The vaginal opening is not able to stretch sufficiently to accomodate the baby's head, especially during a first pregnancy. As a result, when the baby's head pushes down in the second stage of labour, it causes a tear. Tearing towards the back passage is most common and least painful whereas tearing towards the front can be very painful.
Tears can be of different degrees:
First-degree: this is the least severe tear and is superficial.
Second-degree: this tear involves the skin as well as the muscles of the vagina and those that lie beneath.
Third-degree: the most severe kind of tear, this involves the muscles of the back passage and will need to be stitched up be a senior doctor.
If your midwife feels that your perineum (area between vagina and anus) is not stretched enough to allow the baby's head to come through and that you might tear badly, you may be offered an episiotomy. An episiotomy is a small cut made with scissors at the vaginal entrance to widen it so that the baby has more room to come through. You will require stitches if you have an episiotomy. Some hospitals routinely perform episiotomies as compared to others.
* When the baby's head appears the midwife(or doctor) will ask your permission to perform an episiotomy.
* Your pelvic floor will be numbed with a local anaesthetic.
* However, if there is no time, no injection will be given but the stretching tissues have a numbing effect anyway and you will not feel any pain.
* At the peak of a contraction, you will be given a small cut at the bottom of the vagina. There are two types of cuts:
- midline cut: this cut starts from the bottom of the vagina and ends just before the anus.
- medio-lateral cut: starts like a midline cut from the bottom of the vagina but goes sideways to avoid the anus.
* Once the baby and placenta have been delivered, you will be stitched up which might take upto half an hour as different layers of muscle and skin need to sewn back together (by soluble stitches).
* The procedure is painful, so do ask for a local anaesthetic.
Although some hospitals perform episiotomies more commonly than others, it is required in the following instances:
* There is a chance of a third degree tear.
* Baby's head is very large and there is no way you can make room for it without tearing yourself very badly.
* Breech baby
* Premature baby who is not strong enough to force its way or apply great pressure on the vagina.
* Baby is in distress and needs to be delivered fairly soon (though not urgent enough to have a caesarean).
* You are having difficulty controlling your pushing and hence there is danger of tearing badly.
* Assisted delivery (through forceps or ventouse) is required.
There are no certain ways of preventing tearing or episiotomy but you can try the following to minimise the need for one:
* Try to relax your pelvic floor during labour by doing the pelvic floor exercise.
* You can consult your midwife about this.
* Keep an upright position during delivery.
* Try to push down for as long as possible as this gives your body time to stretch.
* You can try placing a warm flannel on your perineum during labour.
* Massaging the perineum with creams and oils during pregnancy can help soften the area, thus enabling it to stretch easily.
Although stitches used are soluble and will dissolve after about 9-10 days, the wound will still continue to hurt and you will feel very sore. This pain is made worse by the swelling and bruising experienced during labour.
You can try and help yourself by the following:
* Always sit between two pillows (one pillow to support each buttock), so that you reduce any pressure on the perineum.
* Use a cooling cushion for continued relief
* If sitting down on pillows also hurts, try to sit on an inflatable rubber ring.
* Have a warm bath with only common salt added in the water.
* This will help heal the stitches faster.
* If your stitches sting on passing urine, pour some warm water on them while urinating. This will help to dilute the acidity of the urine and prevent stinging.
* After passing urine, clean the area well using fresh water (preferably through a shower head). You can add savlon to the water as well.
* Keep the stitches clean and dry.
* When you empty your bowels for the first time after delivery, it can be a very painful experience. You can help minimise the pain on the stitches by pressing a sanitary towel against them and leaning as forward as possible on the toilet seat. Never worry that your stitches will come out with the pressure when emptying your bowels.