To tear or not to tear?

Ask your mother if she had an episiotomy, and chances are good she will say yes. A few decades ago, they were routinely given to all laboring women with the belief that if you cut the perineum you would reduce the chances of a 4th degree tear.

A fourth degree tear is when the tearing goes completely through the perineum, all the way from the vagina to the rectum. It requires a lot of stitches to repair, and causes significant pain in the postpartum period, as well as greater blood loss and a host of problems where excretion (pooping) is concerned. Naturally, this is something that everyone hopes to avoid experiencing, and if cutting the perineum with scissors reduced the severity of tearing, we would not complain about the prevalence of such a procedure.

After nearly 100 years of routine episiotomies being performed on all laboring mothers in the belief that physicians were reducing rates of severe tearing, the first clinical trials on episotomies were conducted. Study after study during the 1980s and 1990s showed  that episiotomies significantly increased the rates of tearing.

The Cochrane Collaboration analyzes data from scientific studies to present the most up-to-date and accurate information about medical research. It’s recent review on several clinical trials show routine episiotomies to be completely unjustified; they are associated with worse rates of tearing. (1)

But what about an episiotomy when a tear is believed to be imminent? If the care provider sees that the tissue in the perineum is blanching and expects it to tear, would it be better if it were cut or if it tore spontaneously? Multiple studies suggest the answer is no, and that an episiotomy increases damage to the perineum, even when it is done in an effort to “save the rectum.” (2) (3) (4)

So how can you prevent tearing? Avoiding an episiotomy or forceps assisted delivery certainly helps. Pushing (spontaneous being preferred over the valsalva “hold your breath” technique) and position of delivery (side lying being one of the best) may also play a role. But I’m convinced that one of the biggest factors is speed of delivery.

There have been a couple studies showing lower rates of tearing associated with delivering the baby’s head in between contractions rather that during a contraction. (5) This is a common practice among midwives, but rarely seen with obstetricians.

Not surprisingly, the studies I saw of midwife attended births had dramatically lower rates of third and fourth degree tears than surveys of births attended by OBGYNs. For example, a study of 1,211 women delivered by midwives showed only 14 women with third or fourth degree tears (6). Another large study where most births were attended by midwives showed only 0.25% (96 out of 38,252) women experienced severe tearing.(7) Most studies that I saw with obstetricians attending the deliveries had higher rates of tearing. The highest one I saw reported that 7.4% of the women experienced 3rd or 4th degree lacerations.(8)

I have a friend who has 5 children and has experienced fourth degree tears with two of her deliveries. She gave me permission to share her stories here, and I think her births are a vivid example of how strongly speed of delivery influences tearing.

Brandy obviously has an amazing pelvis that has no trouble birthing a baby. Here are brief snapshots of her births:

Baby 1:

Went to the hospital because her water broke. Didn’t feel contractions and was assumed to be in early labor until transition, which happened very quickly. Told the nurse (who hadn’t checked her yet)  that she needed to push and the nurse didn’t believe her. She pushed with the next contraction, and there was panic and commotion as the nurse went to get the midwife and they tried to get a tracing on the baby’s heart rate. Since they couldn’t find a heart beat they were yelling to push, push, PUSH! And Brandy did: with the next two contractions (and in between them) she pushed with all she had and the baby came out like a football, super fast. Brandy had broken blood vessels all over her face and upper body from the strain of pushing, as well as a fourth degree tear all the way through to the rectum. The stitching, blood loss, and postpartum pain in the perineum were much worse than the delivery and took a long time to heal.

Baby 2:

After such a quick first delivery there was some concern that she wouldn’t be able to make it to the hospital with this baby. At 41 weeks a vaginal exam showed some dilation and Brandy was told to come in with the next contractions she felt. She did, and the midwife broke her water at 4 cm, Brandy had a few hours of regular more intense contractions. Then she was tired and laid down to rest. The contractions stopped. The midwife checked her and found her fully dilated. “You’re 10 cm.” She said “Let me know when you feel another contraction and I’ll come back” and then the midwife left the room. (!!!) Suddenly, there was an intense contraction and Brandy was pushing (“It was like vomiting the opposite direction- there was no stopping it”). Her husband ran to the hallway to call for help, and when he returned the baby was delivering and Brandy was panicking because she was alone. She was laying on her back with her feet resting on the bed. The baby was out in two pushes. The midwife barely made it back in time. The baby had her hand up and her hand was born with her head. There was a mild second degree tear.

Baby 3:

This one was a planned homebirth. She called the midwife when she had painful contractions 7 to 10 minutes apart. (Nearly a week prior to this she had several days with non-painful contractions and had dilated to 3 cm). She thought maybe she needed to empty her bladder. She sat on the toilet for a few minutes and tried to pee, and then realized that the effort to pee was actually pushing the baby down. The next contraction she tried her best not to push and called to her husband “I need you now!” He came in and saw that the baby’s head was crowning. Her water broke then, and her husband said “We need to get you to the bed.” In between contractions he helped her stand up, and just the act of standing up was enough to push the baby out. They both caught the baby in their hands and wrapped her in a towel. This baby was born just about as quickly as the first two, but Brandy was trying very hard not to push so that she didn’t birth the baby into the toilet, and she delivered in between contractions. There was no tearing.

Baby 4:

This one is back at the hospital and induced with cytotec because Brandy was having frequent non painful contractions and starting to dilate. Had 8 hours of labor with sharp pains, then her water was broken. Shortly after the amniotomy she felt that she was completely dilated. She was directed to get into the standard hospital position, being partly reclined on her back with her knees bent and legs held up. The Doctor said “You can push now” and her husband said sternly: “She will do whatever she feels she needs to do.” Nurse and doctor did not offer further directions or instructions and Brandy breathed the baby out much like she had with her third, pushing as little as she could. She had a second degree tear requiring several stitches but it healed well.

Baby 5:

This one at the same hospital and with the same doctor as their 4th baby. Baby induced two days after due date with pitocin drip. The water was broken when she was about 4 cm dilated. The doctor stayed in the room for about and hour and a half, and when she was nearly completely dilated he said she could push if she wanted. She felt some pressure to push since the Dr. suggested it and the nurse got her into the default delivery position laying on her back with her knees held up high on either side. She was then told to push and pushed with the first contraction, then realized that it did not feel good to push like that.  She tried to breath normally and pretend she wasn’t having a contraction when the next one came. She felt a little nervous and scared and she wasn’t sure if it was okay that she hadn’t pushed during that second contraction. The third contraction came and Brandy was again told to push. She did, and the baby came out very quickly. She had a complete fourth degree tear again and it didn’t heal well. At 3 weeks post-partum she had to go into surgery and have the stitching redone because a hole had opened up between the vagina and rectum above the perineum. She had 4 months of incredibly limited mobility: she couldn’t take long strides when walking, going up or down stairs was difficult. It over a year before things healed completely so that she could have a bowel movement without intense pain.

In these 5 births, none of the babies were macroscopic (too large), none were posterior. Forceps were not used and episiotomies were not cut. Brandy obviously had a pelvis that birthed babies easily, and the key was to not push them out too quickly. The largest baby (8 pounds 8 ounces) was the third baby delivered at home with no tearing.

(And for you first time moms out there who are reading this: don’t worry; it is very rare for someone to deliver babies this quickly.)

It’s so worthwhile to talk to your nurse and Dr. about preventing tearing when you are in labor. Warm compresses and perineal massage have not been shown to reduce rates of tearing (6), but you might as well try them. They will certainly not cause worse tearing like the episiotomy, and they may serve the important function of reminding those attending the birth that preventing a tear is important to you.

Hopefully, they will be paying attention to how quickly the head is descending and once the head is crowning they will tell you and help you to push gently with contractions (or not at all if possible) and deliver the head slowly in between contractions. If you do not have any medication you may feel a “ring of fire” as the head crowns, which is your body’s way of telling you not to push.

Too often the cure (stitches) is preferred over the prevention (a gentle and slow delivery). But I think most care providers are happy to help you achieve this if you ask for it and remind them (and of course if the baby’s heart tones are reassuring).

(1) Carroli G. Belizan J. Episiotomy for vaginal birth. Cochrane Database Syst. Rev. 2000;(2):CDOOOO81.

(2) Dannecker C. et al. April 2004 Episiotomy and Perineal Tears Presumed to be Imminent: The Influence on the Urethral Pressure Profile, Analmanometric, and Other Pelvic Floor Findings-Follow-up Study of a Randomized, Controlled Trial. Acta Obstetricia et Gynecologica Scandinavica Vol 83, Issue 4, p 364-368

(3) DiPiazza et al. June 2006. Risk Factors for Anal Sphincter Tear in Multiparas. Obstetrics and Gynecology; Vol 107, Issue 6, p 1233-1237.

(4) Clemons et al. May 2005. Decreased anal sphincter lacerations associated with restrictive episiotomy use. American Journal of Obstetrics and Gynecology. 192(5):1620-5.

(5) May 2007. Albers et al. Minimizing Genital Tract Trauma and Related Pain Following Spontaneous Vaginal Birth. Journal of Midwifery and Women’s Health. Volume 52, Issue 3, p 246-253

(6) Leah et al. Dec 2010. Midwifery Care Measures in the Second Stage of Labor and Reduction of Genital Tract Tauma at Birth: A Randomized Trial. Journal of Midwifery and Women’s Health. Vol 50, Issue 5 p 365-372

(7) Groutz et al. April 2011. Third-and fourth-degree perineal tears: pervalence and risk factors in the third millennium. American Journal of Obstetrics and Gynecology. Vol 404 Issue 4. Pages 347

(8) Dandolu et al. 2005 Risk factors for obstetrical anal sphincter lacerations. International Urogynecology Journal.Vol 16, no 4, 304-307

When push comes to shove

Directed pushing is the most commonly used approach during the second stage of labor (that’s from when the cervix is 10 cm dilated till when the baby is born). Most often the mother will be directed to hold her breath to the count of 10 and push. The goal is to repeat this “hold your breath while I count to 10” three times during each contraction until the baby is born.

Spontaneous pushing is when the mother is allowed to push (or not push) in whatever manner she feels she should. Most women make some noise when they push and are not holding their breath for more than a few seconds.

For over a decade there have been studies showing that spontaneous pushing is associated with better outcomes than directed pushing, and there are more than a few researchers calling for reform in this area.

A 2011 review of randomized trials of directed pushing (“Valsalva”) verses spontaneous pushing concluded:

“The evidence from our review does not support the routine use of Valsalva pushing in the second stage of labour…  spontaneous pushing and encouraging women to choose their own method of pushing should be accepted as best clinical practice.” (1)

What to know about pushing:

Holding your breath for more than a few seconds at a time is not helpful, and if directed pushing is continued for long periods of time it is detrimental to the baby (decreased blood flow to fetus and lower oxygen levels, associated with abnormal heart rate patterns and lower apgar scores at birth) and it is also detrimental to the mother (postpartum bladder and urinary troubles and more severe tearing are more likely with directed pushing).

There is no correlation with length of pushing and negative outcomes (for baby or mom) as long as the baby’s heart rate is being monitored. That means it is just fine to be in the pushing phase for two or three or four or five hours…; there is no time limit as long as that baby’s heart rate looks good. A long second stage is only disadvantageous if the mother is using a directed pushing technique and holding her breath.

What to do about it:

Push when you feel like pushing (and not before). You do not need to start pushing at 10 cm. The pushing sensation (Ferguson’s reflex) is more closely associated with station than with dilation, and most people feel it when the baby’s head is at +1 station.

Don’t be afraid to be vocal. It’s better to make noise when you push (or be exhaling or blowing air out) than to hold your breath.

If you have an epidural try to have the dose adjusted so that you have enough sensation for pushing: ideally you should feel an urge to push and you should be able to move your legs and the muscles in your lower body.

If you have an epidural that is blocking all physical sensation and you have no desire to have your dose lowered so that you feel the urge to push, delayed pushing or passive fetal descent is a better approach than directed pushing. Passive fetal descent means that you take a nap or watch a movie until the baby is near crowning. You let the uterus do the job of bringing the baby down, and then only push as the head and shoulders are born (as directed by the care provider).

Why in the world would anyone tell me to hold my breath while they counted to 10?

It is surprising that directed pushing has lingered as long as it has. Perhaps some quirks of human nature come into play: we are creatures of habit, and we are not as patient as we should be.

In easier births where the pushing phase is short directing pushing does not appear to significantly impact the birth. In more difficult births the blame is placed elsewhere (fetal distress, failure to progress, or Celphalopelvic Disproportion (CPD)) and the directed pushing is assumed to have helped the effort rather than to have caused additional problems.

And lastly, there is a seemingly logical premise behind directed pushing: the attending care provider believes that the shorter the second stage is, the better the outcome will be for the baby. So push! Push harder! Till your face turns purple! Let’s get that baby out!

If you find yourself surrounded by an enthusiastic group of cheerleaders at your delivery coaching you to hold your breath for a count of 10 while you push, remember:

You can ask to do spontaneous pushing or delayed pushing (passive fetal descent) instead.

Your care provider should be familiar with the terms. These approaches are becoming more common and the evidence supports them as a better option for you and your baby. (And in my opinion, they’re much more pleasant to experience!)


1. May 2011; Prins et al.; Effect of spontaneous pushing verses Valsalva pushing in the second stage of labour on mother and fetus: a systematic review of randomised trials. Volume 118, issue 6, p 662-670
And since the night is late, I’ll paste my remaining references below, in no particular order. The information in the above bullets under “what to know” and “what to do about it” did all come from research papers published in reputable scientific journals, but I don’t have time now to do detailed footnotes.


*Feb 1993; Thomson. Pushing techniques in the second stage of labour. Journal of Advanced Nursing; Volume 18, Issue 2,
*Nov 1997. Petersen et al. Pushing Techniques During Labor: Issues and Controversies. Journal of Obstetric, Gynecologic, and Neonatal Nursing. Volume 26, Issue 6, p 719-726
*May 2007. Albers et al. Minimizing Genital Tract Trauma and Related Pain Following Spontaneous Vaginal Birth. Journal of Midwifery and Women’s Health. Volume 52, Issue 3, p 246-253
*June 2005. Simpson et al. Effects of Immediate Versus Delayed Pushing During Second-Stage Labor on Fetal Well-Being: A Randomized Clinical Trial. Nursing Research. Volume 54, Issue 3, p 149-157