A patient asked me this week: “How can I avoid stitches with my delivery?”

It is the wish of every woman who is planning a vaginal delivery to have no stitches.

There are many factors that relevant in determining the likelihood of this. These are considered in this article.

  1. Delivery technique. Keeping baby’s head well flexed with delivery and a controlled slow delivery of baby’s head with gradual slow stretching of the perineum can help minimise tearing. There should be guarding of the perineum and watching the perineum closely as baby’s head crowns and starts to deliver.

Reducing the risk: Being managed by an experienced highly skilled obstetrician as private patient. As a public patient you have no say as to who will deliver your baby.

  1. Experience of the accoucheur. With an experienced obstetrician or a senior midwife there is greater knowledge and skills to minimise the likelihood of tearing. This is indicated in hospital statistics. There are fewer 3rd and 4th degree tears in the two private hospitals where I work than is reported by public hospitals. In public hospital your delivery is more likely to be done by a junior midwife or a student midwife.

Reducing the risk: Being managed by an experienced highly skilled obstetrician as private patient. As a public patient you have no say as to who will deliver your baby.

  1. Warm moist washer. Applying a warm moist washer to your perineum in advanced second stage just before delivery may logically be of benefit. The warm moist washer will soften your tissues and hopefully give them more elasticity. It is worth a try. Studies suggest it helps. Some midwives are keen others are not. But this is something you can initiate yourself with the support of the midwife and/or your partner just before delivery.

Reducing the risk: Bring your own washers. There will be hot water tap in your delivery room.

  1. Epidural. An epidural reduces the risk of tearing. That is because there is more control of the delivery of baby’s head. Without an epidural a woman can have an incredible urge to push as baby’s head is crowning. Despite telling a woman not to push at that moment as slow, controlled stretching of the perineum is best, the delivering woman has an overwhelming desire to ‘bear down” and sometimes can’t help herself and pushes forcefully at the wrong moment. Without a slow controlled delivery of baby’s head there is increased risk of nasty tearing.

Reducing the risk: There is no need for you to have an epidural if coping with pain. But remember a slow controlled delivery of baby’s head is important to reduce the risk of tearing.

5. Perineal massage. This is recommended by some midwives and in social media. Sadly, there is no good medical evidence that it makes any difference. It won’t do any harm, but I suspect it will not do any good. I use the example – you want to work in the garden and so weeks before you rub your hands together repeatedly to try to prevent blisters when you do your garden work.

6. EPI-NO. This has been available for many years. But even so it lacks popularity. If it was as good as the manufacturer wants you to believe it would now be extremely popular, but this is not the case. Studies have mixed results. Those sponsored by the manufacturer of EPI-NO suggest it is of benefit. Others not sponsored by the manufacturer of EPI-NO suggest it is of no benefit. It certainly wont do harm. If you wish you purchase an EPI-NO and use it as recommended then I have no objections. But please let me know your personal experience.

7. Size of baby, especially of baby’s head. The bigger the baby the more stretching of the vaginal opening and so the greater the likelihood of tearing.

Reducing risk: To know, as accurately as possible, the size of your baby before delivery. An ultrasound scan estimate is more accurate than palpating your abdomen in estimating this. If the baby is large for dates, then you can do nothing and hope for the best, request early induction of labour to avoid baby getting too big, have elective Caesarean section. Considering your desire to have vaginal delivery and that ultrasound scan estimates are not accurate; I suggest early induction of labour as the most appropriate option. Some women are not keen on this option and so decide to wait and see. Sadly, some of these women in retrospect regret this decision.

  1. Elasticity (ability to stretch) of your tissues. This is something you don’t control, as it is something you were born with. It is often not known until delivery. If your tissues have less elasticity, they are more likely to tear significantly, even with a normal sized or small baby. This lack of elasticity predisposes you to both nasty vagina and perineal tearing.

Reducing the risk: Vaginal tearing is suggested by vaginal bleeding with descent of baby’s head with pushing in second stage labour. That there will be significant perineal tearing is suggested by superficial perineal tearing of the perineum as baby’s head starts to crown.

If it looks like you will have nasty tear then an episiotomy is a better option. Sometimes, and even despite an episiotomy, there can be nasty 2nd degree or even 3rd or 4th degree tearing of the perineum. Sadly, sometimes the perineum is intact as the baby’s head is delivering but on inspection after delivery tearing, even major tearing is seen. It is impossible to always prevent the tearing.

  1. Ethnicity is an important consideration. Medical articles, my personal experience, the experience of colleagues find that women of Asian ethnicity are more likely to have nasty tearing, both of the vagina and perineum. This would be related to lack elasticity of tissues. As well, Indian ethnicity women often have shorter perineums and so have an increased incidence of 3rd and 4th degree tears. While there is an increased incidence of nasty perineal tears, the majority of Asian women do well and don’t have major tearing problems.

Reducing the risk: Being very aware. Advising the patient before labour of the increased risk. Doing an episiotomy sooner rather than later if it is suspected significant tearing will happen.

  1. Perineal scar tissue. If you have significant scar tissue in your perineum from your previous delivery(ies) then there is increased likelihood of tearing this time. That is because scar tissue does not have the same elasticity as non-scarred tissue and so will not stretch as well.

Reducing the risk: Being aware of the increased risk. Great care with delivery and doing an episiotomy sooner rather than later if that there will be significant tearing is suspected.

  1. Previous 3rd and 4th degree perineal tear. There will be significant scar tissue in your perineum and so there increased likelihood of tearing this time. There is increased risk of further tearing of your anal sphincter muscle and if this happens of faecal incontinence, despite careful repair of the tearing.

Reducing the risk: A Caesarean section delivery is the safest option. Some women who have had only minor trauma to the anal sphincter are keen to have vaginal delivery. I have no objection to this request as long as they understand the risk and agree to an episiotomy. The episiotomy cut direction is medio-lateral and so well away from the anal sphincter.

  1. Operative vagina delivery. If a forceps delivery is planned then I suggest and episiotomy is cut. That is because forceps are applied to either side of baby’s head and so increase the stretch of the vaginal opening with delivery and so there a greater likelihood of a nasty tear. If a vacuum delivery there is no need for an episiotomy, unless it looks like there will be nasty tearing. That is because the vacuum cup is attached to the top of baby’s head and so does not increase the stretch of the vaginal opening.

Reducing the risk: Ask the obstetrician if you can have medio-lateral direction episiotomy if it is decided you will have a forceps delivery.

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