I’ve delivered thousands of babies, but it still amazes me to see a baby’s big noggin fit through that small space. Even in the best of circumstances, the vagina usually ends up with a few battle scars. The majority of vaginal tears are minor, but severe tearing and complications can also occur. If childbearing is in your near future, it can be helpful to know the different types of tearing that could occur, how to prevent bad tearing, and how to heal a tear.
Types of vaginal tearing
Up to 80% percent of women will experience some amount of vaginal tearing at the time of delivery. Luckily the majority of these will be mild tearing of the skin around the vagina or urethra. Mild tearing can definitely cause some initial pain, but a tear usually heals within 4-6 weeks and doesn’t normally cause any long term side effects. More severe tears that go from the vagina to the muscle around the rectum occur in 3% of deliveries; and tears that extend from vagina to through the rectum (the dreaded “vag-anus” tear) occur in ~1% of vaginal deliveries.
The more significant tears that extend to the muscles around the rectum and into the rectum itself have a higher rate of causing long term pain, difficulty controlling stool or gas, painful intercourse, and even in some cases fistulas (where the rectum and vagina connect become connected and stool passes spontaneously through the vagina). While these issues can usually be resolved with time, therapy, and additional surgeries, sometimes they do go on to cause ongoing issues.
How to prevent vaginal tears
Probably the most significant thing you can do to reduce your risk of severe vaginal tears is to ask your doctor to avoid performing an episiotomy unless medically necessary. It was previously thought that this procedure, cutting the perineum (the skin between the vagina and rectum), would prevent further damage to the muscles and allow for a more controlled delivery of the baby’s head. What we now realize is that cutting an episiotomy is more like unzipping a zipper half way - it makes it easier to unzip fully (tear into the rectum) when pressure is placed on the top. While there are medical reasons and episiotomy should be performed (e.g., if the babies heart rate begins to drop near delivery), they are no longer recommended to be done routinely, and thanks to this data, the rate of episiotomy has decreased 75% in the last 20 years.
Using a lubricant like mineral oil or KY jelly in the vaginal canal as the baby is delivered has been shown to help reduce tears as has applying warm, moist cloths to the perineum while pushing. Massaging the muscles of the perineum while pushing also reduces tears. Performing perineal massage in the weeks before delivery may or not help – study outcomes have been conflicting – but isn’t harmful, so may be worth trying. The position of delivery and type of anesthesia choice not been shown to have an effect on tearing.
While there are some strategies that have been shown to help reduce tears, my personal opinion is a lot of the time it comes down to the elasticity of a woman’s vagina and the size and position of the baby. Some women have great skin that stretches well; others, not so much. Some babies slide out petite and in proper position; others are 10 pounds with their fist up by their face, acting like superman, but shredding their mom’s vulva as they exit.
The use of vacuum or forceps with delivery has been shown to increase your risk of having a more severe tear, but the purpose of these is to avoid a cesarean section, which is likely to also have risk of major complications.
Caring for your vaginal tear
Most women describe the pain from their mild laceration to be an achy and burning type of discomfort for a couple weeks. For more severe tears, pain can be quite sharp and intense for a couple months. In the first 24 hours after delivery, ice packs can help with the pain and swelling. Then for the next couple of weeks “sitz baths” may provide more relief. A “sitz bath” is a shallow pan than is placed on the toilet for you to soak your bottom, but you can get the same effect by soaking in a warm shallow bath. Taking anti-inflammatory medications such as ibuprofen or naproxen can help relieve most discomfort.
Use caution when proceeding with bodily functions. The acidity of the urine will sting the tiny breaks in the skin that occur with delivery. This pain can be avoided by using a squirt bottle of water to dilute the urine as you pee. If you lose your magic hospital squirt bottle, local box stores now sell upside down versions that are even eaiser to use. The other important thing to remember is to avoid constipation at all costs. Even if you don’t have a tear that goes all the way into the rectum (but especially if you do), you want to keep your poo as soft as possible. Hard stools can pull and stretch the perianal skin and therefore pull on your stitches, creating all kinds of ouch. To keep all things flowing smoothly, drink a ton of water, eat lots fiber (or whatever food ‘helps you go”), and take in stool softeners daily (docusate sodium and polyethylene glycol are safe to take with breast feeding and usually do not cause diarrhea) until all is healed. Also, do not have sex until you confirm that your vaginal tear is completely healed.
Once your tear is no longer painful you can start back on kegel exercises to help improve you pelvic floor muscles. It is very common for women to experience significant incontinence in the weeks after delivery, but this should improve over time. If you are still having trouble controlling your urine, stool, or gas by your six-week postpartum visit then talk to your doctor about pelvic physical therapy or other treatment options.
Vaginal tears are extremely common and usually heal completely within 6 weeks of delivery. The vagina is literally made to stretch and expand to accommodate the baby, but occasionally rigors of childbirth take their toll. Talk with your provider about the best ways to avoid tears and how best to care for your bottom after delivery.