6 Practical Ways to Decrease your Risk of Tearing in Childbirth
One of the most common questions I get asked is “How can I decrease my risk of tearing during delivery?” Whether it’s a friend whose just found out she’s pregnant, a veteran whose been there before, or a stranger turned friend on the internet, this question is at the top of a lot of women’s minds. And it’s understandable, seeing as it can impact the immediate postpartum healing experience and also have longer term effects on pelvic floor function and sexual health.
Statistically speaking, most of us will experience some degree of tearing during childbirth ( 80%-90%) with rates being highest for first time moms. There is however actions that are both provider and patient influenced that can help to decrease the chance and the severity of tearing. As you approach the later weeks of pregnancy, it’s a great idea to talk with your provider about your own preferences when it comes to birth and decreasing your risk of tearing. Included throughout this post are prompts that can help facilitate that conversation if you choose to have it.
Types of Tearing
Don’t worry, we aren’t going full anatomy class, but I do think it’s important to know the different types of tears that can happen during birth to better understand why these tips are effective. There are 4 different degrees of perineal tears. The perineum refers to the skin and muscles in between the vaginal opening and the anus. The following tips will target decreasing the chance and severity (mainly 3rd and 4th degree) tears in this region. Although the perineum is most commonly affected, you can have tears in other areas of the vulva including the labia and inside the vaginal canal.
Below are the 4 different types of perineal tears1st degree: a tear that only affects the skin layer of the perineum
2nd degree: a tear that affects both the skin and muscles of the perineum
3rd degree: a tear that extends through the skin, muscles, and into (but not through) the anal sphincter
4th degree: a tear that extends through the entirety of the perineum including the skin, muscles, and anal sphincter
So, now that we have those visuals in mind, let’s chat about ways you can avoid tearing when it comes to your own birth. Perineal Massage
Perineal massage can be used in the weeks leading up to labor and during the pushing phase of labor —so we’ll touch on both!
Starting in the last month of pregnancy, perineal massage can be done by you or your partner to help stretch the perineal tissue. If your belly poses to be a barrier, you can use a wand or perineal massager like this one. If this massage makes you feel uncomfortable or you have no desire to perform it in the first place, then pass on this tip!
The how to:If this is something you want to perform, speak with your provider to ensure you have no medical reasons not to and if not, starting around 36 weeks, begin perineal massages on an every other night basis working your way up for both pressure applied and length of massage. To perform this type of massage, take your thumb or your partners finger and insert into the vaginal canal about 2cm or to the first knuckle. Gently apply pressure downwards and then massage from one side of the perineum to the other creating a “U” shape at the vaginal opening. Use of a non-scented oil can make for a more comfortable experience.
Your provider can also provide this same massage during the pushing phase of your labor to help stretch the tissue just prior to the birth of your baby. Factors including the presence or absence of an epidural, your providers experience with perineal massage and your comfort level with this technique all factor into whether this tip may be right for you. Having a conversation with your provider in the weeks before birth can help inform your decision and allow all members of your birth team to know your specific desires.
Q for your provider: Is there any medical reason I shouldn’t perform perineal massage in the weeks leading up to my labor? Are you familiar with perineal massage during pushing and is that a practice you routinely offer?
Warm Compress
Placing a warm compress (towel or wash cloth) on the perineum during the second stage can help to increase blood flow to the area and allow for more flexibility of the tissue. Your provider can easily do this during your pushing phase of labor. However, if this is something you’re not comfortable with, you can do it yourself or opt to submerge yourself in warm water pending your birth facility has that option.
Q for your provider: Are warm compresses available for pushing and do you routinely offer to support the perineum with one?
Pushing Position
Certain pushing positions are better than others when it comes to risk of perineal tearing. Side lying positions, hands and knees, or upright positions can all help to decrease this risk. A squatting position however actually increases the risk of second degree tears (and blood loss) and is thought to be influenced by the fact that there is nothing counteracting gravity to allow for sloooow birth of the baby’s head. Which brings us to our next point.
Q for your provider: I would like to push in different positions including side lying and hands and knees. Is this something you support?
Breathing Technique during Pushing
There are typically two different types of breathing when it comes to pushing. Closed glottis refers to— honestly not breathing — but the act of taking a big deep breath in, holding it and pushing down into the contraction for a specified length of time (typically 10 seconds) and repeating that 3 times through each contraction. Open glottis pushing refers to pushing that allows for the throat to stay open and air to pass through the mouth often creating a low humming or vowel sound while pushing into a contraction. This type of pushing is often self guided and the mother will find herself doing shorter but more frequent spurts of pushing throughout a contraction.
Open glottis pushing has been associated with less perineal trauma and long term pelvic floor dysfunction when used throughout the pushing phase of labor. More specifically, this type of pushing right at the end of delivery can be super helpful in allowing the muscles to stretch slowly and decreasing the risk of tears altogether. I like to think of it like blowing out multiple candles one by one on the biggest cake you’ve ever seen! These little “puffs” can help the perineum to stretch little by little while also allowing for time in between “puff pushes” to readjust to the new stretched length before birthing past the largest diameter of your babe’s head.
Q for your provider: Do you typically recommend a breathing technique with pushing?
Timing of Birth
Specific timing of the birth of your baby in relation to when you have a contraction can also be helpful in decreasing perineal trauma. Birthing your baby’s head in between your contractions rather than with your contraction can actually work in the same way as open glottis pushing in that it allows slow crowing with maternal interval pushes rather than a long sustained contraction force. This option of course depends on your personal clinical scenario, if you are laboring unmedicated or with an epidural and whether your baby allows for this.
Q for your provider: Allowing for slow birth of my baby’s head is important to me to prevent tearing. As long as it’s medically safe, are you comfortable with a two step delivery?
Avoiding Episiotomy
This tip seems obvious but you can’t assume you know the habits of your provider unless you have this conversation prior to birth. The old school practice of cutting an episiotomy is not evidence based, doesn’t support healing when compared to natural tearing, and lastly doesn’t hold space for the opportunity to not tear at all! There are very rare circumstances that can require expedited delivery and need for an episiotomy but in general, this practice is outdated and not necessary. Having a conversation with your provider in the weeks leading up to labor can help gauge their attitude towards this practice and ensure your requests are made known.
Q for your provider: What is your stance on the use of episiotomies? Do you routinely perform those?
The ugly truth:
Despite all the research we have to support these practices and all the planning we do in effort to decrease our risk of tearing, it can unfortunately still happen even with all of our best efforts on both patient and provider accounts. Factors that increase the risk of tearing include primiparity (first time moms), large for gestational age (bigger babies), certain ethnicities (collagen composition), and instrumental deliveries (forceps and vacuum assisted).
Although we can’t always predict our birth outcomes, we can choose to prepare in ways we feel most comfortable and confident. If these practices align with your goals, I would encourage you to have a conversation with your provider about your preferences and desires when it comes to birth and your risk for perineal tearing.
Stay well momma, you’re worthy! xo,
Skyler Jacobs, CNM
Sources:Aquino CI, Guida M, Saccone G, Cruz Y, Vitagliano A, Zullo F, Berghella V. Perineal massage during labor: a systematic review and meta-analysis of randomized controlled trials. J Matern Fetal Neonatal Med. 2020 Mar;33(6):1051-1063. doi: 10.1080/14767058.2018.1512574. Epub 2018 Sep 19. PMID: 30107756.
Neta JN, Amorim MM, Guendler J, Delgado A, Lemos A, Katz L. Vocalization during the second stage of labor to prevent perineal trauma: A randomized controlled trial. Eur J Obstet Gynecol Reprod Biol. 2022 Aug;275:46-53. doi: 10.1016/j.ejogrb.2022.06.007. Epub 2022 Jun 15. PMID: 35728488.
Tunestveit JW, Baghestan E, Natvig GK, Eide GE, Nilsen ABV. Factors associated with obstetric anal sphincter injuries in midwife-led birth: A cross sectional study. Midwifery. 2018 Jul;62:264-272. doi: 10.1016/j.midw.2018.04.012. Epub 2018 Apr 21. PMID: 29734121.
Ugwu EO, Iferikigwe ES, Obi SN, Eleje GU, Ozumba BC. Effectiveness of antenatal perineal massage in reducing perineal trauma and post-partum morbidities: A randomized controlled trial. J Obstet Gynaecol Res. 2018 Jul;44(7):1252-1258. doi: 10.1111/jog.13640. Epub 2018 Apr 2. PMID: 29607580.
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 Apr;60(2):175-182. doi: 10.1111/ajo.13127. Epub 2020 Feb 17. PMID: 32065386.