Having an episiotomy or suffering a tear during childbirth is common. Find out what the difference is between the two as well as the types of episiotomy and tears you might experience.
This article covers:?
The difference between an episiotomy and a tear
Types of episiotomy
When might I need an episiotomy?
How is it given?
Types of tear
Episiotomy recovery and care
Recovery from a serious tear
Sex after a tear or episiotomy
Massage of the perineum
During childbirth, the vagina stretches to enable the baby to be born. The entrance to the vagina and the perineum – the skin between the vagina and the anus – need to stretch to allow the baby’s head to emerge (or whatever part of the baby is arriving first).
A tear happens when the baby stretches the vagina during birth to the point at which the skin of the perineum strains and then tears. Most women will tear to some extent during childbirth.
What is an episiotomy?
An episiotomy (pronounced ‘e-pees-ee-O-tomy’) is a cut in the perineum, made by a doctor or midwife, in order to make the opening wider, and possibly to prevent a more serious tear.
The two most common types of episiotomy are:
- Midline – a cut from the vagina directly towards the anus.
- Mediolateral – a cut from the vagina at an angle off to one side of the anus. In the UK, this is more common than the midline.
NICE (the National Institute for Health and Clinical Excellence) states that ‘a routine episiotomy should not be carried out during spontaneous vaginal birth’. Instead, an episiotomy should only be considered necessary for you or your baby if:
- The baby appears to be in foetal distress (this means the baby has a significantly increased or decreased heart rate, and there is a real risk to the baby’s life or well-being if he or she is not born quickly).
- There is a clinical need for an instrumental birth, which means the use of forceps or ventouse.
- Breech birth, which means the baby is not being born head first.
- You’re having a very long labour and are exhausted.
- You have a large baby.
- You have a serious health condition and you need a speedy labour and birth to keep you safe.
Before an episiotomy is done, the affected area will by numbed with a local anaesthetic. Most commonly, the doctor or midwife will make a cut from the vagina at an angle off to one side of the anus (a mediolateral episiotomy). Once your baby is born the skin will be stitched using dissolvable stitches.
Tears are described in ‘degrees’ which indicate their size and effect:
- 1st degree – This involves the skin of the perineum and the back of the vagina. These tears are often so small they don’t need stitching, and in fact they heal better naturally.
- 2nd degree – This is when the skin and back of the vagina plus the muscles of the perineum are torn. These tears need to be stitched closed.
- 3rd degree – This involves the skin, back of the vagina, muscles of the perineum and extends partially or completely through the anal sphincter. Stitches are needed to close these tears.
- 4th degree – This is the same as the third degree tear, but extends into the rectum. Stitches are needed to close these tears, too.
Occasionally a tear may occur at the top of the vagina. This is known as a periurethral laceration. These tears are often quite small and require only a few stitches, if any.
It can take up to a month for your tear or cut to heal and for your stitches to dissolve (small tears with no stitches usually heal faster than this). In the meantime you may continue to feel some mild to moderate pain. Sometimes, having an episiotomy or suffering a tear can lead to scarring. Ask your midwife or GP about pain relief. You can use the following painkillers:
- Paracetamol – this is safe to use, even if you are breastfeeding.
- Ibuprofen – this is safe to use in breastfeeding as long as your baby was not premature (born before 37 weeks of pregnancy), was not a low birth weight and has no medical condition.
Note: Aspirin is NOT recommended if you are breastfeeding, because it can be passed to your baby via your breastmilk.
- You may find bathing in warm water and/or using a Valley cushion (a specially designed inflatable cushion to make sitting down much more comfortable) can help.
- If you find you’re still uncomfortable after a few weeks, speak with your midwife, health visitor or GP.
You might want to try the following suggestions during the healing period as well:
- Keep the cut/tear and surrounding area clean.
- After going to the toilet pour a jug of warm water over your perineum to rinse it.
- Although urinating can be painful, it can be less painful if you pee in the bath (just before getting out), or in a warm shower.
- Ask your midwife, GP or health visitor about medication to help you pass stools more easily, so you can avoid putting pressure on your stitches.
- After passing a stool be sure to wipe front to back, away from your vagina, to make sure your stitches remain clean.
- Place an ice-pack or ice-cubes, wrapped in a towel or cloth, onto the affected area, to relieve the pain
- Restart your pelvic floor exercises as soon as you can after birth. They enhance blood circulation, and aid the healing process.
Some 4% of women who deliver vaginally end up with a 3rd or 4th degree tear. This can cause considerable pain for some time and may lead to anal incontinence. Do speak to your midwife, health visitor or GP to get help, and possibly a referral for further medical or surgical advice.
If you continue to have problems after a tear or an episiotomy, you will probably be offered a course of antibiotics to reduce the risk of infection.
You may be nervous about resuming your sex life after you have had a cut or a tear. In fact, studies have found that nine out of 10 women who had an episiotomy reported that resuming sex was painful, but this did improve after time.
- Share your anxieties with your partner. Read our article ‘Sex after having a baby’ for more guidance.
If you are still experiencing pain during intercourse, or at any other time, after the area appears to be healed then do talk with your GP or health visitor.
Massaging the perineum in the last weeks of pregnancy has been shown to reduce the likelihood of tearing during birth, and of needing stitches or an episiotomy. You can do it alone, or your partner can do it with or for you. Here’s how to do it:
- Get comfortable, lying against some pillows on the bed, with your legs bent at the knees so you or your partner can reach your perineum.
- Massage oil (vegetable based) into the skin of the perineum.
- Then place your fingers around 5cm (2 inches) inside your vagina and press downwards towards the anus; move to each side in a U-shaped stretching movement. This may give a tingling/burning sensation.
- Hold the stretch for 30-60 seconds then release.
NCT's helpline offers practical and emotional support in all areas of pregnancy, birth and early parenthood: 0300 330 0700.
You might find attending one of NCT's Early Days groups helpful as they give you the opportunity to explore different approaches to important parenting issues with a qualified group leader and other new parents in your area.
The Royal College of Obstetricians and Gynaecologists has further information on 3rd and 4th degree tears.