Childbirth, tear or cut - Treatments

No cut (episiotomy) unless you really need it

Midwives and doctors used to do many more cuts than they do now, because they thought it was better for you and your baby. But now there's good research showing that it's better not to have a cut unless you really need one.

Nowadays, many hospitals train doctors and midwives to deliver babies without cuts whenever possible. If you don't have a cut, you're less likely to have stitches, an infection or bleeding.

Good-quality research has shown that if cuts are done only when needed the number of cuts and more serious tears in a hospital come down. One summary of six good-quality studies showed that when hospitals followed this rule:

• The number of women who had a cut reduced from 73 percent to 28 percent.
• The number of women who had either a cut or a tear running backwards from their vagina reduced from 82 percent to 72 percent.
• The number of women needing stitches reduced from 86 percent to 64 percent.
• About 4 in 100 women in these studies had bad tears. This was regardless of their hospital's decision about when to make a cut.[1]

But the research also found that having your baby in a hospital does slightly increase your chances of a small tear in the area forwards from your vagina. This kind of tear may involve the labia (the folds of skin around your vagina), clitoris or urethra (the opening that you pass water or urine from). This type of tear is generally less serious than tears running backwards towards your back passage.

Having a birth partner with you during labour

There has been some good research on having a birth partner to support you during labour.

The research showed that with this kind of support, you have a slightly higher chance of giving birth without your doctor having to use forceps or a vacuum pump (ventouse) to help the baby out.[2] If you don't need forceps or a vacuum pump, you're less likely to have a tear or need a cut.

In the research we found, the birth partners were all women. We didn't find any research which looked at male birth partners, so we can't say whether having a male partner with you would work in the same way.

The woman supporting you could be a midwife, a student midwife, a nurse, a trained birth attendant (sometimes called a doula) or your mum. It doesn't matter who the woman is. The important thing is that she stays with you until your baby is delivered.

In the research we looked at:[2]

• 18 percent of women without this support had a forceps or vacuum pump delivery.
• 16 percent pf women who had support from a birth partner had a forceps or vacuum pump delivery.
• But having a birth partner didn't seem to lower the chance of having a tear or needing a cut.

A 'hands-off' method of delivering your baby

There are two main methods midwives can use to deliver a baby.

In the usual method a midwife puts one hand on your baby's head and uses gentle pressure to stop the baby from coming out too quickly. The midwife also supports the area between your vagina and back passage (called the perineum) with the other hand.

In the other method the midwife simply waits with hands ready but not touching you or your baby's head. This is the 'hands-off' approach but nowadays it's not used that much. We found two studies that suggested that you are less likely to need a cut if the midwife simply waits in this way, with the hands ready but not touching you or your baby's head.[3] [4]

The hands-off method may cause more pain later than the hands-on method. Ten days after delivery women whose midwives used the hands-off method had worse pain around the perineum.

Being upright during the birth of your baby

You can have your baby in an upright position rather than lying down. You can squat, kneel or use a birthing chair or special cushions. Researchers combined the results of 19 studies (a systematic review) and found that women who stay upright are less likely to need a cut.[5] But they have a slightly higher chance of a tear than women who lie down to have their baby.

The research found that:

• 43 in 100 women who lie down had a cut
• 36 in 100 women who stayed upright had a cut
• 16 in 100 who lie down had a medium-sized (second-degree) tear
• 18 in 100 women who stayed upright had a medium-sized tear

The research on staying upright to have your baby is reasonably good. But we still don't know enough about the risks and benefits of different upright positions such as squatting or kneeling.

Vacuum pump (ventouse) and forceps delivery

If you need extra help to deliver your baby, your doctor may use a vacuum pump (also called a ventouse). This is a cup attached to a small vacuum pump. The cup fits over your baby's head, and the vacuum pump makes a tight seal. In this way your doctor or midwife can pull your baby out while you push.

Your doctor may also use forceps to help your baby out. Forceps are like large pincers or tongs with curved ends that fit around the baby's head. The handles lock in position so that there's no pressure on your baby's head. Your doctor or midwife will use the forceps to pull at the same time as you push.

There has been good research showing that if you need extra help to deliver your baby, the vacuum pump method is less likely to cause serious damage to the area between your vagina and your back passage (your perineum) than forceps. We're not sure what is meant by 'serious damage' because the research didn't make this clear.[6]

The vacuum pump also hurts less, both during and after birth. And you are less likely to have problems controlling wind or leaking loose bowel movements (liquid stool) afterwards.[7]

The suction cup used with the pump can cause a blood blister on your baby's head.[6] This means that blood collects under the skin of your baby's head, and it can get quite large. But it will get better on its own. The vacuum pump can also cause slight bleeding at the back of your baby's eyes. The bleeding isn't serious and does not affect your baby's eyesight.

However, the vacuum pump doesn't always work. For 1 in 10 women, it doesn't help get the baby out and doctors have to use another method. Forceps are slightly more likely to work the first time.

One summary of 10 good-quality studies (randomised controlled trials) found that:[6]

• 1 in 5 women who had a forceps delivery had had damage to their perineum.
• 1 in 10 women who had a vacuum pump delivery had damage to their perineum.

We're not sure what is meant by 'damage' because the summary didn't make this clear. But in the same studies, a third of the babies delivered with forceps had bleeding in the back of their eyes compared with half of the babies delivered by the vacuum method.

Waiting before you push

Once the opening to your womb (your cervix) is fully open (dilated), your baby's head should start moving down the birth passage towards the opening of your vagina. This is called the second stage of labour.

It is a natural for a woman to get the feeling to push or bear down so that she can help her baby to come out. Your doctor or midwife may advise you to start to push as soon as your cervix is open. Or you may be encouraged to wait until your baby's head has had a chance to move further down the birth passage.

We don't know which method is better for preventing tears or cuts because there hasn't been enough research on this. We found only one good-quality study. In that study nearly half the women had a tear during delivery whether or not they waited before pushing.[8]

Most midwives now encourage women to wait until their body tells them to push.

Different ways of breathing as you push

In the past, midwives encouraged women to hold their breath and push long and hard to help their baby out. Nowadays, you'll probably be encouraged to breathe more naturally while you push.

But we don't know which way of breathing is best for avoiding birth tears or a cut. We found only two small studies.[9] Both studies found no difference between the two methods of breathing.

A cut (episiotomy) down the middle of your perineum

A doctor or midwife can make a cut in one of two ways:

• They can cut directly backwards towards your back passage, down the centre of the area between your vagina and your back passage (your perineum).
• They can cut off to the side of your back passage.

Some doctors think that a cut down the middle of your perineum hurts less, heals better, and interferes less with your sex life than a cut to the side of your back passage.

But the three studies that we found didn't support this claim.[10] The studies were not of good quality. But they suggested that a cut straight backwards is more likely to tear badly into the ring of muscle around your back passage than a cut off to the side.[10] [11] [12] The muscle around your back passage helps you to control your bowel movements. So tearing the muscle can mean you may have problems controlling wind or leaking loose bowel movements (liquid stool) afterwards.

Epidurals

Epidurals are injections of painkillers into the spine. They mean you won't feel any pain during labour. Epidurals are given by doctors called anaesthetists. A tube is put into your back (spine) so that more of the painkiller can be given if you need it.

Epidurals are great at relieving pain. But being numb in the second stage of labour can make it harder for you to push your baby out yourself. If you have an epidural you are more likely to need help with forceps or a vacuum pump (ventouse) to help your baby out than if you have other kinds of pain relief. Also both forceps and the vacuum pump increase your chances of having a cut or a tear. But a vacuum pump is less likely to cause serious damage to your perineum than forceps.[6]

We found one summary of the research (called a systematic review).[13] It showed that:

• 19 percent of women who had an epidural needed help to get the baby out with forceps or a vacuum pump.
• 14 percent of women who had other kinds of pain relief needed help to get the baby out with forceps or a vacuum pump.

You can have an epidural that wears off before you go into the second stage of labour. This might not affect your chances of needing forceps or a vacuum pump.[14]

Massaging the perineum

This treatment hasn't been studied to the same scientific standards that we use to judge other treatments on our site. (To learn more, see .) But we mention it here because you may be interested in this treatment. As you read this information, keep in mind that more research is needed to say whether this treatment works.

Massaging your perineum means putting one or two fingers inside your vagina and applying pressure downwards and sideways in a sweeping motion. This aims to make the muscles in this area stretch more easily during childbirth.

If you are having your first baby, massaging regularly in the last four weeks of your pregnancy can help you avoid an episiotomy and stitches. In one summary of three high-quality studies (called randomised controlled trials), women who massaged at least once a week were less likely to need an episiotomy than women who didn't massage.[15]

Massage doesn't seem to prevent tears, or improve your sex life after childbirth.

If you've given birth before, massage may not reduce your chances of an episiotomy. But it can help reduce the risk of after childbirth. In the studies, women who massaged in the last few weeks of pregnancy had less pain three months after childbirth than women who didn't.[15]

You can also massage your perineum using a massage device. But there's no research to show whether or not they work.

Anaesthetic spray

Some midwives have tried using a spray that contains a local anaesthetic. The aim is to help with pain and reduce the risk of a tear. Your midwife will spray your perineum just before you give birth.

One study looked at a spray that contained an anaesthetic called lidocaine.[16] It found that the spray didn't help women have less pain. We need more research before we can say whether this treatment can help prevent a tear.