The Terror Of Tearing: Demystifying The Dreaded ‘tearing’ During Birth
A very common fear before giving birth for the first time is the idea of tearing. And it’s obvious why. The image of having your body ripped open is dreadful and appalling. It’s terrifying. The very idea makes anyone cringe and cower, and gives the impression that birth will be excruciatingly painful, and damaging to your very bodily integrity.
But this particular image is somewhat misleading. It’s an inaccurate analogy that is based on centuries of not understanding everything that happens during birth, and focusing exclusively on the idea of the mechanics of one body bursting out of another. Yes, that sounds scary, like the movie Alien, or The Substance, or countless other iconic images of parasitic host-body horror. But this is not a good metaphor for birth, because it misses all the quiet ways our body can help us birth the baby, and stay intact while doing so.
Here are twelve facts about your perineum that might change the way you think about a baby emerging from your body.
1.When To Push Hard And When To Hold Back
Your body communicates with you the whole time you’re in labour. What you feel and where you feel it dictates your instinctive and physical response. Your body guides you towards comfort and safety through its powerful sensations.
But what does this actually mean? Picture that you’re doing yoga, or warming up before doing some kind of exercise. When you are stretching, how do you know when to stop? How do you avoid injuring your muscles or skin when you are stretching your legs or back? For that matter, how do you know when you’ve achieved a stretch at all?
Our body communicates with us when we are challenging its limits. We ‘feel’ it when we stretch: we feel when we are succeeding in stretching, and we feel when we’ve reached our capacity. We don’t blithely stretch to the point of doing serious damage. This is because our body doesn’t want to hurt itself. When we start to feel the burn of a stretch, we hold back a bit and advance more slowly, more cautiously, sometimes having to pause and breathe for a beat before we lean in a bit more, or sometimes knowing we’ve reached our maximum and stopping there.
This happens during birth too. Our perineum feels when we’re exerting too much pressure, and we instinctively ease off the pushing until our body has adjusted, breathing and letting gravity slide the baby out for a moment before our body tells us it’s safe to start pushing again. It’s like anything we do with our body–we can feel when it’s enough or too much and we instinctively adapt our efforts accordingly. One thing to remember is that your body doesn’t want to tear. Your body wants to let you know exactly how hard or soft to push to avoid any injury.
2. When to Push And When to Pause
One of the things your body tells you during second stage labour is when to push and when to pause. In the movies, there is often a group of people gathered between the mother’s knees shouting when to push and when not to, but in reality most people don’t need any coaching at all. In fact, this kind of coaching can undermine your ability to tune in and listen to what your body is telling you to do. No one on the outside of your body can feel exactly when the burning sensation shifts from feeling productive (like a pleasant stretching feeling) to feeling precarious (like stretching too far). Only you, the person who is doing the pushing, can feel exactly when you hit this invisible line, and only you know exactly when to push and when to pause. Imagine being shouted at like that when you’re trying to have a bowel movement!
3. What Positions To Use
Another thing our body tells us when we’re pushing is when and how to shift positions. Picture that you have a muscle knot in your back, and stretching it feels really good. You might lean one way and it feels great, but then your body tells you to shift slightly to the left to get a deeper stretch in the area, and we lean into that feeling to make the most of it, and then our body wants to stretch even further in the original direction. If we follow the body’s urges, we often find ourselves rotating and moving and shifting back and forth between several positions to get the maximum benefit: to get the most relief with the least discomfort.
As you push your baby down and around and through the maze of your pelvic bones, your body can tell you how to move to make the most of your efforts. It’s like leaning into the sensation so that it feels most productive, which creates open passageways for the baby to find space to keep progressing downward and forward and outward. I have observed people kneeling to push, and then intuitively raising one knee so that they’re in a semi-kneeling/semi-squatting position, then rotating their hips slightly, and then as the baby starts to crown, they instinctively raise themselves to an almost standing position to relieve pressure from the pelvic floor. It looks like they’re backing away from the pressure, which seems to actually relieve the strain exactly at the right moment. Again, our body shies away from injury, so if the pressure is too much, we tend to automatically move away from it, thus protecting our skin’s integrity.
While we know that lying on our back is not a good pushing position for most people, it is not something you have to rigorously avoid if it feels good. Instead, avoid being limited to any particular position. Even though upright pushing positions (kneeling, squatting, standing…) outperform supine or semi-supine positions in studies, the biggest factor is the freedom to move and follow your body’s urges to change positions throughout the pushing process. This might include being on your back for part of it. Trust your body! Move as your body wants to. Freedom of movement throughout pushing is one of the biggest secrets to keeping your skin intact.
4. Using Our Breath And Our Voice
Another way our body helps us push exactly as hard as we need to and no harder, is that our voice often changes to facilitate our efforts. People frequently breathe deep into their pushing, sometimes roaring, or sometimes just using low breath-force (like inflating a balloon), when they are pushing with maximum strength. But when the baby starts to approach the perineum–the crowning phase–people’s voices often go higher, their breath becomes more staccato, the roaring shifts to panting or almost squeaking, the long, strong Oooh’s and Aaaah’s become shorter Ee! Ee! Ee!’s, which is almost like releasing a valve in little bursts to avoid an excess of pressure. Most people don’t know they’re doing this. It’s just a natural response to the feeling of too much pressure on our perineal skin.
5. Tuning In And Not Out
If you have the luxury of pushing in a quiet room, with supportive doctors or midwives, free from external distractions, it is easiest to trust your inner voice, your body’s intuitive understanding of how to push most effectively and avoid damaging your pelvic floor. For many people, it is very challenging to hear your body’s subtle cues and directions if you are also receiving loud coaching from people in the room. A chorus of commands to ‘push, push, push’ can easily overwhelm our softer inner voice. In one study comparing coached pushing to spontaneous pushing, they found that when mothers received no external coaching at all, the risk of tearing was reduced to 1%.
6. Consider Pros And Cons Of Epidural
Since so many of the ways birth helps us avoid tearing involve listening to all the subtle communications from our body–when to push, how hard to push, what position to move into…– another risk factor for tearing is muffling those communications. While epidurals have many upsides, this is one of the downsides: the risk of tearing is higher. It’s the same as how we are told not to eat hot food when our mouth is numbed after getting a filling–our pain receptors are muted and we could burn ourselves without knowing it. An epidural numbs you from upper-belly to mid-thigh, so you don’t feel most of the sensations of labour, and you therefore don’t feel when your body is telling you to go slow or change positions, either. I am not saying to avoid an epidural, but if your number one goal is to avoid tearing, an epidural can negatively affect your odds. It doesn’t cause tearing, but it can increase the likelihood of it happening.
7. Your Hormones Help
Another contributing factor is the hormonal interplay of labour. Throughout labour–indeed throughout pregnancy–our hormones rise and build and infuse us with softening agents that make all of our parts more supple and flexible. We have hormones that make our joints stretchy, our muscles loose, and our skin more pliable. The vagina is a sphincter composed of fibres that allow it to expand greatly when it is saturated with the right hormones. The hormones of labour help our body achieve an unparalleled level of stretchy flexibility so we can safely ease our baby out without incurring any harm.
8. Back & Forth
Another thing that helps the vaginal sphincter ease the baby out is the slow and gradual way the baby emerges. Usually you push when your body tells you to push, but when you pause to take a breath, your baby gets sucked back up into your body. It might feel like your progress is always undermined by regression after every push–some back after every forth. But this is nature’s way. You’re not doing anything wrong. The baby rocks back and forth, back and forth, on its journey out. This in/out, in/out, in/out journey causes two things. One is friction, as the rubbing brings blood and oxygen to your skin which both warms and softens it. And the other is the slow, gradual, easing of the baby’s head as it emerges from your body. Rather than a single “POW” as the baby shoots out, the pushing phase might take an hour or two (or even three) of gradual, slow rocking, gently moving your baby’s head through the birth canal, millimetre by millimetre, back and forth.
A sudden powerful egress would probably cause more injury, but the slow, cautious process of baby’s emergence helps protect our pelvic floor. It’s kind of like easing a cork out of a champagne bottle, by rocking it gently, releasing pressure bit by bit, to prevent that alarming ‘bang’ if it flies out too fast. So while pushing might be slow and tiring, this slowness is a trait we have evolved with to help protect the integrity of the perineum as the baby exits our body.
9. You Don’t Stretch So Much As Grow
As well, one of the most common misconceptions about birth is that the vagina stretches suddenly, cold-turkey, which leaves it forever stretched out, like a threadbare elastic, never as tight as it once was. This is misleading, because although there is some stretching, the main thing the vagina actually does is grow: not stretch but grow. When suffused with the right combination of hormones, and affected by the friction of the baby’s head rocking its way back and forth, in and out, the area gets filled with blood, warmth, and hormones, which causes it to expand: to get bigger. It’s like an erection, which likewise causes a body part to increase in size when affected by hormones, blood flow, and friction. The vagina gets enormous during birth, big enough to birth the baby, bigger than you’ve ever seen it before. Most people have no idea their vagina is capable of becoming so huge, because it only achieves this ‘birth erection’ during birth. And then after, it slowly decreases back to its usual size. It can squeeze just as tightly as it did before. It is no more forever ruined and threadbare after giving birth than a penis is after getting an erection.
10. If You Do Tear, You Don’t Feel It Happening
As you can see , nature has provided us with many helpful tools to help reduce the risk of tearing. But sometimes it does happen. Sometimes because the baby emerges very quickly, or their position isn’t perfectly aligned, or our position puts additional strain on our pelvic floor, or we are medicated and can’t feel all our body’s subtle cues, and sometimes for none of these reasons but just because it happens sometimes.
But one fact that might provide comfort, is that most people who do experience tearing don’t even know it happened until later when their doctor or midwife tells them. You almost never actually feel it happening. The word ‘tearing’ evokes such a horrifying image of our body ripping apart, that it’s hard to believe that the actual event can be so inconsequential that it goes by unnoticed.
This is partly because our body is so full of natural pain-muffling hormones during birth. Our oxytocin and endorphin levels are sky-high, so our sense of pain is very altered. Most people who found out they tore are astonished to learn that it happened, because they didn’t feel it at all at the time.
11. Most Tearing Is Minor And Heals Quickly
And it is also partly because most incidents of tearing are so minor. The majority of birthing tears are teeny tiny micro-abrasions that heal on their own, not unlike the mini-cracks you get beside your mouth or on the backs of your hands in cold or dry weather. Many tears are so minor that they don’t even require any stitches. And others that might be classified as more serious, such as second or third degree tears, occur along natural fault lines–not through nerves or muscle–so with stitches, they heal quickly, easily, and thoroughly. If you need stitches, they give you a local anaesthetic to numb the area before they start.
12. Pelvic-Floor Physiotherapy Can Help
Finally, if you are one of the rare people who has more serious tearing, you might consider consulting a pelvic floor physiotherapist afterwards. They can help you heal more quickly and more perfectly, and help you avoid any long term effects. Through gentle exercises, pelvic floor physio can be a positive part of your postpartum healing.
The word tearing is awful, the idea of tearing is horrific, but the reality is rarely that big of a deal. The process of birth itself provides many ways to help our skin stay intact, but even when tearing does occur, it’s almost never as bad as we fear, neither as painful, nor as serious, nor as scary. And in the rare cases that it occurs, pelvic floor physiotherapists can help us navigate our way to healing.
Stephanie Ondrack is a retired birth doula (or maybe on an extended sabbatical) and has been with The Childbearing Society since 2003. She lives in East Van with her partner, kids, chickens, and cats.