bruising has healed, but talk to your health provider if you’re concerned. Also, remember that sex after the birth feels strange for everyone at first, but if it doesn’t get better, and feels tight and painful, consult your doctor. Finally, a tiny minority of women have raised or itchy scar tissue. A simple operation can remedy this, and can be safely carried out a few months after the birth.
‘Perineal massage helps women to become aware of and in control of their bodies,’ says midwife Gail Johnson, and it can also increase elasticity and flexibility. Try a five minute massage every day from week 36 onwards:
- Find a comfortable position, propped up on your side against cushions or standing with one leg on a chair.
- Using an unscented vegetable oil or olive oil, bring your hand up round the back and gently stretch your vagina with index and middle fingers.
- Stretch gently to the back, left and right and towards your tailbone, but not towards your front.
- Breathe out as you stretch, and relax your fingers as you inhale.
- Stretch six times in each direction. Alternate leg position and repeat with the other hand.
- Do your pelvic floor exercises to promote circulation and speed the healing process.
- Try an ice pack wrapped in muslin to relieve swelling and reduce pain.
- Add a couple of drops of lavender swished in an egg-cupful of milk to a warm bath for a soothing soak.
- Witch hazel is anti-inflammatory: try sprinkling some on a sanitary pad, chilling in the fridge and then applying to the affected area.
- Arnica gel is particularly good for relieving bruising.
- Eat well, drink plenty of fluid and get the balance right between rest and exercise.
Leila Jerman, 33, is mum to Sofia, now 16 months
‘Before I gave birth to Sofia, people would tell me they had torn and I would think, “Oh my God! What does that mean and is it going to happen to me?!” But when it came to it, I had been in labour for 31 hours, I’d had gas and air, two pethidine injections and an epidural, and it seemed like the birth wasn’t ever going to happen. The midwife suggested that I had an episiotomy, and I just thought, “Yes, get her out!” They did it pretty much as I gave the final push, and it wasn’t nearly as bad as I‘d imagined it would be. I don’t remember it hurting, either during the procedure or afterwards. It was slightly uncomfortable and the stitches were a bit tingly, but a few weeks later, that was it – everything was fine.’