we recently asked you which birth or pregnancy topic you most wanted to hear from us and the
overwhelming favorite was how to prevent or limit tears from a vaginal childbirth fair
um so this week we are going to cover the evidence that's out there about how to prevent or limit
perineal lacerations things you can do leading up to delivery and during the delivery itself
if this is your first time meeting us i'm sarah i'm a board certified ob gyn and just had a baby
myself yeah and i'm kurt i'm a board certified pediatrician and we are the doctors bjorkman
welcome back as we mentioned this week's episode is all about how to prevent
tears lacerations from vaginal childbirth yes um but just in case you aren't please make sure
you subscribe to our channel over this past year we went through pregnancy and childbirth and now
parenting ourselves and i've been trying to share as much of that with you as possible so there
actually is data and medical evidence studies have been done um about things first-time moms
can do to prevent severe perineal tears and so we are going to share those kind of top four things
with you today as we'll share a couple of the more controversial things um at the end of this episode
starting out about 53 to 79 of women or most women will have some perineal laceration during
a vaginal delivery now most of these are termed first or second degree lacerations
well the severe lacerations third and fourth degree are those that extend through into the
anal sphincter complex yeah worrying about tearing during your delivery is very common
and totally understandable right your vagina and your pelvic floor are very precious things
but i want to reassure you that the vagina is really stretchy if the folds allow it to stretch
to accommodate that baby um and also it heals incredibly well yeah and there's some data showing
that it's able to stretch almost three times to make room for that baby yes but before we get into
talking about this anymore we should cover kind of what these tears are and where they occur
let's first talk about anatomy so most tears happen here in the vagina and downward um through
what we call the perineal body or this area between the vagina and the anus tears can happen
elsewhere you can tear up toward the clitoris the labia um the urethra but these are not as common
yeah and as we've already alluded to there's a classification system for these tears based
on how severe they are yes a first degree tear is one that just involves the skin or the mucosa and
usually doesn't require any repair after a second degree tear is one that also includes some of the
vaginal muscle and is going to require at least a couple stitches yes so a third degree tear again
involves that vaginal mucosa the vaginal muscles and also involves the anal sphincter or the muscle
that controls your anus a fourth degree involves all of that plus also involves the rectal mucosa
and these third and fourth degree lacerations are severe injuries that require very
careful surgical repair and care afterwards we are going to have a video um in the coming month about
how to take care of these perineal lacerations no matter what type of
tear you had um so stay tuned for that some quick thoughts from an ob gyn about repairs
one you should know exactly where your tear was and where stitches were placed also
you should be comfortable during this repair if you are not let your provider know
so they can either give you more local numbing medication or even increasing the dose of your
epidural to make you more comfortable you should absolutely not be jumping off the bed in pain
so now let's talk about some things you can do to prevent or at least limit perineal lacerations
okay so just as you can imagine an elite athlete would stretch their muscles before competition
the same concept is true of the vagina and your kind of perineal muscles right so this is called
perineal massage and peroneal massage is just kind of what it sounds like either done by yourself or
with hell from your partner stretching the vagina and those peroneal muscles in the weeks leading up
to delivery and also during labor we've included a really nice guide from the uk's national health
service and it's linked in the show notes below so looking at four scientific studies
of nearly 2 500 women who compared those who used perineal massage versus those who did not
they found that first-time moms who started doing perineal massage from 34 weeks onward had a lower
risk of having a tear that required stitches and had a lower risk of needing an episiotomy
and then the use of perineum massage during labor and that pushing or second stage of labor
has also been studied an analysis of two studies looking at this process found that those women
who had peroneal massage during second stage of labor were about half as likely to have
those severe third or fourth degree tears this studies did not show any statistical
significance in the difference of those less severe first or second degree tears
all right so perineal massage we started this at about 34 or 35 weeks kurt absolutely had
to help because i couldn't reach um he wasn't really excited about it but i like all of you
was very terrified of my vagina ripping um and so i was gonna do absolutely anything i could
to try to stretch and prepare for birth yeah and i would i would agree i wasn't really a big fan
but you know we're a team and i wasn't the one actually carrying the baby and wasn't going to
have to actually go through childbirth so so you stepped up being a team member was the least i
could do um you know it definitely added some intimate and memorable moments to our pregnancy
journey so um if this is something you're thinking about just tell your partner they've got to do it
because that's what happened with us yes it is using a warm compress during active labor is
something else that you can do to help limit the risk of severe tears so an analysis of two studies
of over 1500 women found that applying a warm compress so a warm wet washcloth to the perineum
during the pushing stage of labor significantly decreased the risk of third and fourth degree
tears cutting the risk in about half it did not increase the chances of having a completely intact
perineum so no tears at all but it did decrease the chance of having those severe lacerations
the use of different birthing positions gets a lot of hype some of that is for good reason and we are
going to make an episode on different positions um so stay tuned for that yeah but when it comes
specifically to using birth different birth positions and preventing tears from childbirth
the data is mixed and somewhat limited and that there's no clear benefit from one position
over another so with that we work with your ob work with your labor nurse to find the position
that's going to be most comfortable and effective for you so as kurt said the studies on pushing is
limited in quality and quantity however looking at more than 22 studies with seven thousand women
they did find that women who pushed in an upright or lateral position were less likely
to need an operative delivery or an episiotomy but were more likely to have a second degree tear
that being said another randomized control trial they looked at five randomized control
trials of women who had epidural anesthesia and they found no difference um between those who
pushed in a lateral position versus lithotomy yeah another recent randomized trial compared
women who pushed in a lateral position with delayed pushing as compared to women who were
in the lithotomy position or on their backs with pushing at complete dilation did find that women
with a delayed pushing on their sides were more likely to deliver with an intact perineum being 40
as compared to only 12 in that other group of women pushing on their backs delayed pushing is
certainly something you will hear about when you are investigating ways to try to prevent tearing
during childbirth but there isn't a lot of strong data to back this practice up yeah there's been a
systematic review looking at nine studies of almost three thousand women comparing those
who push within one hour of getting to complete or those who waited one to three hours after getting
to complete dilation and found no significant difference in the rates of perineal laceration or
episiotomy between these two groups yeah as an ob gyn though i have to say that there is something
to be said for control as you are in those final moments of delivering your baby so when
you are feeling that ring of fire because baby's head is right there it is so important that you
control your pushing and control your breath um because controlling that final delivery will help
prevent tearing your ob can help you and guide you through this by telling you kind of little pushes
you know control your breathing and they can also kind of help by supporting your perineum
and making sure those little flailing arms stay in on their way out so they don't cause any extra
stretch so i ended up with a first degree and then a labial laceration my first degree did not
require stitches um the labial act did and that actually ended up kind of being a pain uh because
my stitch didn't dissolve and at about four weeks postpartum i had this little labial abscess and i
also that same night like had a clogged duct and i was just totally miserable and was just
kind of like i'm not having fun motherhood sucks like nobody tells you about this um anyway it
all resolved um with a little help from my ob gyn but things i felt that helped me were definitely
as we talked about doing the perineal massage pretty religiously starting at 34 or 35 weeks
also i felt like having the epidural really helped me with control at the end and those little pushes
at the end really was thank goodness um also the epidural i remember asking the ob if i had any
tears and if she was going to fix it and she was like i'm done didn't feel a thing so loved the
epidural for that as well as for postpartum things that really helped me were sitting on ice packs
using my peri bottle religiously tylenol and motrin around the clock and again these are all
things we're going to go through in an episode all itself on how to take care of perineal lacerations
and as promised we want to cover a couple more controversial topics and options for potentially
preventing or limiting tears in childbirth so the first of these is something called an episiotomy
and that is when the ob makes a cut in the vagina to make room for baby and potentially
limit or direct where the tearing happens we aren't going to go into this much today other
than to say that episiotomy is something that acog does not recommend being used routinely
though there may it may be appropriate in certain instances so the practice of
episiotomy is something you should talk to your ob gyn about what they do and their thoughts on that
the other controversial option we're going to talk about today are birth training devices such as the
epidome so these are special inflatable balloons that are actually used and inflated in the vagina
to help stretch the vagina in the weeks leading up to delivering the thought process here is that
over those weeks that mom-to-be can practice inflating that balloon to increasing sizes
to both help stretch the vagina and then also help prepare her for that
intense sensation of crowning it is really important to note that the epino and other such
devices are not fda approved in the united states nor are they even for sale in the united states
and that's because there is a case report of a woman who was using um a balloon like this and
was inflating the balloon into her vagina and there was a hole in the balloon um over the
course of five to ten minutes of her continually inflating air through this leaking balloon it
caused that air to enter the bloodstream causing a severe illness that was almost life-threatening
to her yes so because of that it's not for sale in the united states it's not fda approved and so if
you are using one of these birth training devices make sure you are following the device specific
instructions very carefully and make sure you are testing the integrity of that balloon before use
to summarize all the things that have some data to back them up about limiting or preventing
tears from childbirth the first is starting with perineal massage at that 34 to 35 weeks
of pregnancy mark yes the next things you can do are to apply warm compresses to the perineum
during labor and again to continue with that perineal massage either your partner or your ob
gyn while you're pushing yeah there wasn't great data to support any specific pushing position
over another so work with your ob provider to find the position that's going to be best and
most effective for you and work with your ob provider or your doula or your midwife
to help you find control for those last pushes when delivering your baby that is
all we have for you this week i hope that these tips help you to prevent
some of those severe lacerations during birth know that you can do it and your bottom will be okay
stay tuned with us for upcoming episodes about how to take care of your bottom after you have a
perineal laceration episodes about infertility car seat reviews and all sorts of other parenting
things yeah so make sure you're subscribed look forward to seeing you guys back next week bye
we're doctors but not your doctors anything we've said in this video
is for education or entertainment purposes only it is not medical
advice any specific medical questions you have should be directed to your provider