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Vaginal tears during labor
What are vaginal tears during labor?
During childbirth, the skin and muscles around the vagina can tear as the baby passes through the birth canal. In most cases, the tear is relatively mild and soon heals, but more extensive tears need to be repaired to avoid any complications.
During labor, hormones are released to help soften the tissues of the vagina and the perineum, which is the area between the vagina and the rectum. This allows the skin and muscles in this area to stretch, which is necessary for the baby to pass through the vagina during birth. However, if the tissue is not able to expand sufficiently, vaginal tearing can occur.
Most women - around 90% - experience vaginal tearing to some degree during vaginal childbirth. 
Factors that can increase the risk of vaginal tears during birth include:
- An instrumental delivery of the baby by using forceps or vacuum extraction;
- A prolonged second stage of labor;
- A first pregnancy;
- Shoulder dystocia, in which the baby's shoulders become stuck in the vagina after the head has passed through;
- Occiput-posterior fetal position in the uterus, in which the back of the baby's head is facing the mother's spine;
- A large baby (over 4kg);
- Induction of labor, and;
- Use of an epidural anesthetic for pain relief during labor.
Vaginal tears can be classified into four different grades, according to the extent of the tearing:
- First-degree tear - restricted to the tearing of only the skin around the vagina;
- Second-degree tear - in addition to the skin around the vagina, this also involves tearing of the perineal muscles;
- Third-degree tear - in addition to the skin around the vagina and the perineal muscles, this also includes the anal sphincter, the muscle that controls the opening and closing of the anus, and;
- Fourth-degree tear - the tear extends all the way through to the anus and includes the lining of the bowel.
The more severe a tear is, the longer it can take to heal and the more likely it is to cause complications. For women who do have a tear, around 9% experience the more severe third- and fourth-degree tears. 
An episiotomy is an incision made in the perineum, the skin between the vagina and anus. In the past, it was performed routinely during labor to prevent more extensive tearing as the baby passed out of the vagina. However, this procedure is no longer routinely performed; rather, it now tends to be used in certain situations, such as those involving:
- An instrumental delivery using forceps;
- An unusual fetal position;
- A baby in distress, when a quick delivered is necessary, and;
- Increased chance of extensive vaginal tearing.
Episiotomy is performed under a general anesthetic, so there is no pain during the procedure. In cases where an epidural anesthetic has already been administered, no general anesthetic is necessary. In other cases, a local anesthetic may be delivered to the area by injection.
Types of treatment
First-degree tears generally do not require repair and will heal on their own. More extensive tears will generally require repair.
Repair of vaginal tears
Vaginal tears can be repaired with surgery to stitch together the damaged tissue. In less severe cases, this is carried out in the delivery room soon after birth. More severe cases may need to be repaired in the operating room.
Follow-up appointments may be recommended in the following weeks to ensure the tear is healing well.
Management during healing
Depending on how severe a vaginal tear is, complete healing can take anywhere between several weeks to a few months. To reduce the level of discomfort and promote healing, the following may be done:
- Regularly using icepacks to cool the area for 2-3 days after birth to help reduce swelling;
- Rinsing the vaginal area with warm water after passing urine to reduce stinging;
- Taking pain-relief medications, such as acetaminophen and ibuprofen, as advised by your healthcare providers;
- Sitting on a padded ring or pillow;
- Avoiding constipation, which can place strain on the damaged area, by taking laxatives or stool softeners, drinking plenty of water and eating a healthy diet, as advised by your healthcare providers;
- Pressing a clean pad against the area of the tear to provide support during a bowel movement;
- Taking extra care with hygiene to help prevent an infection;
- Being careful with sudden or strenuous movements;
- Avoiding sexual intercourse until your healthcare provider advises it is safe;
- Physiotherapy and pelvic floor exercises, as advised by your healthcare providers, to help strengthen affected muscles, and;
- Attending scheduled follow-up appointments with healthcare providers.
Loss of blood
In rare cases, a vaginal tear can result in a significant loss of blood that may require a blood transfusion.
Given the close proximity of the vagina to the anus, a tear can easily come in contact with feces, which may result in an infection, particularly in the first week after birth. Signs of infection can include:
- Tenderness or soreness in the area of the tear;
- Pus or bad-smelling fluid draining from the tear, and;
- A fever.
Rarely, an abscess or a potentially life-threatening form of infection, called necrotizing fasciitis, can occur. Drainage or other forms of treatment may be required.
Antibiotics may be recommended to prevent an infection during the healing of the tear, or if signs of an infection develop.
Failure of a tear to heal
A tear, or its repair, may fail to heal completely, requiring further surgery. For this reason, it is important to attend follow-up appointments as recommended by your healthcare providers.
Perineal pain and painful intercourse
Trauma to the perineum can lead to ongoing pain in the area, which can make sexual intercourse painful. If these symptoms occur, your healthcare provider can discuss treatment options.
Fecal incontinence and urgency
Fecal incontinence is uncontrollable leakage of gas (flatus), liquid or feces from the anus. This can occur when the anal sphincter, the muscle that controls the opening of the bowel, is damaged as a result of tearing.
Fecal urgency, which is the need to go to the toilet as soon as the urge to pass a bowel motion is experienced, may also develop.
Wearing pads can help to manage any leakage. Surgical techniques are available to repair the anal sphincter.
Rectovaginal fistula is a very rare complication of serious vaginal tears. It occurs when an opening develops between the lower bowel and the vagina. This means that the contents of the bowel, such as gas or feces, may pass through the vagina. Most rectovaginal fistulas require surgical repair.
Giving birth in subsequent pregnancies
Women who have serious third- or fourth-degree tears during birth may be at increased risk of developing more severe tears during subsequent births. Your healthcare provider can discuss birthing options, such as having a caesarean section.
Vaginal tears heal well or completely in many women. Even in cases of serious third- or fourth-degree tears that require repair to the anal sphincter, around 60-80% of the women have complete wound healing 12 months after the birth. 
While there is no sure way to prevent vaginal tears and damage to the perineum during childbirth, there are some practices that may help to reduce damage. These include:
Warm compresses pressed to the perineal area during the second stage of labor (generally performed by a midwife) can help to reduce damage to the perineum.
Regularly massaging the perineal area during the latter part of pregnancy may help to reduce damage to the perineum during childbirth. Your healthcare provider can discuss whether this is suitable for you and how to correctly perform the massage.