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Perineal Tearing During Birth: What It Is and How to Avoid It

Tearing during birth can seem scary, but there’s a lot you can do to minimize your risk. Learn the #1 thing you can do to avoid tearing, plus 7 other tips to increase your chances of not tearing.

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When I gave birth to my first daughter, my perineum tore. I didn’t hurt in the moment and I healed up fine. But it still makes me a little nervous when I think about it.

And I’m not the only one who worries about tearing during birth.

It’s quite common for women to be afraid of perineal tearing during birth. (So don’t feel bad if you are!) And while it’s no surprise, given the statistics, it actually doesn’t need to be feared.

Let me tell you why.

The Statistics You Haven’t Heard About

First of all, let me say what you may have already heard. In the United States, about 80% of women tear giving birth vaginally. That’s a huge percentage.

But before you get worried, let me give you another number. 

If you’ve been with me for a while, you’ve probably heard about Ina May. She founded a community in Tennessee in the 70s and called it “The Farm.” She and her friends started attending each other’s births and have since become the most sought after midwives in the country.

I reference Ina May often because of the birth outcomes she and the other Farm midwives were able to achieve. 

Their birth statistics from 1970-2010 are published online. In that time they cared for 2,844 women. Not counting first degree tears (which I’ll explain later), 2,302 of those women didn’t tear. That’s nearly 81% that didn’t tear.

Obviously, there’s something a woman or her care provider can do to minimize the risk of tearing. And that’s why I wrote this blog post.

Understanding Perineal Tearing

Your perineum is the muscles and tissues between your vaginal opening and your anus. It is part of your pelvic floor. When giving birth, a woman’s perineum has to open and stretch to accommodate her baby’s head.

Let’s be clear: women’s bodies were designed to give birth, so women’s perineums must have been designed to be able to do so without severe damage. 

That said, a lot of factors contribute to how flexible that tissue is. And that means tearing does happen. There are different degrees of tearing, though.

First-degree tears are more like scrapes than tears. These tears are only skin-deep and can heal on their own.

Second-degree tears affect both the skin and muscles of the perineum. They require stitches but heal relatively quickly and usually without many long-term consequences. This is the kind of tear I experienced. Second degree tears are the most common.

Third-degree tears affect the skin and muscles of the perineum and extend into the anus. These require more extensive stitching and generally take longer to heal.

Fourth-degree tears affect the skin and muscles of the perineum, extend into the anus, and reach the rectum, the tunnel-like chamber between your intestines and your anus.

Third- and fourth-degree tears are rare, but they do increase your chances of long-term negative consequences. The main health concerns of these severe tears are incontinence (not being able to control when you pee, poop, or pass gas) and sexual discomfort or difficulty reaching orgasm.

Avoid Episiotomies!

Before we move on, we need to address episiotomies. An episiotomy is a cut a doctor makes in the vaginal opening before birth. Sadly, they are still really common, even though research has clearly shown they don’t help in the ways they were originally purported to.

Here’s the truth: it is almost always worse to get an episiotomy than to tear naturally. Episiotomies don’t heal as well and they usually cause more pain than natural tears postpartum. Beyond that, episiotomies are the #1 risk factor for severe (third- or fourth-degree) tears.

So if you’re worried about tearing, one of the best things you can do is do everything you can to avoid an episiotomy.

A Word on Perineal Massage

If you’ve asked around or searched online, you’ve probably heard the advice to do perineal massages during the last few weeks of pregnancy.

I heard it too. And I wanted to know what the research said.

Here’s what I found.

In a nutshell, perineal massage during pregnancy isn’t harmful but it also doesn’t provide that much benefit.

To go into a little more detail, researchers have found a few things consistently.

First, perineal massage only helps first-time moms. Mothers who have given birth before see no benefit from doing it.

Second, the benefit to first-time moms was only seen in studies that looked at birth settings with extremely high episiotomy rates.

In the US (as of 2023), average episiotomy rates in hospitals are about 5%. The studies that found benefits from perineal massage were in places that had episiotomy rates over 20%. That makes it hard to draw real comparisons or to generalize those findings.

But how are episiotomies connected to perineal massage?

Most likely, the connection is the mother. In other words, the kind of woman who does perineal massage is more likely to make other choices that protect her perineum.

The Best Thing You Can Do to Avoid Perineal Tearing

What the researchers and other professionals have concluded is that women who are motivated to maintain an “intact perineum” (the medical term for not tearing or getting an episiotomy) are probably more likely to refuse an episiotomy.

They are probably also more likely to carefully choose a care provider who has a low or non-existent episiotomy rate.

Some doctors and hospitals have low episiotomy rates. That’s great. But some still regularly perform episiotomies, sometimes without even asking the mother before doing so.

And remember, episiotomies are the leading cause of severe perineal tears. 

That is why getting to know your care provider and choosing them and your birth place carefully is the best thing you can do to avoid perineal tearing during birth.

So the time you could spend doing perineal massage is probably better spent choosing a great care provider and making sure you’re on the same page about birth.

Other Tips for Preventing Tearing During Birth

Now that we know how important choosing the right care provider is for your perineum, we can talk about some other things that will decrease your chance of tearing even more.

Like I said, I tore during my first birth even though I was at home with a midwife. I definitely could have been more conscious about some of these things.

So let’s dive in.

Stay Hydrated and Eat Well

Pregnancy isn’t just about your baby. It’s about you, too. Your body supports your baby and it’s certainly involved in labor.

And the tissues and muscles of your body are only going to be as healthy as your diet is.

Staying hydrated is super important during pregnancy to keep your blood volume up and your body temperature down. But it’s also important in ensuring your skin and other tissues are soft and flexible.

In addition to drinking plenty of water, make sure to eat a nutrient-dense diet. 

I recommend The Brewer Diet, as do many midwives. If you follow The Brewer Diet, you should be getting plenty of protein, salt, and vitamins daily.

A few specific nutrients can help your perineum be ready to expand during birth: vitamins A, C, and E and collagen.

Vitamins A and E have many functions and one of those functions is to keep your skin healthy. Vitamin C helps your body produce collagen, among other things. And collagen helps your body’s tissues remain strong and resilient.

Making sure you’re getting enough of each of these nutrients, along with a well-balanced healthy diet (especially in the last trimester of pregnancy) may help prevent tearing during birth.

Exercise

Another way to get your body, and specifically your perineum, ready for labor is to exercise. No surprises there.

Exercise helps your perineum be ready for birth in three ways. Exercise can…

  1. Stretch and relax your pelvic floor,
  2. Strengthen your pelvic floor and legs to protect your perineum, and
  3. Help your baby get and stay in a good position for birth.

We’ll talk about the importance of each of those things later in this blog post.

For specific exercises and stretches that tone your perineum and pelvic floor, check out 9 Exercises to Prevent Tearing During Birth.

Encourage Optimal Fetal Positioning

One thing that can increase your risk of tearing during birth is an un-ideal position of your baby. Ideally, your baby has their head down and their nose pointing toward your spine. That would minimize tearing.

If your baby is turned and has their nose pointing toward your abdomen, a wider portion of their head comes through your vagina first, which obviously puts more pressure on those tissues.

To encourage your baby to get and stay in that ideal position, do the exercises in 6 Exercises to Prepare Your Body for Labor. You can also regularly do the forward-leaning inversion from Spinning Babies to give your baby more room to get into position.

In addition to exercises, paying attention to how you sit every day can make a big difference.

To understand why the way you sit matters, think of your uterus as a hammock.

If you spend a lot of time reclining, the hammock of your uterus will be essentially sitting on your spine. That will encourage your baby to get comfortable there, with their noise pointing to your abdomen (not ideal).

If you intentionally sit upright most of the time, along with doing your labor prep exercises, your uterus will form a hammock in the front much more often. And that will encourage your baby to settle in with their nose toward your spine. 

Relax Everything

Relaxation is vital for birth no matter what your desired outcomes are. But if you want to avoid tearing during birth, it’s even more important. Learning to relax your pelvic floor is something you can do during pregnancy (with the exercises mentioned above).

But it’s not just your pelvic floor you need to relax. Your whole body is connected, so if your shoulders are tense or your jaw is clenched, your perineum probably will be too.

During pregnancy, practice relaxing your entire body. Learn to recognize when you’re holding tension in your body and consciously learn to let it go.

Use Warmth and Water

Two things you can do during labor to help prevent tearing are to utilize warmth and water. Some midwives prepare warm compresses for birthing mothers. Pressing warm towels or washcloths on the perineum can help the tissues to relax and expand more easily around the baby’s head.

Warm water in the form of birth pools, baths, or showers can also help. This is one reason some women like water births. 

Control Pushing and Crowning 

The pushing stage of labor, especially crowning, can be really intense. But if you can stay calm and control your pushing, you have a better chance of avoiding tears.

First, only push when you have an urge to push. Directed or coached pushing can have negative consequences, including unnecessary pressure on your perineum and pelvic floor. Instead, try to follow your body’s cues and push only when you feel you should.

Second, try to crown slowly. Crowning is the moment when your baby’s head reaches your vaginal opening. It’s the moment of the biggest stretch.

Crowning can be painful. But if you relax and let your baby slide through slowly, rather than trying to quickly push them through, your perineum will have more time to expand and you’ll be less likely to tear.

Choose a Good Birth Position

Your position for the moment of birth may also contribute to either minimizing or increasing your chances of tearing. While research is somewhat conflicting, one study found that for both first-time moms and women who have given birth before, the best positions, in terms of not tearing, are standing and side-lying (beating out squatting and hands-and-knees, among others). 

This may be for several reasons.

One likely reason is that when upright or on her side, a woman has more control over how fast her baby descends. Another may be that these positions don’t inherently stretch the perineal tissues, like squatting or having your legs pulled toward your hips might.

Many women have also found that putting their knees closer together than their ankles helps their baby come out and come out slowly. 

Tearing During Birth: Not Something to Be Afraid Of

Now you know all about perineal tearing during birth. Now you know that it’s not inevitable and that you have a lot of power to minimize your risk of tearing. 

To summarize, choose a care provider with a low rate of episiotomies and prepare your body for labor by eating well, exercising, and encouraging optimal fetal positioning. During labor, relax, use warmth and water, slow your pushing, and choose a good birth position. 

That’s a lot of things you can do to decrease your risk of tearing during birth. So don’t believe anyone who says it’s unavoidable. 

Like all things, be intentional. And don’t let fear win the day. You have the knowledge now and knowledge really is power. 

Until next time,

Allison

READ MORE:

The Cascade of Interventions [Explained]

Is Childbirth Painful? (The Answer Might Surprise You)

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