Hi! I'm a new doula and I am working with a mom who had a routine episiotomy with her first birth which then extended into a fourth degree tear. Seven months after her birth she had correctional surgery because the tear did not heal properly. She is pregnant again now, due in May, and was told by the surgeon who repaired the injury that she should plan a C-Sec the next time around. After talking with her new OB, who is supportive of natural and low/no-intervention birth, she has decided to plan a vaginal birth. Her doctor encouraged her to hire a doula and plan to labor and deliver in ways that support the perineum to help prevent another tear.

I have done extensive reading and attended a training course, but this will be my first birth. I'm aware of a few methods that will help prevent another tear--avoiding an episiotomy, water birth (not an option at this hospital), alternative birth positions, perineal support--but I could use some expert suggestions.

Thanks in advance for your help!

I have good news for your client. The key factor to avoiding another anal tear is to not have an episiotomy. To a lesser extent, giving birth spontaneously is also protective. I have two studies looking at anal sphincter injury rates at the next birth after having one at the first birth:

Martin S, Labrecque M, Marcoux S, et al. The association between perineal trauma and spontaneous perineal tears. J Fam Pract 2001;50(4):333-7.

Peleg D, Kennedy CM, Merrill D, et al. Risk of repetition of a severe perineal laceration. Obstet Gynecol 1999;93(6):1021-4.

Martin et al. found that only 1% of 1,900 women having no episiotomy at the second birth had a repeat anal tear. This was the case even though 18% of the group had a vacuum extraction and 2% had a forceps delivery. Peleg et al. found that 2% of 290 women giving birth by their own efforts and not having an episiotomy had a repeat anal injury. No women having instrumental deliveries and no episiotomy had an anal tear, but there were only 17 women in this group. Among women having an episiotomy and a spontaneous birth (n = 376) , the repeat anal tear rate rose to 11%, and it soared to 21% in women having both an episiotomy and an instrumental vaginal delivery (n = 56). A care provider who supports normal birth would surely refrain from episiotomy, but it wouldn't hurt to ask.

Other strategies to avoid a repeat anal injury based on the obstetric research would be:

• Avoid an epidural. Epidurals increase the need for instrumental vaginal delivery and episiotomy.
• Give birth in a position other than recumbent or semi-recumbent, in other words, upright, side-lying, or hands and knees. Women are more likely to have episiotomies and instrumental deliveries when they deliver on their backs.
• A recent study found that neither warm compresses nor perineal massage at the time of the birth reduced tears in women attended by expert midwives who performed an episiotomy less than 1% of the time, but easing the head out in between contractions did. If she likes the sensation, though, warm compresses may help your client relax the perineum.

Common sense says to keep the legs comfortably apart for the birth. If the perineum is already at full stretch because her legs are wide apart, the perineum will have nowhere to go. I can also tell you from experience that your client is likely to need extra reassurance at the time of the birth when she feels the burning sensation as the head comes through the vagina. Phrases such as "Let the baby come," "Ease the baby out," "Let go around the baby," or "Breathe the baby out," may prove helpful.

Anyone else have any suggestions?

-- Henci