Let’s Talk Perineal Tear Prevention!
Perineal tearing is a common concern for those planning a vaginal birth. Understanding what perineal tears are, their levels, and the techniques for prevention can empower birthing individuals to take steps to reduce their risk. While we can’t necessarily prevent lower levels of perineal tearing, research does state that we can prevent larger degrees of grade 3 and grade 4 tears, which is significant in itself! Understanding what can place us more at risk for higher level tears can help us put forth more preventative effort so that we can reduce our risk of pelvic floor dysfunction in our postpartum recovery time.
What Are Perineal Tears?
A perineal tear is a tear in the perineum, the area between the vaginal opening and the anus, which can occur during childbirth as the baby passes through the birth canal. Tears are classified into four grades based on their severity:
1. Grade 1: Minor tears affecting only the vaginal lining or skin of the perineum with no pelvic floor issues. These typically are not closed with stitches.
2. Grade 2: Tears that extend into the pelvic floor muscles but not the anal sphincter. These may require smaller amounts of stitches.
3. Grade 3: Tears that involve the anal sphincter. These will typically require increased stitches.
4. Grade 4: The most severe, involving the anal sphincter and rectal lining which will require significant effort for closure to prevent medical complications.
Grades 3 and 4 tears do place postpartum Moms at a higher risk of long-term pelvic floor dysfunction (bladder leakage, pelvic organ prolapse, fecal issues, and pelvic pain) making prevention strategies crucial.
Risk Factors for Perineal Tears
Certain circumstances increase the risk of more severe tearing during childbirth. These include:
• First vaginal birth: The perineum is less accustomed to the stretching required for birth.
• Baby’s weight: Delivering a baby over 4 kg (9 lbs) increases stress on the perineum and pelvic floor muscles
• Prolonged second stage of labor: Extended pushing can fatigue the pelvic floor and increase tearing risks.
• Shoulder dystocia: When the baby’s shoulder becomes stuck behind the pubic bone, the perineum may experience significant stress.
• Instrumental vaginal delivery: The use of forceps or vacuum assistance can increase the risk of severe tears.
What You Can Do During Pregnancy to Prevent Perineal Tears
There’s a lot we can do to prepare our perineum and pelvic floor muscles to for the amount of stretch that they are going to have to overcome to accommodate a baby to pass through them.
1. Perineal Stretches
Antenatal perineal massage has been shown to reduce the risk of high level perineal trauma (grade 3 and grade 4 tears.) Regularly stretching the perineum increases tissue elasticity, preparing it for childbirth as well as encouraging pelvic floor relaxation with high levels of stretch. Some research does show that antenatal perineal stretches has shown to reduce the risk of 2nd stage labor, and reducing the risk of perineal pain and anal incontinence in the postpartum period.
2. Improve Baby’s Positioning in the Birth Canal
Optimal fetal positioning can help reduce stress on the perineum during delivery. As baby is moving down and out of the pelvis, they have to be able to descend down the birth canal and then down and past the pelvic floor muscles, placing the most stretch and stress on the posterior pelvic floor muscles. Techniques include inversions, pelvic mobility work, and incorporating movement and stretching exercise to open up various portions of the pelvis, pelvic floor muscles, and improving uterus positioning.
3. Stretch the Posterior Pelvic Floor Muscles
Stretching these muscles helps prepare the perineum to lengthen and relax during birth. Effective stretches include:
• Child’s Pose with Hip Internal Rotation: Opens the hips and stretches the pelvic floor.
• Happy Baby Pose: Can be done side-lying or supine to improve mobility and reduce tension.
• Deep Squat Holds: Encourages pelvic opening and lengthening of the posterior pelvic floor.
What You Can Do During Labor to Prevent Perineal Tears
While pre-birth work is important and helpful, there is a lot we can do during birth to decrease our risks of tears with improving positioning of our pelvis with birth positions, prepping the perineum and pelvic floor muscles with heat, pushing strategies, and hands on work to place less stretch on the perineum.
1. Choose Optimal Birth Positions
Certain birth positions can reduce pressure on the perineum, improve pelvic outlet opening, allow for better pelvic floor elongation,and help with reducing rates of instrumental use. In a study completed in 2020 by Zhang et al.) it found that upright postures (walking, standing, leaning, semi-sitting, squatting, kneeling, and a birth chair) have been found to lower rate of instrumental delivery, have shorter active pushing phases, and a large decrease in the risk of severe perineal trauma.
In this same study, it was found that squatting and sitting on a birth seat, did however increase the risk of 2nd degree tears.
Other studies have found that upright birth positions have been found to lower rates of shoulder dystocia, lower rates of pain, and decrease rates of emergency cesarean.
Unfortunately upright birth postures aren’t always possible with an epidural, so another study completed in 2012 by Walker et al. Found that sidelying birth positions were less likely to need instrumental assistance and had less rate of episiotomy compared to those who gave birth on their back, so sidelying with pillow or partner support can be a great option if you aren’t able to move and shift as much with an episiotomy.
2. Use Warm Compresses
Applying a warm compress to the perineum during the pushing stage increases blood flow, softens tissues, and reduces the risk of tears. As we know with all other muscles, warmth helps improve tissue pliability and allows for better relaxation and elongation of muscles. If we use this with our pelvic floor muscles we can assume it will also help with improving these muscles ability to tolerate stretch. A study in 2021 my Modoor et al. Found that warm compress on the perineum did reduce grade 2-3 perineal tears and improve pain intensity.
3. Control Your Pushing
Good quality evidence on what type of pushing is best for reducing serious perineal laceration or episiotomy. Per the research that is done, it is really a mommas preference. From what we know, slow, controlled pushing allows the pelvic floor muscles to stretch gradually. Focus on steady downward pressure rather than hard, fast pushes can allow the pelvic floor muscles to gradually stretch, Finding a position that allows you to open and expand your pelvic floor muscles with pushing versus contracting and guarding your muscles is good guidance. Learning how to open and elongate your pelvic floor muscles with having a bowel movement on the toilet can be a great time to practice expanding through your pelvic floor muscles. Listening to your provider’s guidance during the pushing stage can also help as they can visualize your perineum while pushing. It’s important that your muscles are relaxed and open while birthing a baby and not contracted and shortened.
Preventing perineal tearing requires a multifaceted approach, including preparation during pregnancy and mindful techniques during labor. While some factors remain outside of our control, focusing on what we can influence—such as positioning, perineal massage, and controlled pushing—can significantly reduce the risk of larger tearing or other perineal trauma.
Preparing your body and mind for birth is equally important. Reducing fear and anxiety through education and practice can help prevent muscle guarding, enabling your pelvic floor to relax and open as needed during childbirth.
By taking these steps, you’re empowering yourself for a safer and more comfortable birthing experience.
References
• Abdelhakim, A.M., Eldesouky, E., Elmagd, I.A. et al. (2020). Antenatal perineal massage benefits in reducing perineal trauma and postpartum morbidities: a systematic review and meta-analysis of randomized controlled trials. International Urogynecology Journal, 31, 1735–1745. https://doi.org/10.1007/s00192-020-04302-8
• American College of Obstetricians and Gynecologists. (2018). Prevention and management of obstetric lacerations at vaginal delivery: ACOG Practice Bulletin No. 198. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2018/09/prevention-and-management-of-obstetric-lacerations-at-vaginal-delivery
• Arnold, M.J., et al. (2021). Obstetric lacerations: Prevention and repair. American Family Physician.https://www.clinicalkey.com
• Beckmann, M., Stock, O. (2013). Antenatal perineal massage for reducing perineal trauma. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD005123.pub3
• Evidence reviews for position for birth: Intrapartum care: Evidence review G. London: National Institute for Health and Care Excellence (NICE); 2023 Sep. (NICE Guideline, No. 235.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK596256/
• Modoor S, Fouly H, Rawas H. The effect of warm compresses on perineal tear and pain intensity during the second stage of labor: A randomized controlled trial. Belitung Nurs J. 2021 Jun 28;7(3):210-218. doi: 10.33546/bnj.1452. PMID: 37469347; PMCID: PMC10353617.
• Royal College of Obstetricians and Gynaecologists (no date). Reducing your risk of perineal tears. https://www.rcog.org.uk/for-the-public/perineal-tears-and-episiotomies
• Walker C, Rodríguez T, Herranz A, Espinosa JA, Sánchez E, Espuña-Pons M. Alternative model of birth to reduce the risk of assisted vaginal delivery and perineal trauma. Int Urogynecol J. 2012 Sep;23(9):1249-56. doi: 10.1007/s00192-012-1675-5. Epub 2012 Feb 2. PMID: 22297706.
