5 ways to prevent perineal tears during birth

I remember the screaming the most. It was the first time I had peed since giving birth to my firstborn son four years ago, and the urine soaked the stitches from my second-degree perineal tear. This caused one of the most intense burning sensations I’ve ever experienced—which my mother-in-law could hear me screaming about in the hallway outside my hospital room door.

Because I had an epidural, I didn’t feel the tearing during delivery or the postpartum stitches my OB-GYN gave me right after. But I definitely noticed the stitches as they burned every time I went to the bathroom until they came out a few weeks later.

The uncomfortable stitches also made postpartum bowel movements pretty unbearable, although I did take warm baths as often as I could to relieve the pain. This was one of the most unpleasant parts of childbirth for me. Luckily, current research has lots to offer in terms of tips and techniques to help lower your risk of severe perineal tearing during birth.

What is a perineal tear?

The perineum is “the diamond-shaped inferior outlet of the pelvis” in a woman’s body, which is at risk of trauma and tearing during labor occurring mostly along the posterior vaginal wall toward the anus, according to a 2018 study.

In 2015, researchers found more than 85% of women having a vaginal birth will suffer some form of perineal trauma, with spontaneous tears requiring stitches occurring in at least one-third of women in the U.K. and U.S. So, if you’ve experienced tearing during childbirth, know that you are not alone.

Degrees of perineal tears

There are four degrees of perineal tears:

First degree tear: Superficial injury to the vaginal mucosa that may involve the perineal skin.
Second degree tear: First-degree laceration involving the vaginal mucosa and perineal body.
Third degree tear: Second-degree laceration with the involvement of the anal sphincter.
Fourth degree tear: Third-degree laceration involving the rectal mucosa.

As you can imagine, third- and fourth-degree perineal tears are associated with “significant pain, discomfort and impact on quality of life and intimate relationships” according to a 2020 study.

What is an episiotomy?

An episiotomy is a surgical cut of the vagina and perineum, designed to prevent serious tears during childbirth. However, performing a routine episiotomy (in which a physician gives you one as a matter of course) guarantees the mother will have perineal trauma and sutures after delivery.

Should I get an episiotomy?

There are some benefits to an episiotomy. A 2005 study found women who have never given birth are more likely to experience tearing, but a mediolateral episiotomy may help lower the risk for anal muscle tears.

However, a 2004 study revealed that avoiding episiotomy increased the rate of intact perineum and only having minor perineal trauma, while lowering postpartum perineal pain. A 2017 study found that being more selective with episiotomies (as opposed to performing routine episiotomies) resulted in fewer women with severe perineal and vaginal trauma. These add to the growing evidence that routine episiotomies should be avoided.

Choosing whether or not to have an episiotomy should be discussed with your OB-GYN before delivery, as an episiotomy may not be necessary in most low-risk labor and deliveries.

How to prevent perineal tears

Some of the risk factors for perineal tearing are outside your control. A 2019 study showed that a high incidence of perineal trauma was linked to maternal age, the number of babies born (parity), the induction of labor, gestational age, fundal pressure, and nationality.

A 2020 study found common risk factors for third- and fourth-degree perineal tears included carrying infants who were large for their gestational age and having interventions used during labor and birth including instrumental deliveries. Another 2020 study found instrumental delivery, midline episiotomy and a persistent occiput posterior position during childbirth were associated with more severe perineal tears. Avoiding these things as much as possible could help prevent tears.

A 2021 webinar by Evidence Based Birth lists the following risk factors for severe tears:

Care provider
Giving birth for the first time
Higher birth weight of baby
Forceps or vacuum use
Episiotomy
Shoulder dystocia
Prolonged or very short pushing phase
Occiput posterior fetal position
Family history

There are a few specific techniques pregnant women can utilize to prevent perineal tears.

Lateral or upright birthing positions

When giving birth in the hospital, I was directed to lie flat on my back with my feet in the stirrups. However, some studies have found that different birthing positions may lower your perineal trauma.

A 2012 study found that giving birth in the lateral position (lying on your side) resulted in less perineal trauma compared to childbirth in the lithotomy position (on your back with feet in stirrups). This position also resulted in fewer episiotomies. Giving birth in the upright position (standing or squatting, kneeling upright or on hands-and-knees, and using a birth seat) was also shown to reduce episiotomy rates.

Warm compress

Some evidence shows that applying a warm compress to the perineum area during labor may reduce third- and fourth-degree tears. Also, women who used warm packs on the perineum during labor had significantly fewer third- and fourth-degree tears, less pain during and after birth, and were less likely to have urinary incontinence, according to a 2007 study.

Perineal massage

Perineal massage during labor may reduce third- and fourth-degree tears during childbirth, according to a 2017 study. A review study of perineal massage during labor—with most women having their midwives perform perineal massages in the second stage of labor (during or between pushing time) with the index and middle fingers using a water-soluble lubricant—found a significantly lower incidence of severe perineal trauma. Adding perineal massage to your birth plan is definitely worth considering.

Water births

Opt for a water birth to help lower your risk of perineal tearing! One study found that hospital-based deliveries with second-stage water immersion had a lower risk of perineal lacerations.

Hands-off technique

The hands-on technique for childbirth is used to control the fetal head during delivery, while the hands-off approach involves not touching the perineum during the crowning process. The hands-off technique has been shown to maintain intact perineum and reduce perineal pain and episiotomy use while not increasing the risk of severe perineal trauma, postpartum hemorrhage, or longer duration of second-stage labor compared to hands-on technique, according to a 2020 study.

Summary: Preventing Perineal Tearing During Birth

To minimize the risk of perineal tears during childbirth, a range of proactive measures can be considered. Here are some evidence-based strategies that may help:

How to Prevent Tearing During Birth:

Perineal Massage: Starting perineal massage during the later stages of pregnancy can increase the elasticity of the perineum, potentially reducing the risk of tearing.
Lateral Birthing Positions: Lying on your side or adopting upright positions during labor may result in less perineal trauma compared to lying on your back with feet in stirrups.
Warm Compress: Applying a warm compress to the perineum during labor can reduce the incidence of severe tearing and provide pain relief.
Controlled Pushing: Working with your healthcare provider to push in a controlled manner, especially when the baby is crowning, can help to minimize tearing.
Water Birth: Water immersion during the second stage of labor has been associated with a lower risk of perineal lacerations.
Hands-off Technique: Allowing the perineum to stretch naturally without manual support (hands-off) may reduce the incidence of tears compared to the hands-on approach.

How to Avoid Tearing During Birth:

Avoiding Instrumental Delivery: If possible, avoiding the use of forceps or vacuum during delivery may reduce the risk of severe perineal trauma.
Opting Out of Routine Episiotomy: Evidence suggests that routine episiotomies should not be performed, as selective episiotomy is associated with better outcomes.
Proper Positioning and Breathing Techniques: Proper positioning and breathing techniques during labor can aid in gradual stretching of the perineum.

How to Prevent Perineal Tear:

Maintaining Good Health: Good nutrition and prenatal care can ensure you and your baby are at a healthy weight, reducing the risk of tears associated with macrosomia (a larger-than-average baby).
Pelvic Floor Exercises: Strengthening the pelvic floor muscles through exercises like Kegels may improve tissue elasticity and recovery.
Education and Preparation: Being well-informed about your options during labor and delivery can empower you to make decisions that might reduce the risk of perineal tear.

A note from Motherly

Although no amount of perineal tearing or stitches feels good, lowering your risk for severe tears can make a huge difference in your labor and recovery experience. Talk to your OB-GYN or midwife about any of these techniques to see if they are an option for your birth plan.

FAQ: Preventing Perineal Tears During Childbirth

What exactly is a perineal tear?

A perineal tear is a laceration of the skin, muscle, and other soft tissues in the perineal area, which lies between the vagina and the anus. These tears can occur spontaneously during childbirth as the baby passes through the birth canal.

How can I prevent tearing during birth?

To prevent tearing, you can try perineal massage in the weeks before delivery, adopt lateral or upright birthing positions, apply a warm compress during labor, perform controlled pushing, opt for a water birth, and use a hands-off technique as the baby crowns.

Are there specific birthing positions that can help avoid tearing?

Yes, lateral positions (lying on your side) and various upright positions (such as squatting, kneeling, or hands-and-knees) have been associated with reduced rates of perineal trauma compared to the lithotomy position (lying on your back with feet in stirrups).

What is an episiotomy, and can it prevent tearing?

An episiotomy is a surgical incision made in the perineum to enlarge the vaginal opening. While it was once thought to prevent more severe tearing, evidence now suggests that routine episiotomies are not beneficial and that they should be performed selectively, if at all.

Can perineal massage really prevent a tear during childbirth?

Perineal massage during pregnancy, particularly from the 34th week onwards, can increase the area’s elasticity and reduce the likelihood of tearing. It is recommended to do this regularly as part of your birth preparation.

Is a water birth safer for my perineum?

Water birth can provide a more gentle birth process, potentially reducing the risk of severe perineal tearing. The water can support the perineum, allowing for a more gradual stretching as the baby is born.

What should I discuss with my healthcare provider regarding perineal tearing?

You should discuss the risk factors for perineal tears, preventative measures, the pros and cons of episiotomy, pain relief options during stitching if a tear occurs, and techniques to optimize your chances of avoiding a tear.

What are the degrees of perineal tears and their implications?

There are four degrees of perineal tears, ranging from first degree (minor skin and tissue tears) to fourth degree (extensive tears affecting the anal sphincter and rectal mucosa). Third- and fourth-degree tears can have significant implications for pain, recovery, and quality of life.

How does a warm compress work in preventing perineal tears?

Applying a warm compress to the perineum during labor increases blood flow to the area, which can help the tissues stretch more easily and may reduce the severity of perineal tears.

How soon can I start perineal massage, and how is it done?

Perineal massage can typically start at 34 weeks of pregnancy. It involves gently stretching the perineal tissue with lubricated fingers and can be done by yourself or with a partner’s help. It’s best to consult a healthcare provider for proper technique and frequency.

Sources

Aasheim V, Nilsen ABV, Reinar LM, Lukasse M. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev. 2017;6(6):CD006672. Published 2017 Jun 13. doi:10.1002/14651858.CD006672.pub3

Abedzadeh-Kalahroudi M, Talebian A, Sadat Z, Mesdaghinia E. Perineal trauma: incidence and its risk factors. J Obstet Gynaecol. 2019;39(2):206-211. doi:10.1080/01443615.2018.1476473

Aquino CI, Guida M, Saccone G, et al. Perineal massage during labor: a systematic review and meta-analysis of randomized controlled trials. J Matern Fetal Neonatal Med. 2020;33(6):1051-1063. doi:10.1080/14767058.2018.1512574

Dahlen HG, Homer CS, Cooke M, Upton AM, Nunn R, Brodrick B. Perineal outcomes and maternal comfort related to the application of perineal warm packs in the second stage of labor: a randomized controlled trial. Birth. 2007;34(4):282-290. doi:10.1111/j.1523-536X.2007.00186.x

Dannecker C, Hillemanns P, Strauss A, Hasbargen U, Hepp H, Anthuber C. Episiotomy and perineal tears presumed to be imminent: randomized controlled trial. Acta Obstetricia et Gynecologica Scandinavica. 2004;83: 364-368. doi:10.1111/j.0001-6349.2004.00366.x

Dekker R. Evidence-Based Birth. The evidence on the top 5 ways to prevent tearing during childbirth. 2021 webinar.

Foroughipour A, Firuzeh F, Ghahiri A, Norbakhsh V, Heidari T. The effect of perineal control with hands-on and hand-poised methods on perineal trauma and delivery outcome. J Res Med Sci. 2011 Aug;16(8):1040-6.

Frohlich J, Kettle C. Perineal care. BMJ Clin Evid. 2015 Mar 10;2015:1401.

Goh R, Goh D, Ellepola H. Perineal tears – A review. Aust J Gen Pract. 2018;47(1-2):35-38. doi:10.31128/AFP-09-17-4333

Gupta JK, Sood A, Hofmeyr GJ, Vogel JP. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database Syst Rev. 2017;5(5):CD002006. Published 2017 May 25. doi:10.1002/14651858.CD002006.pub4

Huang J, Lu H, Zang Y, Ren L, Li C, Wang J. The effects of hands on and hands off/poised techniques on maternal outcomes: A systematic review and meta-analysis. Midwifery. 2020;87:102712. doi:10.1016/j.midw.2020.102712

Jiang H, Qian X, Carroli G, Garner P. Selective versus routine use of episiotomy for vaginal birth. Cochrane Database Syst Rev. 2017;2(2):CD000081. Published 2017 Feb 8. doi:10.1002/14651858.CD000081.pub3

Meyvis I, Van Rompaey B, Goormans K, et al. Maternal position and other variables: effects on perineal outcomes in 557 births. Birth. 2012;39(2):115-120. doi:10.1111/j.1523-536X.2012.00529.x

Pergialiotis V, Bellos I, Fanaki M, Vrachnis N, Doumouchtsis SK. Risk factors for severe perineal trauma during childbirth: An updated meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2020;247:94-100. doi:10.1016/j.ejogrb.2020.02.025

Poen AC, Felt-Bersma RJF, Dekker GA, Devillé W, Cuesta MA, Meuwissen SGM. Third degree obstetric perineal tears: risk factors and the preventive role of mediolateral episiotomy. BJOG: An International Journal of Obstetrics & Gynaecology. 1997;104: 563-566. https://doi.org/10.1111/j.1471-0528.1997.tb11533.x

Ramar CN, Grimes WR. Perineal Lacerations. StatPearls Publishing. 2021.

Sidebottom AC, Vacquier M, Simon K, et al. Maternal and Neonatal Outcomes in Hospital-Based Deliveries With Water Immersion. Obstet Gynecol. 2020;136(4):707-715. doi:10.1097/AOG.0000000000003956

Wilson AN, Homer CSE. Third- and fourth-degree tears: A review of the current evidence for prevention and management. Aust N Z J Obstet Gynaecol. 2020;60(2):175-182. doi:10.1111/ajo.13127