Perineal Tear Prevention
Perineal tearing is one of those things we all hear horror stories about, right? But instead of stressing about if it will or won’t happen to you, let’s focus instead on what we CAN control. This blog post is going to do exactly that. If you’re looking for specific things to focus on and ways to help prevent the risk of perineal tearing during childbirth, this blog post is for you. This blog is going to be research-backed and explain what the evidence suggests as far as effectiveness for various tips and techniques to help reduce your risk for perineal tearing.
What is perineal tearing?
If this is a term you haven’t heard before, let me explain. Your perineum is the tissue between your vaginal opening and your anal opening. Oftentimes, during birth, more frequently during the first experience with birth, the perineum may tear. Perineal tears can happen at different levels or “grades” ranging from minimal to more severe.
There are many factors that go into perineal tearing and your particular risk, but there are ways that we can potentially prevent tearing, or at least prevent SEVERE tearing during birth.
What can be done to prevent perineal tearing?
Great question! Let’s start first with what you can do during pregnancy to potentially prevent perineal tearing…which is, perineal massage.
I say “potentially”, because the research is somewhat controversial on this topic. Does perineal massage or stretching of the perineal tissues during pregnancy really help to reduce the risk of tearing? Here’s my opinion:
I think there are other methods to focus on during pregnancy that can offer more benefit, however, I do think there are some benefits to perineal massaging, such as feeling the stretching sensation and the neurological feedback you will get from massaging and stretching the tissues. If anything, it will help you to practice breathing through the stretching, which will translate during birth! And in reference to the research out there, it does show SOME decreased risk of episiotomies and severe tears in first time mom’s, so if you are in a high episiotomy center, it could be of more benefit to you. Unfortunately, evidence does not show as much support for this in those who have already vaginally birthed children before. And lastly, I will say that the positions we deliver in and how we breathe during our pushing seems to have MORE benefit to an intact perineum.
How + When to Perform Perineal Massage
If perineal massage is something you’re going to do during pregnancy, studies do show that starting around 34-36 weeks is beneficial in preventing severe perineal tears - again, mostly in women giving birth for the first time - and also again, still somewhat controversial on the quality of these studies and the general conclusions drawn.
So, if you are around 34-36 weeks pregnant and are looking to start perineal massage in hopes of preventing perineal tearing, here’s how you might start to prep for that:
Consider trying in the shower or tub or in a comfortable sitting position or standing “captain’s position”.
Lubrication options: vitamin E oil is very moisturizing and can help with tissue elasticity. You can also look into Good Clean Love, UberLube or Coconu.
You can use a pelvic wand to help stretch if you find it is hard to get your hand/fingers down there.
for perineal massage technique, try the following for 5 minutes a day at least 4x a week:
A visual depiction of perinatal massage.
Wash hands and trim fingernails
Find a comfortable position to reach perineum (a few options listed above)
Apply appropriate lubricant if not in tub or shower
Insert both thumbs or index or middle fingers into vaginal opening
Inhale, then as you exhale: Press toward the back wall of the vagina (toward rectum) and hold the stretch until feeling a slight numb or tingling sensation
Continue to breathe steadily, then slowly glide thumbs/fingers out to the side wall of the vagina (make sure to continue to breathe)
Repeat massage in this slow, “U”-shaped path for up to 5 minutes
Can use warm or cold pack on perineum afterward to reduce soreness
Can increase pressure as you feel comfortable doing so over the course of a session or over the course of weeks
Feeling a stretch or burning sensation with this is normal, but you should NOT feel pain with this or see any bleeding
Alternatives to Perineal Massage
Another way to do perineal stretching is through sex! Especially leading up to labor, intercourse can help to naturally stretch the perineum and there is SOME evidence out that the makeup of semen can help with cervical ripening.
A few other things to consider and prioritize in an effort to reduce your risk of perineal tearing is:
Hydration - this is more than just a few days before birth! Our skin hydration comes from continually being hydrated. This can allow for better stretching.
Eating a nutrient dense diet can help with tissue health.
Labor prep exercises and learning to relax the pelvic floor consciously - this is what labor prep flows are for! If you’re not sure how to go about this, make sure to check out MBC Prenatal/Core Mobility program!
Learn birthing positions and practicing them - again, if you’re unsure on what birthing positions you should be practicing, check out MBC’s Labor Prep program!
Practice breath work leading up to labor and birth - all of this is included in the entire MBC Prenatal program, but the Labor Prep program is specific to all things labor and birth and the Prenatal/Core program includes the Labor Prep program AND mobility flows and core strengthening throughout pregnancy.
Perineal Tear Prevention Tips During Labor & Birth
There are many things that can be done in order to promote pelvic floor relaxation and tissue extensibility. Some of these things can be done by you without any assistance, but others may require you to vocalize what you need and advocate for yourself during the labor and/or birth. Sometimes, having a conversation with your provider (or partner) ahead of time can really help when you are in the moment!
Check out the list below to see all the things to consider during labor and birth to help avoid perineal tearing during labor and birth:
Having a provider or setting that has low episiotomy rates (ideally <1%) - you may need to do your research on this one! Simply having a provider with this specific stat can severely lower your risk of tearing!
Utilizing our breath during pushing - using your breath to promote pelvic floor relaxation during pushing can really make a difference.
Slow, controlled, calm birth - this often takes some intentional work to prepare yourself for this type of a birth, as well as all parties that are involved also being on board with remaining calm and controlled during the birth.
Preventing rapid expulsion of baby (if possible) so that the perineum can have time to stretch. This means as baby is crowning, not bearing down with all our might to push baby out but rather allow baby to come in and out of crowning to stretch the tissue. The provider could add assistance for this one as they see if it’s needed (but bring this up with them ahead of time!) Sometimes Fetal Ejection Reflex (FER) takes over and is something that can’t be controlled. FER is a natural reflex that occurs in some women where baby naturally comes out quickly without any pushing effort at all.
A “panting” breath can help with slowing down the expulsion.
Warm Compresses: The evidence on its use is somewhat conflicting. However, some studies show that it is helpful to mom as it brings comfort and can prevent severe tears (3rd and 4th degree). Other evidence shows that a “hands off” technique can decrease your rate of severe perineal tears as well as episiotomy. *Bottom line: talk with your provider about their use with warm compresses and being able to have it as a tool if 3rd or 4th degree tears seem possible.
Utilizing a mirror as baby is crowning to help control the pushing (typically more helpful with epidural use if sensation and feeling is lost).
Perineal Massaging from the provider during pushing is no longer routinely recommended. There are very few studies that show it MAY reduce the risk of severe tears, but has little-to-no benefit if providers already have a very low severe tear rate (1.5% or less). If it is done, there should be FULL CONSENT by you to your provider.
Pushing positions play a role in tearing prevention and risk of episiotomy. For a little further information on your birthing position options, make sure to check out the blog, “Understanding your Birthing Position Options”.
If you are planning a water birth, most often this is a “hands-off” approach.
Final Thoughts
There’s a lot of information out there, but sometimes not quite enough. It’s frustrating that we don’t have further research and concrete evidence on how we can best protect ourselves from perineal tearing, but here’s a summary of what we’ve covered in this blog and the things that we can focus on during pregnancy to help ourselves as best we can!
Educate yourself on protecting the perineum and your risk of severe tears and episiotomy decreases
Make sure your provider’s episiotomy rate is low (ideally <1%)
Focus on push prep practice; prevent valsalva (breath holding) during the pushing and try to go off your body’s urges to push
Consider doing prenatal perineal massaging
Talk with your provider about a slower expulsion of the baby - not forcing baby to come out as crowning is occurring
Talk with your provider about how they typically manage birth (hands-on vs. hands-off approach) and voice your concerns for maintaining an intact perineum
ADVOCATE for yourself!
Practice breath work and mindfulness in different possible pushing positions you could see yourself going into (hands and knees, side lying, squat, etc). You can also practice this breathing during some perineal massage work!
Feel like you could use additional support with this?
If preparing your mind and body for labor and birth is TOP priority for you, Mind Body Core is here to support you in that! There are many options with my Mind Body Core - Prenatal program to help meet you where you are at. If you’re looking for full support through your entire pregnancy all the way through the first couple weeks postpartum, then Mind Body Core - Prenatal Program would be PERFECT for you.
If you’re looking for a program specifically for addressing your core and pelvic floor health during your pregnancy, then my Mind Body Core - CORE/MOBILITY program might be your best option! You will be guided through weekly core and mobility exercises with specific pelvic floor relaxation sessions, educational content covering different dysfunctions you may experience, labor prep guidance and setting yourself up for a good postpartum experience.
And lastly, if you are looking for a program specific to helping you prep for labor and birth, Mind Body Core - Labor Prep program would be an amazing asset to you for this! You will be guided through 5 sections of educational modules that address all the aspects of labor from mental preparation, to labor prep mobility, to choosing options that fit YOUR needs. This program is here to help you feel educated, empowered, and confident heading into your birth experience!