How to Prevent Tearing During Birth: Top 8 Tips to Keep Your Perineum Intact
You’re expecting a baby and probably getting the cute outfits lined up, the nursery ready, and dreaming of the sweet baby snuggles you’ll soon enjoy. But first, you have to navigate the birth itself, and like many women, you may be nervous about the possibility of tearing. The perineum and pelvic floor are important for our bladder, bowel, and sexual function and you may be even less familiar with this area of the body so the idea of an injury “down there” can be scary.
Perineal tears are actually relatively common, and about 3 out of 4 women who have a vaginal delivery will experience some degree of tearing. The majority of tears are mild and heal very well, so I want to start off by reassuring you that if you do tear, YOU DID NOT FAIL! There are also many things we can do to support your recovery if you do have a tear. However, if there are things we can do in pregnancy and during the birth itself that can minimize your tear risk overall including your risk of more severe injuries, why wouldn’t we do so?! Just like everything in birth, there are no guarantees, but coming into it with information and tools can go a long way in providing a positive experience and protecting your body too.
What is a perineal tear?
The perineum is the space between the vaginal canal and anal canal. Therefore, a perineal tear usually refers to a tear in this area but can also occur in other regions including the labia or clitoris. Tears are graded on a 1-4 scale based on the severity. 1st and 2nd degree tears are most common, with 3rd and 4th degree tears being more rare but more impactful. 3rd and 4th degree tears are also sometimes referred to as an OASI (Obstetric Anal Sphincter Injury). Here is a quick breakdown of the different tears:
Grade 1: Tear of the skin only, typically requiring no suturing
Grade 2: Tear of the skin and perineal muscle tissue, often requiring suturing (most common tear)
Grade 3: Tear through the perineal muscle tissue and into the anal sphincter, often requiring surgical intervention
Grade 3a: <50% of external anal sphincter
Grade 3b: >50% of external anal sphincter
Grade 3c: External and internal anal sphincter
Grade 4: Tear through the perineal muscle and anal sphincter into the rectal mucosa, requires surgical intervention
What are risk factors for tearing during birth?
A perineal can happen for a number of reasons, but there are risk factors that may increase your chances of having a tear. Some of these include:
Family history: There may be some genetic predisposition to tears, especially more significant tears such as a 3rd or 4th degree tear, also called an OASI
Fetal size: Larger babies may increase the chance of tears
Maternal age: For first time moms who are over 30 years old, and especially after age 35, the risk of a tear increases
Maternal ethnicity: Some ethnicities are more predisposed to tearing, with people of Asian descent having the highest chance of tearing
Tension in the pelvic floor: If the muscles can’t stretch, they are more likely to tear
Speed of delivery: If things go really fast or forceful, there may not be time for the perineum to stretch. On the flip side, if there is a prolonged labor or pushing stage, the area may get more inflamed and fragile
The use of Pitocin during labor or having an instrument-assisted delivery: The interventions used in birth can impact your chance of tearing
Fetal positioning: How baby is positioned will affect which part of their head presents first during delivery. If they are not in an ideal position, a larger part of their head may come through the birth canal first and lead to an increased risk of tearing
Pushing position and coordination: The position you push in and how well you push can both influence your tear risk
Of course, you can’t change some of these things, but that does NOT mean you can’t still be successful. Understanding your unique risk factors so that you can make truly informed decisions around your birth is an important first step. Then, no matter where you land, optimizing on the parts that you can make change will help you feel more empowered through a process that we can’t fully control.
So what can I actually do to minimize the risk of a perineal tear during birth?
Be mindful of how your positioning in pregnancy can influence your baby’s position
There is only so much space in the pelvis for baby’s head to pass through, and we want the smallest part of baby’s head to enter into the birth canal first. For this to happen, we want the back of the baby’s head (occiput) to face the front of mom’s body (anterior). While baby moves a lot during labor itself, what you do in pregnancy can also make a difference. The back of baby’s head is the heaviest part of their body, so it will often follow gravity. If you are constantly in a slumped or slouched position, there is more of a chance that the back of baby’s head will go toward the back of your body (occiput posterior) which is NOT what we want. Instead, think of maintaining neutral pelvic positions or even forward leaning positions to create a hammock with your belly forward for baby to settle into. To keep it even more simple, think of having a flashlight shining out of your belly button. For best positioning, keep the flashlight pointed out on the horizon or lower.
Emphasize movement including mobility during pregnancy
There are tons of benefits to staying active in pregnancy for both the pregnant person and baby. This includes (almost) anything you enjoy! Remember, just because you are pregnant does not make you fragile! However, no matter what you choose to do to stay active, don’t forget to also focus on your mobility. Stretches/movements that can lengthen areas like your hips, back, and pelvic floor can help you get into beneficial labor positions and also ensure that the areas that need to expand to let baby out are flexible enough to do so easily.
Take a comprehensive childbirth education class
Birth education is so powerful! And no, the hospital childbirth class that basically goes over logistics of getting there and reminding you of hospital policies does not count. Understanding the actual evidence on different types of birth providers and birth settings, various interventions that are available and pros/cons of each, how to stay comfortable during labor, how to work with the physiology of birth, and then how to advocate for your choices along the way can be a game changer! Getting the information and tools for success will not only make your birth experience more positive overall, you can also decide your preferences and advocate for choices about things that are helpful in minimizing your tear risk. If you are local to Eastern Washington, we teach the group Evidence Based Birth® Childbirth Class and can help you get set up with the information and tools you need!
Do perineal massage toward the end of your pregnancy
Perineal massage is an interesting one because often it is thrown around as the only proactive thing you can do to prevent tearing. However, the evidence on perineal massage is actually a little underwhelming. That doesn’t mean it isn’t worth doing though! Here are my thoughts: If it adds another thing to be stressed about, give yourself a break and don’t worry if you don’t get it done as often as you might like, or even at all. But, if you have the capacity to add this to your routine, great! There are very few downsides and it can potentially help mobilize the perineal tissues. Even more beneifical in my perspective though is the opportunity it provides to help you practice some of your comfort measures and mindfulness techniques to help you stay relaxed through the intensity of birth. If you are able to stay calm and not guard your muscles, that will certainly help baby pass through the birth canal and decrease your risk of interventions and tears.
Avoid a routine episiotomy
This should be pretty basic. If someone is cutting your perineum, that is already at least a Grade 2 injury to the perineum. Plus, it will set you up for tearing that extends past the cut in that same direction. There are some very specific instances where an episiotomy is necessary or helpful, but it should NOT be standard practice.
Pay attention to the position you choose to give birth in
There are many considerations for positioning during labor and birth that can be helpful, but when it comes to positioning to prevent perineal tearing, positions that don’t have the perineum on full stretch during crowning will help minimize tear risk when there is a large stretch applied to it from baby’s head. Some of my personal favorites that allow good mobility of the pelvic bones and don’t have the perineum on full stretch include a sidelying position or any variation of a hands and knees or kneeling position.
Get informed about how to push and when to back off from pushing too
Did you know that about 1 in 3 people actually contract their pelvic floor while they are trying to bear down and open their pelvic muscles? This can lead to a long and inefficient pushing phase which can lead to more flimsy and vulnerable tissues. Making sure you have good coordination of the pelvic floor is very important for a vaginal birth! Other considerations around the pushing stage include following “mother-led” pushing vs. directed pushing and backing off at the moment of crowning instead of powerfully pushing through it so that the perineum has more of a chance to lengthen and stretch instead of tear.
Go to pelvic floor physical therapy
I truly believe every person getting ready to give birth deserves to see a pelvic floor physical therapist. A skilled pelvic floor therapist can help you understand and implement all of the factors above plus help you assess and address any specific risk factors for tearing that you have. When you see a physical therapist, they will first talk with you about how your pregnancy has been going and work to understand your current knowledge and preferences regarding your upcoming birth. Then, they will do a thorough head to toe examination to find any areas that may need to be addressed (including helping you with those nagging issues in pregnancy!). You’ll work together to make a plan for how to reach your goals which often includes a combination of hands-on work in the clinic, education, exercise, and homework to keep you moving forward. You can stay in touch as needed to feel your best through pregnancy and prepare for a smooth birth process, and then they can follow up with you after birth to help address any concerns you have in the postpartum period too.
If you are local to Tri-Cities, WA, our team can help you with all of your pregnancy and birth prep needs.
We are conveniently located in Richland, WA and would love to guide you on this major life transition!
Give us a call or submit a contact form to get started on your journey today!