#353 | No Stitches Required: Preventing & Healing Perineal Tears in Birth

I'm Cynthia Overgard, birth educator, advocate for informed consent, and postpartum support specialist. And I'm Trisha Ludwig, certified nurse midwife and international board certified lactation consultant. And this is the Down To Birth Show. Childbirth is something we're made to do. But how do we have our safest and most satisfying experience in today's medical culture? Let's dispel the myths and get down to birth.

Here we are. We're doing our first evening recording in a long time. We're recording this evening because I had a little incident this morning.

Did you notice which child of yours it involves?

Of course, did you it's always the same one. She's away in college. She comes home for a week, and there's an incident.

Unbelievable. So it turned out to be a really great story, though, and it actually really nice example of how the world is still a really good place. You know, there's a lot of negativity around like, oh, society is going to hell. People are terrible. Like, you know, there's a lot of that out there, and today I had a really nice example of how society is still really good and helpful and kind. And so I'll, I'll share it before we begin. Because, first of all, I was so impressed by our community and the way they showed up for this episode, we asked for some anecdotes about perineal tearing. It can be a little bit of a dry topic, I guess, but women just like shared so much great content for this episode. So I was really happy to see that. And then I had this incident with my car, and I thought for certain that my car was done today, like today would be the last day or drive my car. I thought something really serious had happened, because my car dealer keeps telling me that, you know, watch your transmission. Watch your transmission. You're at this mileage, and your transmission is going to go out soon. So I have this thought in my head that my transmission of my car is going to go out soon. So Ruby, My middle child, texts me today and says, Mom, suddenly the car just stopped driving. I don't know what happened. It just stopped driving. It won't go. I just I had to pull over. What do I do? So, you know, I have to go get her and call AAA and get a tow truck to come get the car. And I'm assuming all right, there it happened. My transmission went out of my car. That's it. My car is done. And I get there, and I'm trying to, you know, do my own little diagnosis of the car to figure it out. And I'm trying to open the hood of my car, and something I would never do in a million years, because I wouldn't want to be able to open the hood of your car. I can do that. I accidentally do it on occasion. Perfectly good at doing that. I just, I would, I'd be happy if I could identify, you know, anything beyond the engine.

Well, I was having trouble today, and I knew that I hadn't gotten my oil changed in a really long time. I'm like, 5000 miles over my oil change. I'm thinking, Oh, shoot. Like, it's either the transmission or maybe problem with the oil. So I'm gonna look at the oil and check the oil. So this woman comes out of the building, and she sees me kind of struggling to get the hood of the car open, and she's an older woman, probably in her mid 70s or something, and she says, Can I help you? And I was like, Oh no, I'm fine. I can do this, like this one open. And she's like, Are you sure? Can I please help you? And I'm like, I don't know. I just can't get the hood the latch, and so she comes over and she puts her hand under there, and she gets the latch, and the hood goes right up. And I'm like, Wow, how nice. This like, a little embarrassed, but this other woman, what a lovely woman, helped me out. So then I'm fiddling around in the car and checking the oil, and the oil is totally fine. By the way, 5000 miles over, and it's totally fine, plenty of oil and still clean. So it wasn't that so I'm more convinced now that it's the transmission, and I'm waiting for the tow truck and some gentleman walks out of the building and says, was he handsome? I mean, he was good, decent looking man, decent, for sure. That would be part of this. Okay. What happened?

Yeah, he was healthy looking. Healthy looking and and I'm like, Oh no, no, no, thank you. I'm just waiting for a tow truck. And he's like, Are you sure? And I'm like, yeah, the tow truck's coming. And he's like, I'm happy to help. And I'm like, Well, are you a mechanic? And he's like, Well, no, but I work on cars. And I'm like, well, then get over here. Sure.

This is, like, the scene from My Cousin Vinny, where she's like, they're like, are you mechanics? She says, No, well, what experience we have? She's like, my father was a mechanic. All my brothers are mechanics. My two uncles on my mother's side are mechanics. They're like, I grew up working in their car shop. She's like, okay, so yeah, intentions, okay, so what did this guy, what did he say? So I'm like, I think it's my transmission. I explained what happened and and he said, Well, have you tried to start it? And I'm like, No, I'm afraid that if it's my transmission and I started, I'm just gonna, like, blow it up. And he's like, Well, do you mind if I start it? And I'm like, Sure, go ahead, whatever. He's like, okay. He gets in my car and he starts it up, and it starts up, fine. He's like, starts fine. He said, Do you mind if I drive it?

And then he drove away. You never saw him again. This is the story of the good person, right, almost.

So he Zoe's like, I said, Sure. So he drives away and he's out of sight. No, oh shit, I

just gave my car. Are you kidding? He actually drove out of sight. He drove out of sight. And I'm like, oh. There we go. I just somebody drive off of my car, Stranger in my car, coming back. I don't know what happened next, and I'm happy to know that you got your car back, because obviously you did. But this would be such a great story if you never saw your card. No car, just an unbelievably with this car, of it disappearing on me. What happened? He comes back around, and he pulls up, gets out of the car, and he says, your car is totally fine. It's not your transmission or he didn't say your car is fine. He said, your transmission is fine. I'm like, if you thank God. And he said, It's your alignment. You have an alignment problem. And I was like, Oh, that makes sense, because, like, last spring, Ruby slammed the car into the curb, and I had popped two tires, and I never fixed the alignment, so that makes sense. Okay, phew, it's my alignment. He says, You got to go to my guy Tom around the corner at ACE tire. And I was like, Okay, great. I'm going to ask for Tom. Thank you so much. You're so kind, so helpful. Turns out his doctor in the building where I was in the parking lot, and he's like, I gotta go back to work now. So nice say, so I canceled the tow truck, drove my car to ace tire. Why does alignment make a car not run the car? That wasn't the issue. The car was running, just Ruby. Said it wasn't Ruby because she got she because she panicked and said it wouldn't drive, and it wouldn't, it was we wouldn't drive well. So she just pulled over and stopped and never tried again. And then I never tried. So, oh, communication, yeah. It goes back to the the idea that somebody told me it was my transmission. So it just like all things went to that the brain just went to like, Oh, this is the problem. That's how beliefs work exactly. It's part of the point of sharing the story. And so I go to Tom at ACE tire, and I explained to him what happened. I said, it's, you know, so I need a I need my alignment fixed. And so he says, Do you mind if I drive the car? I'm like, Please drive the car. He drives the car. He comes back, gets out of the car, and he says, problem fixed. I was like, Really, just like, that problem fixed, and he's like, your car was in, you didn't know it, but your car was in four low, four wheel drive, low. So when the car was in like, four wheel drive, it makes the tires all like, kind of lock up if you drive too fast. So Ruby didn't realize she had put the car in four wheel drive. And so there was nothing, literally nothing wrong with the car.

And was Tom handsome.

Tom was handsome. Yes, you know what. Now you've named his, his name and where he works. So he's gonna, he's gonna get a little attention this week. He might, anyway, the point of the story, the long story all comes back to like, I didn't pay a penny, wow, for any of this today. Yeah, I thought my car was ruined. Two, three people just very generously helped me out. Nobody charged me a dime. Yep. Totally changed the trajectory of my day. My car would have been towed and at a shop and been down a car and all this, and it was just like, you know, humanity is still really good. And the other side of the story is that you don't need to change your oil every 3000 miles, because mine was still beautiful, and I'm 5000 miles over my oil change. And the third point of the story is beliefs and how literally, my brain would not go echo. Wasn't even rational. I didn't even think to check that. You know, it might have been something so simple as the car had been put into four wheel drive, and I didn't notice, and nobody noticed until Tom drove it.

Well, we've made very clear over the years that we don't give medical advice, but now we've also made clear that we do give auto device, yes, don't get your oil change, says Trisha Ludwig of down to birth. Show everybody free. Don't go get your oil changed. Feel free to delay the oil change. What problem can that cause for anybody? Well, eventually you do have to change. So Tom is going to hear this, and he's going to be so happy until you say, don't get your oil change. And he's going to be like, Wait a minute. I thought this was good for business. Now she's telling everyone not to come get the oil change. So, all right, give and take.

That was a good story, but it just really made my day. You know,

yes, and there are so many stories in our lives where people really come to the rescue, and those are some of my favorite stories. And I hope everyone listening can remember a time or a day in their life when the same thing happened, because I am sure other people have experienced something similar. So that's keep believing in the good of humanity. Because, you know, humanity is good. People are good. Generally, people want to do good and help you absolutely agree.

All right, so should we talk about the perineum now, or are we just, like, totally off topic for the night, and gonna, you know, talk about engines and fancy cars? Well, I don't have too much to contribute when it comes to cars, so I think we better go back to the perineum. Okay? And. We did have a lot of responses. I know some women wrote in with whole stories, some wrote in with brief comments, and dozens and dozens wrote in with questions. Now many of the questions were the same. I think I have 40 unique questions, but several of those questions were asked many, many times. So we have more content than we can provide in the episode. Oh, I almost forgot to mention, and I bet you did too, the most common question we had whether women have had one baby already, or two and tore or had an episiotomy, or whether they haven't had a baby yet. Can I prevent tearing? Is it preventable? Is it genetic? What can I do about it? We did a whole workshop on Patreon. I wish everyone would understand the value of joining our Patreon, even just for a month or two, and having access to about 50 hour long workshops where we go deep, deep on content. I mean this, these are educational. There's no there's not like this other part where we're like sharing people's stories, and we're chit chatting. This is a full workshop on preventing tearing so you just have to go to patreon.com/down to birth show. Just see what's in there. And if you want to stick around, you can participate in our ongoing workshops all the time, but you can just go in and access this whole library. And did we make that one workshop downloadable? In the shop. You can also go there and click the word shop and just buy a single workshop. But it's far better value to join for a month or two.

Just join and binge just like it's all there, yeah, just me know it really is. It really is fulfilling for us to do the work, knowing that women are benefiting. And obviously this is our work, but we want this to be so accessible for absolutely everyone to partake in. So please partake. I mean, there's, I don't think there's anywhere else to get this information. So we've done all the research on dozens and dozens of topics, including this one. So to prevent tearing, go consume an hour long workshop on this. There are tons and tons of things in there. So anyway, we are going to talk on a broader level about it tonight. And I didn't know how you wanted to begin. Should we start with anything in particular? Do you think?

I think we should just kind of give the background on what tearing is, what it actually means, and then we'll go into people's questions and
stories. Yeah, please also define for a second, third, fourth, right? Okay, so when we're talking about tearing, we're talking about the skin between the vaginal opening and the rectum, that is your perineum, and that is the tissue that needs to stretch during birth to help the baby get out. And sometimes it tears, it's actually really common to have first degree tears and even second degree tears, and we're really not too worried about those. It's really what we want to do is prevent the third and fourth degree tear. So a first degree tear is, you know, it's just like a nick, basically, a second degree tear is actually tearing into the muscle, and a third degree tear is tearing deeply into the muscle and to the rectum, whereas a fourth degree tear is actually tearing into the rectal sphincter. So that is obviously the most severe type of tear, and what we really want to prevent is those third and fourth degree tears, because the recovery is difficult. The long term health consequences are more significant. I mean, ideally, we're preventing second degree tears too. First Degree tears are just gonna they're just like, they're gonna happen. Don't even worry about that. Don't even think about that. Like you're gonna have a little, a little skid mark. We call them in the birthing world, when you give birth, all these questions around whether they're preventable, they are largely preventable. It would be irresponsible for anyone to say they're wholly preventable, because the baby's position alone can be something that will cause tearing your epidermis, health, your nutrition. I mean, in that workshop, we get into all of the things that do affect whether a woman tears and recovery and all of that. What I do want to convey, though, that I think is so compelling, is that Aina may Gaskin published her tearing statistics after she had over 2000 clients give birth at the farm. I think I remember them all off the top of my head. Believe it or not, I guess everyone will believe that with me and numbers. But I just want to tell everyone what her numbers were that she published in her book, I believe it was Ana May's guide to childbirth, where she has this published in an appendix, and I want everyone to understand in the hands of a skilled provider, how very much less likely tearing is. I believe it was 69.5% of women didn't tear at all. 19.1% had a first degree tear. So that's like already 90% of women who basically have no tearing. Then it was about nine and a half percent who had a second degree and then it was point 3% and point 1% who had a third and fourth degree tear. So point 1% is one per 1000 women. Point 3% is three per 1000. Right? So as Trisha said, those are the ones we're really looking to avoid, because they're the ones that are so difficult, problematic and all that, and episiotomy makes those tears more likely, not less. But I just wanted to say off the bat for the women who are really afraid of tearing, that there is, there is so much to do that can prevent them. And some women even asked, Does every woman tear does it just happen? The answer is absolutely not. So now we can get into the rest of it, if you'd like Trisha, but I just wanted everyone to not worry that much about it, that there really are so many things we can do to prevent it.

Yeah, and I want to also just add to that, that anime statistics are similar to larger studies that have been done on home birth. So this does indicate that the birth setting makes a really big difference in the severity of the tear. So, and that's not just because, well, we'll talk about why that is. It's because of a lot of things that a woman can do, as you said, and the goal is not to prevent 100% of tears. The goal is to reduce the chance of a severe tear and prevent long term health consequences and pain difficult recovery from that. Okay, so why don't we begin with me just sharing very quick anecdotes. There's not going to be much to respond to here, so I just want to get them out of the way quickly. The women who didn't tear some of the reasons they feel they didn't tear. Now, you and I know there's a lot that goes into why women don't tear. That's all part of that workshop we did, but I still think it's worth sharing some of these things that women said about their experiences. I surrendered and accepted the pressure of crowning. I didn't rush it, and I had no tearing. That's a big component of it. How you push, how you breathe is a component of reducing or preventing tearing. Another says I birthed side lying and I had no tearing. Another says I birthed on hands and knees in water and had no tearing. In fact, many women shared stories of their water births, and only one water birthed and did tear, and all the others who wrote in really credited water birthing without tearing, without tearing. My midwife suggested I feel the baby's head as I push and I didn't tear. I highly recommend. So that woman, what do you say to that one? I want to know.

I think, why is it a correlation? That might be the number one thing you can do to help reduce tearing is to actually feel your baby's head as it's coming out. Why? How? Because it gives you instant feedback on what's happening, and it takes away a lot of the sort of panic that sometimes women feel when they feel their baby crowning, that that intense burning sensation known as the Ring of Fire, which not everybody feels, but many, many do, and the desire to kind of just get past that as quickly as possible when you feel your baby's head, it just brings you this sense of connection and calm and reduces that kind of worry that I need to hurry up and get this baby out. You just feel a little bit more in control, and there's more feedback going into your own brain.

Okay, the others on this list said, I didn't tear. I birthed in water. My midwife didn't rush me, and my labor was six hours in all. Another says I was so terrified and of tearing, and I didn't tear at all with my 10 pound, four ounce baby, first born baby in water, and then another says I did perineal massage. Several women said this, actually, I did perineal massage both pregnancies, home births, no tearing. Babies were nine and 10 pounds. So she credits it with perineal massage, which I know is a bit controversial, and we discussed that and perineal massage with, what is this? Myrrh oil for weeks before birth, no tearing. Three times myrrh oil, that really it could. I mean, people report using different kinds of oils, yes, yeah, apricot oil, okay, castor oil, even, yep. So yeah, the research on prenatal perineal is a little bit mixed. So doing massage on your perineum in late pregnancy, some have demonstrated it reduces tear, and some have shown no difference. So the one thing that we have said about that if a woman does want to do that, go for it. The thing that might be helpful about it is that it does give you a little bit of the comfort level with feeling, some of that stretching sensation that you are going to feel in labor, and getting more relaxed and comfortable with that. Okay?

And then we had a group of women who said they had moderate tearing, a woman who had two home births and two second degree tears, and she wrote, I don't really see it as a problem. I thought that was an interesting addition there. I had a second degree tear, because my daughter was born with her hand up against her face, and obviously makes the crowning a little more complex with the hand and knuckles there absolutely, if you have a new elbow, if you have a new goal hand, or, you know, a hand at the face, or hand over the head, any of those things are going to increase the risk of tearing. That's just positional, and that's because they're putting very uneven pressure. Her on the perineum.

I pushed too early and should have waited. I ended up with a second degree tear. So again, there's another little testimony about the importance of not pushing too aggressively, which women do, because they just can't wait to get the baby out. Experience the relief. I had two first degree tears. Again, that's kind of a non issue. Two births apart, two years two births, two years apart, and I want to know if I'll fully re heal. How can someone who's had two first degree tears wonder about fully re healing? That doesn't even make sense, does it? Oh, they stitched her, yeah, so she may have been stitched Yes? Well, yes, and that's the problem. And truthfully, a first screw tear probably almost never needs to be stitched. For sure, I had an episiotomy with my first and for my next two babies, I had minor tears at the site. So there you go. I guess meaning that she tore beyond the episiotomy, which is really common.

I think she No, I think she said at the site. I think she means right at the point of the weakest, you know, where the scar tissue is.

Oh, in her subsequent birth, she tore where she had the episiotomy. Yes, yes, yes, common.

And then I did perineal massage three times a week for seven weeks, and I had just a 1.5 degree tear. I'd love to know who assessed that with with a posterior baby. Those were the moderate tears, okay, general observations and concerns that came in. One woman wrote, I tour with all four babies because no doctor told me how to slow down. Another one, actually, this was the first one. But many came in that said, no one is talking about labial tears. So we need to talk about labial tears. Many women reported having labial tears. I want you to explain what it is and all that. Let me just finish this list. I'm worried about the scar tissue from my first and that it will not stretch when I and I will tear again. Okay? I want you to comment on that too. Actually, midwife Here, eat a healthy diet, stay hydrated, ease the baby's head out and don't let providers cause tearing, because they are, quote, making room for the baby's head. Great. Comment. Very grateful to her for that. And then I want you to comment on this, so you have three things to comment on. One doula wrote it and said, I had a client pop a standalone hole in her perineum, which can happen like it with the tear doesn't happen right at the periphery of the perineum. It happens a little lower down, so the periphery is intact, but there's a tear lower down, and that can happen too. And I don't know if you want to comment on that, but I think when a woman has a very weak pelvic floor, or the dermis isn't doesn't have good integrity, that can happen, and sometimes it tears upward and does reach the perineum like the perimeter. So those are three things I'm wondering, if you want to comment on, well, we can go backwards. Do you want to say anything about that standalone tear?

Yeah, I have never seen that happen. I'm not saying it couldn't happen, but I have never, I've never witnessed that. I don't have a lot of feedback on that, because I've, I never saw it.

What do you say to the woman who said, I'm worried the scar from my first will not stretch and I'll tear again. That's an interesting concern. What do you say to that, um, I, you know, the scar tissue really shouldn't be so thick, so some people do have sort of abnormal scarring where they build up more keratin in the skin, and their scars are thicker and less stretchy. But that is also not the norm. Most of the time, if you are going to tear again, it usually is right over the scar line like that is the point where it tears. So she could do a little bit of scar massage therapy. They're using some oils and things to help break down any extra scar tissue and just kind of soften the area. Maybe a little pelvic floor therapy would help too. You could do some internal work to just soften and loosen things there. But I would also really try not to focus on that. The idea is just to focus on the physiology of birth, and do your best to not do things that are going to increase your risk of tearing, which we're going to talk about, and let the body do the rest.

Right? It's very common for women to tear in one birth and never in her others, and for her to tear the first time and not ever again. So I think it's a reasonable concern. I can see imagining the same concern if I had torn. But I think that you're right. It we absolutely it absolutely doesn't indicate that she'll tear again. It definitely does not. And all the concerns about labial tears, can you talk about what a labial tear is and then how they happen? Some women wrote in with specific questions, like, how can it tear upward? And I'm so scared about that, so can you talk about that? Yeah, so a labial tear is literally just a tear, not in the perineal tissue, but in the labial tissue. So it's just different tissue that's being stretched. So the most pressure, the maximum stretch and pressure is put. On that perineum, the base of the vaginal opening, the bottom part, because that's where the back of the head of the baby's coming through, that gets the maximum stretch. But you're also stretching. You know, your your vaginal opening is like a, you know, like a diamond, a little bit like at the top has to stretch, and the bottom has to stretch, and the top can stretch, and sometimes stretch so much that that skin splits. So labial tear is usually just like a split in the skin. They are often not repaired because they're usually pretty minor, but sometimes they do need to be. And the same stuff that we're going to talk about preventing perineal tearing is the same stuff that you do to try to prevent labial tearing.

Okay, good, yeah, we did have three or four women right out, and one asked, but the others had experiences.

Minor tears of the labia are common, just like nurse degree tears of the perineum are super common, okay, but severe tears very uncommon.

Speaking of severe tears, here are some of the comments regarding severe complications or tears. I had a third degree tear, and the doctor said, I qualify for a C Oh, wow, look at that. You get I've got news for you. You qualify for a C section. It's your lucky day. All right. So sorry about the sarcasm. We hear this all the time qualify, a doctor found an opportunity to insist on a C section. I qualify for one. What that is? Not Earth. Ridiculous description, ridiculous terminology. I had a third and it was a third degree I had a third degree tear. And the doctor said, I qualify for a C section next time around. But she asks, but wouldn't that be worse? Well, that's risk of much bigger cut. It's a bigger cut. It's a much riskier procedure for you and the baby. You don't want to do it unless it's absolutely necessary. Yes, I can't believe that. That's unbelievable. Okay, next one, I had a third degree tear and a delayed hemorrhage after the OB missed a stitch. So if there's a stitch, well, a third degree, there's some internal tearing. So the doctor missed something, and I guess it caused bleeding. Now, would that still be considered hemorrhage if the blood isn't coming from the uterus?

Yes, you can still have a hemorrhage from lacerations.

Yes, wow, wow. Interesting. I did not know that I had an episiotomy, and the healing was hell, harder than my C section recovery. It's, see, this is the thing about tearing. Well, episiotomy. And episiotomy is not a tear, it's intentional damage. It's a cut. It's not the tissue just responding to pressure. It's damage caused by the doctor. I mean, it is no matter, even even on the in the very rare instances when they could be beneficial. I mean, extraordinarily rare. I have to be very careful about even implying that it's generally okay to do them, because it is generally not okay to do them. But you usually hear about the problem not being with a tear itself. It's always the recovering how they stitch. This is so common for women to say episiotomy and healing is much harder.

When you have an episiotomy, you are more likely to have a severe tear beyond the episiotomy. So you get a episiotomy that's just, oh, a little snip. Well, that little slant, that little snip, can easily become a third or fourth degree tear, and that is the problem, and the recovery with a third or fourth degree is very difficult.

Next for my first baby in a hospital, I had a second degree tear stitched, and it caused too much scar tissue, which led to painful sex that is not uncommon and needed to be cauterized, yeah. But with my next two babies, I let my second degree tears heal naturally and had no issues with healing and no pain whatsoever with sex.

So it it was pretty uncommon in the days that I was training to be a midwife to ever let any tear be unstitched. It's much more common now, and rightfully so, because so many women have poor results from the stitching, where the stitch the the tissues are actually not brought back together smoothly enough, and so sometimes the inside tissue can be left outside. Right the outside is supposed to be your skin tissue, and only your skin tissue, if in any of your internal tissue is sewn up so that it is facing the outside, not the skin protective layer that will not heal, it will never become skin, and that can be really painful and really uncomfortable, and that's usually when they have to use something on it to, kind of like, change the tissue texture. They cauterize it, basically, or re stitch.

I didn't know that that was possible. This makes me really upset, because it's not the first time we've learned about this and starting our podcast, doctors are just not trained in doing a good job on any kind of procedure or surgery around the vagina. Like it just gets me so upset that it's not taken so much more seriously how to restore a woman to her original condition. It's like. Is how this is one of the reasons necklace. This is one of the reasons they prefer to do episiotomies, because they believe it's cleaner and easier to sew back together, whereas a tear is more jagged and it's harder to align. And I don't buy it. What we have learned, what we have learned is that the perineum, the vaginal tissue, is extremely good at healing itself. It's just like your mouth, inside your mouth, you know, things in your mouth just heal really quickly. Yeah, because of increased blood flow, there's so much blood flow, but I'm just saying they should do a better job recovering. And if they do an episiotomy, their excuses it's easier to stitch, but it's not because there's more likely to be a third or fourth degree tear, but they should learn how to do this kind of surgery, just like they have to do how to they have to learn how to do C sections. This is so unacceptable that they do such a shoddy job at this Okay, in the last one, speaking of infuriating techniques and lack of experience and lack of ethics, this one gets the blood boiling. It really does. This final comment is from a woman who said, What should I do if they gave me a quote extra stitch, I didn't ask for one, and now I slightly tear every time we have sex. You should sue.

That's That is unbelievable. It's an outrage. I mean, if anyone doesn't know what this disgusting, it's disgusting. It's a it's a completely disgusting thing. Doctors, I mean, honestly, these must be, they call it the husband stitch. This must be, honestly. These must be men. These must be men who are inherently violent. This. These cannot be normal men who love women. This can't be normal that a doctor would give a woman, quote, an extra stitch intentionally make her vagina smaller without her permission and Wink, wink to the husbands. And husbands have been told this, oh, I gave her an extra stitch. How dare you not be punching him in the face. They should be sued. I mean, not to mention that would be horrible for sex, because the opening is now tighter, but the inside her vagina is no different. So now any passage through the opening would be as this woman experiencing tearing I mean,

I hope it really doesn't actually work.

It's not even a consideration if it works. This is complete abuse. This is absolutely should be such high grounds for a lawsuit. I would hope what these women can do, in addition to suing Whoever does this to them, this unbelievable abuse. I hope they can go get it removed, even if they have to be open and bleeding again and just heal again because to live like this the rest of your life because someone damaged you like this. I hope there's something these women can do. Yeah, it's horrible. It just is an outrage. I can't even believe that the audacity to modify someone's body and for such a reason and without consent.

I mean it, it's hard for me to even believe that that's actually still done. Oh, but we hear about it, I know it's done. It's just really hard to believe. All right, well, let's get into some of the questions. I know we covered a bit of ground, but let's try to answer some of these questions with topics I think we didn't quite address yet. Is it normal for the midwife or OB to take forever to examine if the tear needs to be stitched?

No, that's not normal not to take forever. No, no, no, they should be able to pretty quickly make an assessment on that and make that determination. And what I wanted to say, that I forgot to say earlier when you were talking, is that, you know, the stitching part for a lot of women is they report that as being the worst part of their birth, or the most painful part of their birth. So we really, you know, if there's question about whether you should be stitched or not, the answer should probably be no thank you.

If you tear upwards toward the clitoris and urethra, how do they fix it?

Oftentimes, it's just fixing itself. If it's severe, they may have to put a stitch.

How many women end up needing their tears to be re repaired?

You should not have to have your tear re repaird. I don't know what the statistic is on that, but a lot of times pelvic floor therapy can help with that, or even the use of estrogen cream can help with healing that is taking longer than usual.

Similarly, I feel like they stitched me up badly. Is that possible? And what should I do?

Yes, that's possible, and pelvic floor therapy and estrogen cream, and possibly needing the tissue treated by by a midwife or an OB. What we were describing before was sort of that a granulation tissue and need for silver nitrate on the tissue.

Trisha, if her birth was only a week or two earlier. Is it not too late to just go back to the hospital, and potentially before it's fully healed and there's all scar tissue? Is it possible to maybe redo it before it's too late? She's already been stitched? Yeah. I mean, if she's a few days after giving birth and she just feels like they didn't quite do it right, or something seems off, do you think she should maybe go. Back while I don't, I don't think, unless there's something grossly abnormal, I don't think that that's probably the best course of action. I think you want to give it time to heal. She's only a few days out. You can't really tell if it's unless there's some gross anomaly with it.

Yeah, just the idea of them doing a bad job, and then everything, you know, sealing in place the way they do it. Just the thought is, do you know, just such an uncomfortable thought? I'm just desperately thinking like, what could you do before it gets to that point, if that's the case for anyone, okay, should a midwife or surgeon treat third or fourth degree tears only a surgeon, right? That is generally the job of an OB mid wives are not typically trained to repair third or fourth degree tears, although some may be okay and when is letting a tear heal without stitches. Optimal. I know you often talk about, like, even most second degree tears, natural tears are we talk about this in the workshop. You talk about like how to heal optimally. You keep your legs together, don't climb on stairs. There's a whole thing about doing it responsibly. But when you're assessing a woman, if you're with a midwife, you trust and she doesn't want to do anything unnecessarily, what are you looking for? Trisha? How would you assess whether she could maybe go without stitches?

You're sort of looking at how easily the skin aligns. So if you can kind of just put it back together really easily and it touches in all the right places, then if a woman is resting properly after birth and kind of keeping her legs together and not doing a lot of stairs or caring of other children and allowing her body to heal, then that skin is naturally going to hear heal correctly. But if it is really out of alignment, then you might need to use the stitch to sort of put it back in alignment so it heals properly. Okay?

And the final question is, how to control pushing when the fetal ejection reflex takes over.

Well, the fetal ejection reflex is going to do what it's going to do. You can't really control that. But you can use a different style of breath as the baby is coming out that may slow it down. So a little bit, if the baby is the baby just gets shot out, which sometimes happens, like, what are you going to do? You can use your hand to try to slow it down a little bit, but it just kind of happens. And it happens. And it happens what's going to happen is going to happen. But if, if the overwhelming sensation to push feels like too much at the moment of the baby crowning, you can use sort of a panting style of breath to try to not, like hold it, bear down. You know, sometimes at that moment, women actually do hold their breath spontaneously, very different than holding your breath with somebody's direction. So if you spontaneously feel the urge to hold your breath and bear down, you work with that. But if you are using sort of like a panting style breath as your baby is coming out, then that can slow the descent of the baby so you're not using as much force.

And there is one more, and I looked up the research on this today just so that we could give a response. I don't love the question to begin with. I don't love that anyone is thinking this way. Nothing personal against the woman who submitted it, because I would think this way. But she asked, Are older women more likely to tear. I don't like it, because I was just talking to a group of my clients about that, about this topic this week, again, we're, we will. We are looking at statistics to apply to an individual So, so what if women your age are more likely to tear? Is what I want to say. It doesn't have anything to do with you. But I looked up the research on this, and it was kind of interesting. I didn't get into which studies were high quality versus low quality. So I have no comments on that, and that's one of the most important things to consider. However, of the research out there, there were a couple of studies that showed, quote, older women were more likely to tear. One showed 16% more likely. One showed almost twice as likely. Then there was a study that showed younger women are more likely to tear. Then there was one that said, we see no difference at all. So just let it go, because there are so many ways to prevent tearing. Just focus on the things you can control, and don't worry about the things totally out of your control, like your age, right?

So the theory there might be lack of, you know, collagen in the skin, the tissue being more friable. And then with the younger person, it might be, well, they have tighter pelvic floors, and sometimes that's been associated with more tearing. So the thing is, also your your skin integrity is is genetic and largely based on diet.

And very much, yes, absolutely. One thing we know for certain is that women who are not well nourished are more likely to tear that doesn't mean your diet has to be perfect, though. Let's not get like crazy about this is like we're talking about sort of malnourished versus well nourished. And some amount of this is out of our control. If you have a really fast birth, you know, it really. Strong fetal ejection reflex. You might tear a little, it's okay. Your baby came out quickly, like it's okay. So we have to not get too hung up on it. We have to control the things that we can control, which we know are, where you give birth, how you give birth, the position you give birth, in lack using spontaneous pushing and not controlled pushing and bearing down, touching your baby's head, giving the perineum time to stretch when your baby's head, when you feel that ring of fire, using a different style, breathing and relaxation that like that panting breathing, or even horse lips, just sort of blowing out your breath to let that tissue stretch, touching your baby's head to help as your baby crowns, staying off your back, giving birth in the water is helpful, and using warm compresses is actually evidence based to be helpful. So that has been studied and shown to be helpful. If you feel like you want somebody using some warmth on the perineum, that can be helpful. You don't have to it's just an option.

The main thing is, don't have fear. As always, focus on what you can control. Relinquish to what's out of your control. And there is even so much to know about how to heal optimally, how to heal better than in other situations. So again, just put your focus on the things you can control on check out that workshop of ours. There's an abundance of information there. And as always, you can reach out to us with any follow up questions after you view it

and go back to the story at the beginning of the episode about beliefs and how our beliefs can get us set on the wrong path if we get something fixed in our head that this is what something is, or means or is going to happen. So there are handsome mechanics and helpers everywhere.

Thank you for joining us at the Down To Birth Show. You can reach us @downtobirthshow on Instagram or email us at Contact@DownToBirthShow.com. All of Cynthia’s classes and Trisha’s breastfeeding services are offered live online, serving women and couples everywhere. Please remember this information is made available to you for educational and informational purposes only. It is in no way a substitute for medical advice. For our full disclaimer visit downtobirthshow.com/disclaimer. Thanks for tuning in, and as always, hear everyone and listen to yourself.