There can be a lot of confusion around the decision to suture tears after birth.  Midwives have been healing tears for centuries without suturing; however, modern evidence shows that practitioners also don’t always agree on tear assessment or suturing recommendations, often simply to avoid a valuable transport.  However, for long-term health of mothers, it is important that tears are assessed as best as possible and best practices for suturing recommended.  Then, mothers should make an informed decisions to accept or decline sutures, even if that means transporting to a hospital.

 

Nevertheless, knowing treatments is great, but preventing the need for treatment is just as crucial.  Prevention of tearing starts with nutrition.  Balanced nutrition with traditional whole real foods high in healthy fats and nutrient-dense plants support healthy tissue.  This includes cold-water fatty fish (like salmon), multiple times a week, organ meats, skin-on and bone-in meat roasts cooked in their own fat, and a rainbow of colors in veggies and fruit.  Vitamin A-, C-, and E-rich foods, which are usually yellow and orange, help to encourage cell growth, enabling the skin to grown and stretch, as well as prevent tears and heal.

 

Hydration allows these nutrients to flow through the body and reach the cells.  If you’ve seen how easy it is for your skin to crack in the dry wintertime, you’ll know how easy it is for tissue to tear when it isn’t hydrated.  Tissue stays hydrated with electrolytes and healthy fats which put a barrier around cells, holding hydration within the tissue.

Staying active, stretching, walking, and helping your baby to growing an aligned position so their birth is more straight-forward further prevents tears.  Avoiding induction, even with herbs, gives baby time to be well-positioned and your hormones time to make your pelvis more flexible.  Once labor has begun, using upright and mobile positions encourages baby’s aligned decent.  Don’t push just because you’re 10 cm dilated; wait until your body has the overwhelming urge to push so that you’re not pushing too hard or too long, preventing your tissue from becoming swollen.  Try to release your perineal muscles during pushing so you aren’t adding tension to the tissue.  Occasionally, a gentle warm cloth over the perineal tissue during pushing, without added pressure, may help prevent severe 3^rd and 4^th degree tears.

 

Degrees only describe tears on the perineum (the skin between the vulva and the rectum), not deep inside the vagina, the labia, or up near the bladder.  It is advised that all women be fully assessed for tears even if none are suspected to help avoid missing buttonhole tears that aren’t visible externally and may cause infections and life-long pelvic floor dysfunction.  Tears near the clitoris or bladder ,into bleeding vessels, or 3^rd and 4^th degree benefit from transport for repair.  All tears require rest and nourishment for adequate healing postpartum, so avoid sweets and choose nutrient-dense foods.  Damaged tissue is at its weakest around 10-14 days postpartum, so be sure to take care for 3-4 weeks, especially if you don’t have sutures.

TYPES OF TEARS IN CHILDBIRTH

• Superficial or skin-split - <0.5 cm
  Tears on the surface of the skin, similar to a rug burn or scrape.  They can burn and sting but are too shallow to suture.  Soaking with herbal sitz baths and sprays while urinating is soothing.  Healing is usually straightforward.
• 1^st Degree – between 0.5 and 1.25 cm
  Tears into the mucosa but not into muscle (like biting tissue in your mouth).  IF the tear lays together well, sutures are not needed.
• 2^nd Degree - >1.25 cm
  All 2^nd degree tears are into muscle and will involve some level of scarring and won’t be totally healed for up to 18 months.  IF the tear is less than a few cm long, is laying together well, and the mother has enough discipline and support to fully rest for 3-4 weeks after the birth, suturing may not be necessary.  If these three aspects cannot be met, sutures should be placed every 1 cm o the tear.  Multiple layers of sutures may be needed if the tear is 1.5 cm or deeper.
• 3^rd Degree – into the anal sphincter
  Any anal sphincter damage needs repaired.
• 4^th Degree – into the rectum
  Any tear into the rectum, from the perineum or vagina, needs repaired.

 

Assessment of 3^rd and 4^th degree tears includes visual assessment and internal vaginal and rectal manual assessment.  3^rd and 4^th degree tears should be repaired by a colorectal specialist, if possible, to allow optimal healing and long-term function.