As a doula, part of your role is to help educate and prepare clients for birth. Many pregnant people have a fear of tearing. Next to labor pain, the fear of tearing is a big birth fear. Some parents may wonder about episiotomy vs tearing – which is better?
As a doula, you can help educate them about their options, as well has how to reduce the likelihood of both. In addition to being continuous labor support, you provide invaluable prenatal preparation.
Here is more information about episiotomy vs tearing to help your clients make informed decisions:
What Is An Episiotomy?
An episiotomy is a surgical incision made in the perineum.
Once upon a time, as birth shifted from home to the hospital, providers felt they could improve the birth process. Rather than understanding why tearing sometimes occurs, they thought they could make it easier to repair “inevitable” tears by creating “clean” cuts.
We now know routine episiotomy isn’t evidence-based.
For this reason, both ACOG and the World Health Organization (WHO) advise against routine episiotomies.
What Causes Natural Tearing?
When clients think of vaginal and perineal tears, they are often quite frightened. The fact that nearly 90% of births include some tearing can be terrifying for some to hear. However, it is extremely important we help our clients understand that nearly 99% of tears are minor and heal quickly.
Many minor tears won’t even need stitches – just typical postnatal care, and time to heal.
With so many experiencing minor tears, it seems it may simply be a typical part of birth. There are ways to prevent tearing (mentioned below). However, if tearing does occur it is almost always minor.
When baby is crowing, vaginal and perineal tissue stretches to accommodate their birth. The top of the perineum is thin when stretched, thus as baby is born, minor tearing can occur.
Not all experience the crowning sensation, and not all women will tear.
Some refer to the crowning sensation, with or without tearing, as the ‘ring of fire.’ Though it sounds scary, the sensation is short lived. That burning sensation is like a warning signal to be patient rather than pushing quickly with all the energy and increasing the likelihood of tears.
You can reassure clients that while many feel the burning and crowning sensation, few actually feel a tear sensation.
What Are The Types of Tearing?
As a doula, you can help reassure clients that while tearing is common, the most common ones are minor. There are four degrees of tearing.
- A first-degree tear is superficial and only involves the skin. This requires no stitches or just a few.
- A second-degree tear goes through the skin and some of the muscle just below. This typically requires just a few stitches.
- A third-degree tear goes through the skin, muscles, perineal tissue and requires stitches
- A fourth-degree tear is the most severe and involves the same as third-degree plus the muscles around the anal sphincter. This involves significant well-done stitches to repair.
Fortunately, third- and fourth-degree tears account for just 1% of tears. These severe tears are almost always associated with episiotomies, forceps, and vacuum assisted births.
How Can Clients Avoid Tearing?
As mentioned above, around 90% experience tearing. It is somewhat par for the course in labor. That said, there are things we can do to reduce tearing, and especially reduce the severity of tears.
These things include:
- Giving birth without an epidural (increased risk of vacuum/forceps assisted birth; unable to feel crowning)
- Being upright and using gravity during pushing phase
- Pushing with the urge to push rather than “purple” or forceful directed pushing
- Warm compress and perineal support by a healthcare provider
- Patience
- Breathing baby down vs pushing hard
- Declining episiotomies unless medically necessary
In some cases an episiotomy is truly medically necessary. Though rare, the times it may be needed include:
- Baby in fetal distress while crowning
- Need for vacuum or forceps
- Risk of tearing upward toward clitoris and urethra, which is more difficult to repair and thus episiotomy is preferred to a natural upward tear
- Body anatomy with short perineum, a diagonal cut may be preferred
Discussing episiotomy vs tearing is not always a pleasant conversation. However, as a doula, it is important to help your clients prepare for birth. Understanding their birth options and potential complications can help your clients best prepare for birth.
Author: Aliza Juliette Bancoff
Aliza Juliette Bancoff is a well-known doula and doula trainer who has been providing doula services to families for over a decade. She is the founder of Main Line Doulas, a doula group providing doula support in the great Philadelphia area for the last decade, the International Doula Institute, which provides online doula training and lactation training and certification programs and the International Breastfeeding Institute which provides lactation training and certification. She is the co-founder of United Birth, a company devoted to increasing access to doulas across the country to make the perinatal time safer both physically and emotionally. “Every birthing person deserves access to quality doula support. And we are working to make that a reality across the country. The work we are doing to get doulas to every birthing person will decrease the black infant and maternal mortality rate significantly by 2030.” Says Bancoff. Aliza is known for her compassionate and empowering approach to doula work, and she has been featured in numerous media outlets, including United Nations Maternal Health Report, Parent Magazine, CafeMom, theBump and many more. Aliza's journey into doula work began when she gave birth to her first child and felt a strong calling...