• The Fit Midwife

To cut or not to cut.....

Cut and tears…. Possibly the single biggest fear most women have when they think about their labour. Everyone knows someone who had the worst tear, or the worst stitches etc etc. There is this a huge fear because all you know is, you have pushed something the size of a watermelon out of something the size of a lemon and it feels like it’s destroyed everything in it’s path and nothing looks nor feels like normal.

So this information isn’t designed to scare you. But neither are stories of your mum or best friend or co-worker needing stitches, but you’re still terrified right? Nearly every single woman will tear in some way with her first baby. It’s to be expected. Subsequent babies tend to fly out like a kid on a water slide, after the first one has paved the way so less trauma occurs.

To talk about this properly and get rid of that fear, we need to get the technical terms out of the way. So “A cut”, in the midwifery world is called an episiotomy. Everything else is a tear. Now there are different grades of tears, which I will discuss later. You may even hear the word graze thrown around, this is like a scratch, but stings much more than when you fall over and graze your knee….

Let me make one thing very clear. Midwives do not like to do episiotomies. And we only do them when really necessary. An example of when it might be really necessary is if perhaps we can see a tear is going to happen and it looks as though it will be bad, we sometimes do an episiotomy then so we can control the tear and minimise the trauma. Trust us with this, we look at lady bits all day every day, so we know what to look for!

Or, if your baby is not happy, but almost here (when midwives say “baby isn’t happy” we usually really don’t like the heart rate and feel baby needs to come quickly) and we can see an episiotomy will expedite the delivery safely and is appropriate, we will do it. Or if the doctor is using a kiwi/ventouse cup or forceps, we cut to prevent bad tears and allow access for the instruments (not every time though). If we need to do it, will be done with local anaesthetic (unless you have an epidural, which is usually sufficient pain relief) by way of an injection. Sounds horrific I know, but numbness there is never a bad thing in labour.

For all you UK based ladies, the midwives and doctors will not cut unnecessarily. For my Dubai based women, please make it abundantly clear you only want this if absolutely necessary, they are much more scissor happy!!

Now, tears happen. They are normal but bloody sore. We have 4 different classifications of tear, the first two being the most common, the thirsd not so much and the fourth, rare. They are classified by how much of the muscle in the pelvic floor and rectum are damaged.

  • First degree tear (usually just skin)

  • Second degree tear (skin and vaginal wall muscle)

  • Third degree tear (skin, vaginal wall muscle and some fibers of the anal sphincter)

  • Fourth degree tear (skin, vaginal wall muscle, large portion of anal sphincter)

Can I prevent tearing?

There are steps you can take, to reduce the risk of tearing but I think as many of my midwifery colleagues can testify to, if you’re going to tear, you’re going to tear. Some people have less elasticity in their skin, some people have shorter perineums, some babies come out with their hands up, causing damage on the way out! None the less, some of the things you can do are:

  • LISTEN TO YOUR MIDWIFE: If you do nothing else, do this. Delivery of the head of your baby is usually the trauma causing part, not the body. If you lose all control, don’t listen and shoot it out like a ping pong ball like a thai entertainer, then of course there will be a tear. Slow and steady delivery of the head can save many a perineum and in my experience is the most effective method. You also need a good and confident midwife here! When we tell you to stop pushing, you stop. When we tell you to pant or breathe, you do that too. This is when I get ‘abrupt and mean’ apparently, but it works!

  • Deliver in the water: Evidence suggests that water reduces the risk of tearing, allowing the tissues to become more supple, so they stretch better and also the counter pressure of the water assists delivery of the head!

  • Use a warm compress: If you don’t want to deliver in the water or you are unable to do so, ask your midwife to make a warm compress and use that against the perineum when delivering the head – this is now standard practice in the UK.

  • Perineal massage: This is the massage and manipulation of tissues to encourage them to stretch adequately when delivering baby. It is done daily, usually from around 34 weeks onwards. You can google the 'technique' if you are interested. The evidence is sketchy at best though to be honest, nothing conclusive. But it certainly doesn’t do any harm, so if you want to give it a try then massage away.

  • Epi-No: This is a weird, sex toy looking contraption, that is used from 36 weeks. It’s effectively a balloon that you insert inside, pump it up bigger each time and hope it stretches your pelvic floor muscles. Personally, I think it is expensive rubbish. Every single woman I know who bought one, tore anyway. There are no studies that prove it works and so my advice is save your money.

So what should you take away from this? Firstly... that you probably will tear in some way if it is your first baby. If it’s your second, third or eighth you probably won’t. Secondly, LISTEN TO YOUR MIDWIFE. We get oddly proud when we help women birth their baby's tear free. We brag about it to other midwives over tea. We will so everything we can to prevent it for you.

Don’t be scared of it. Being scared leads to panic, panic leads to losing the plot, which means you don’t listen to the midwife. Episiotomies are not routine midwifery or obstetric practice in this day and age but sometimes are necessary. And the only thing we gush more about than no tear at all is our beautiful handiwork with stitches. Trust me, once you have your baby in your arms I could stitch a Harry Potter lightening bolt down there and you wouldn't mind one bit. The end justifies the means.

Nikki xx

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