Most women and birthing people who have a tear repaired will recover well, although it can take time.
In the first few days and weeks, it is common to experience:
- Pain where the injury is
- Pain which is worse when sitting, standing, or walking around
- Stinging felt on the wound when weeing (passing urine)
- Discomfort felt on the wound when pooing (passing a stool)
- Feeling swollen
- Some bleeding from the injury
- Leaking of poo/wind/wee or needing to rush to the toilet to have a wee or poo
- Feeling depressed or in a low mood because of the impact of their injury on their life
Most of these experiences should resolve by themselves as your body heals.
Once the wound has healed around 2 months after birth, some women and birthing people can experience:
- Pain where the injury was
- Other pain in their pelvis
- Pain during sex
- Worrying about having sex or avoiding having sex because of their injury
- Difficulty controlling their wind
- Leaking of poo (faecal incontinence)
- Leaking of wee (urinary incontinence)
- Anxiety about leaving the house, or not having easy access to a toilet
- Low mood or depression because of the impact of their injury on their life
- Difficulty bonding with your baby because of the impact of their injury on their life
- Feeling isolated because of the impact of their injury on their life
- Changing their lifestyle such as physical activities and social activities because of worries about leaking wee or poo.
- Worrying about having more children because of the impact of their injury on their life
If you are experiencing any of these symptoms, please complete an assessment on MyPathway[DA1]
Women and birthing people who have had complicated tears, large tears or tears which involve their anal sphincter muscles may be more likely to experience these symptoms. However, 60-80% of women and birthing people who experienced a tear into their anal sphincter muscles will not have any symptoms by 12 months after birth.
How can I reduce my risk of having a perineal tear?
During vaginal birth, it is very common for women and birthing people to experience a graze or tear. Although this may not always be preventable there are things that can be done during pregnancy and during vaginal birth to minimise or even prevent trauma.
Reducing your risk of perineal tears
Pelvic Floor Exercises
Pelvic floor exercises are recommended for all women and birthing people.
Pelvic floor exercises assist to train the pelvic floor to contract and relax fully.
During pregnancy and vaginal birth, the strain on the pelvic floor increases. Pelvic floor exercises will help to strengthen these muscles, and strong muscles help prevent or reduce incontinence and trauma.
Being able to relax the pelvic floor muscles can help during the pushing stage of labour.
Muscles that are regularly trained are less likely to be injured. If injury does occur, muscles that are regularly trained are able to recover well.
Perineal Massage
Research has shown that carrying out perineal massage from around 35 weeks of pregnancy can reduce your risk of having a tear, episiotomy or a tear involving your anal sphincter muscles during vaginal birth, especially if it is your first baby. Perineal massage can also reduce the length of time it takes for you to push your baby out, improve wound healing if you do have a perineal injury and can reduce the amount of perineal pain you feel after birth.
Massaging your perineum helps this muscle to become softer and stretcher, so when your baby is being born, this muscle can stretch more easily to allow your baby to pass through.
The following clip shows a quick experiment using your hands to demonstrate just how effective massage can be:
For more information, you can watch a video which uses a model to show how to do perineal massage. Ideally aim to massage your perineum for up to five minutes, three to four days a week. Although even one to two times a week can make a difference. Either you or your birth partner can massage your perineum.
Don’t perform perineal massage if you have current thrush, active herpes, vaginal infection, the waters around your baby have broken or it is very painful for you. If you are unsure whether perineal massage is suitable for you, ask your midwife or doctor.
Ideally aim to massage your perineum for up to five minutes, three to four days a week. Although even one to two times a week can make a difference. Either you or your birth partner can massage your perineum.
Helpful tips to get you started
- Start by deciding the best place to perform perineal massage. You may find being in the bath, or your bedroom most comfortable
- You may wish to lie down or stand up
- You may want to dim your lights, put music on, aiming to create a similar environment that you wish to give birth in
- Make sure your nails are short and wash your hands and perineum before massage
- You may find a bath helpful as the warmth can help the muscles start to relax
- Use lubrication. Using an emollient is best, alternatively, any natural oil that you are not allergic to e.g., almond oil and olive oil etc.
How to do perineal massage:
- Get into a comfortable position. Lying, standing with a leg up, lying on your side or being in the bath can all work.
- Use your thumbs up to your second knuckle, or for your birthing partner, use their forefinger and middle finger.
- Start with smaller and gentler movements and build up as your muscles warm up and relax. Massage inside the vagina, pushing downwards and outwards in a sweeping motion. Massage from 3 o’clock to 9 o’clock. You will make a J and backwards J shape, or a U-shaped motion
- You can hold the stretch, slowly increasing the amount of time and pressure you use as your muscles become softer with repeated massage. You may feel a strong stretch, a tingling sensation, a mild burning type sensation or strong pressure. However, it shouldn’t be painful. It is important that you relax your perineal muscles during massage.
You can use this time to practice any relaxation techniques you plan to use in labour such as deep breathing and visualisation techniques. You could picture your baby’s head stretching your muscles. This will help you learn to relax your muscles when you feel pressure and when you visualise your chosen image.
It may take a couple of weeks of regular massage before you notice an increase in softness and stretchiness in your perineal muscles.
Birth positions
It cannot be predicted how you will labour, or the type of birth you might have. However, you can try and encourage a spontaneous vaginal birth (a vaginal birth without forceps or suction cup). Choosing to birth in a birth centre or at home if this is suitable for you can encourage a spontaneous birth. Labouring and birthing in upright positions and avoiding lying on your back can also help. Positions such as standing, kneeling, being on your hands and knees, or lying on your side if you need to rest, are encouraged. If you are able to avoid an induction or epidural analgesia this can also encourage a spontaneous vaginal birth.
Being upright can help encourage a spontaneous vaginal birth (a vaginal birth without forceps or suction cup) and can help to minimise your risk of a tear which involves your anal sphincter muscles. Choosing an upright position such as kneeling, hands and knees, or lying on your side if you are too tired to be upright, uses gravity to reduce the amount of pressure from your baby’s head on your perineal muscles. Lying on your back or having your legs up in lithotomy poles can work against gravity, increasing the pressure on your perineal muscles and increasing the chance of having a tear which involves your anal sphincter muscles. More information here.
Warm Compress
When you are in the pushing stage of labour, your midwife or doctor can put a warm compress on your perineum when they see it start to stretch. The warmth will help your muscles relax and soften, allowing them to stretch more easily.
It can often feel comfortable and reassuring to have something warm on your perineum during vaginal birth. If you do not like the feeling of the warm compress, it can be easily removed.
Warm compress has been shown to reduce your risk of having a tear which involves the muscles of your anal sphincter.
Hands On
When your baby is being born, your midwife or doctor will offer to have their hands positioned to help control your baby’s birth and support your perineal muscles. One of their hands will use gentle pressure on your baby’s head, helping your baby to be born in a slow and controlled way. One of their hands will be on your perineal muscles to offer additional support to counteract the pressure on these muscles from your baby’s head. They will keep their hand on your perineum for the birth of your baby’s head and shoulders. Your midwife or doctor will help guide you when to push, gently push or breathe, to help control your baby’s birth and minimise the pressure on your perineal muscles.
Episiotomy
Sometimes, your midwife or doctor will see signs that your perineal muscles aren’t stretching as expected. Maybe the pushing stage of labour is taking longer than expected, maybe your muscles look overstretched. If your midwife or doctor is worried that your muscles are not stretching well, they may offer you an episiotomy, to prevent a tear which involves the muscles of your anal sphincter muscles.
Checking for injury after a vaginal birth
All women and birthing people who have a vaginal birth are at risk of having a tear. Injuries and tears are not always obvious. This is why after birth, your midwife or doctor will offer to thoroughly examine your vagina and your back passage (rectum and anus) to check for any tears, and accurately assess their size and complexity. Your midwife or doctor cannot exclude all injuries without being able to touch and look inside your vagina and being able to insert one finger into your bottom to perform a rectal examination.
Your midwife or doctor will ask your permission to perform these checks. They will ideally aim to examine your vagina and bottom soon after birth so that any injury can be quickly repaired. You can use any painkillers you used during labour for this examination. It should only take a few minutes.
What is the OASI Bundle? (S 16)
The OASI (obstetric anal sphincter injury) care bundle is a partnership between the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives (RCM).
It is a collection of techniques which can help reduce the risk of a woman or birthing person having a tear which involves the anal sphincter muscles.
These techniques include talking to you during your pregnancy about your risk of OASI (obstetric anal sphincter injury/a tear into your anal sphincter muscles), using a hands-on technique during vaginal birth, using a 60-degree angle for episiotomy, and offering a vaginal and rectal examination after birth to detect any injury in the vagina and the anal sphincter muscles.
When the OASI bundle was evaluated, the hospitals using it reduced the number of tears involving the anal sphincter muscles by around ten to 20 per cent. More information is on the Royal College of Obstetricians and Gynaecologists website here.