Tearing during birth would have to be one of the biggest fears I hear about when talking to pregnant women (closely followed by ‘I don’t want to poo in front of everyone’)
It’s important to remember that the vagina is designed to birth a baby. During pregnancy and labour, your body is flooded with hormones increase blood supply and increase the stretchiness of the tissues of the vagina and perineum.
It’s also important to know not everyone will tear and of those that do the vast majority will be 1st or 2nd-degree tears. According to the 2019 Mothers and Babies Report 1 in 4 women had an intact perineum with less than 3% of women having a 3rd or 4th-degree tear.
Factors that increase the risk of tearing
Before we look at how we can try and reduce the risk of tearing, let’s look at the some of the factors that may increase the risk of tearing that are generally easier to control for (there are other factors that are very difficult, if not impossible to control e.g. ethnicity).
- Posterior baby – while it’s not possible to absolutely control the position a baby will be in, there are things we can do to encourage baby into an optimal position, including being active during labour and being in upright, forward-leaning positions
- Instrumental birth – particularly with forceps
- Use of synthetic oxytocin (i.e. syntocinon) in women who have previously had a vaginal birth
- Midline episiotomy (ironically episiotomies are often performed to try and prevent tearing)
- Prolonged second (or pushing) stage
- Shoulder dystocia
- Birthing in lithotomy (on your back with legs in stirrups) in a deep squatting position, or in any position which increases the tension through your perineum
- Epidural use
How do I reduce the risk of tearing?
So let’s look at tearing and whether there is anything you can do to help prevent tearing during birth.
Perineal massage during pregnancy
Your perineum is the area of tissue between the opening of the vagina and the anus. It attaches to the pelvic floor – the group of muscles land ligaments that support your bladder, bowel, and uterus. Perineal massage is gentle, manual stretching of your pelvic floor (using your fingers) with the aim of preparing your perineum for the birth of your baby.
Does it work?
The evidence shows that perineal massage during pregnancy does not reduce the risk or 1st, 2nd, 3rd or 4th-degree tears. For first-time mums who were randomly assigned to do perineal massage, there was a 10% decrease in the relative risk of having perineal trauma that required stitches and a 16% decrease in the relative risk of having an episiotomy. The same wasn’t true for those having their second or subsequent vaginal births – these mums saw no difference in risk.
So why is it so often suggested? For some women, perineal massage can help them feel more comfortable and confident with their bodies. And if it is going to help you feel better, then why not do it? If it’s not something you are interested in, know that you don’t have to do perineal massage to birth your baby!
The next question that is asked is how often should I be doing perineal massage? According to the studies, Women who massaged an average of 1.5 times per week had a 17% reduced risk of perineal trauma and a 17% reduced risk of episiotomy. Women who massaged between 1.5-3.4 times per week had an 8% reduced risk of perineal trauma. And those women that massaged more than 3.5 times per week experienced no benefits and actually had a 10-minute longer pushing phase of labour. It appears that less is more when it comes to perineal massage!
Perineal massage during labour
Unlike perineal massage during pregnancy which is done by the mother or her partner, perineal massage during labour is performed by a care provider during the second (pushing) phase. According to Aquino et al ‘ Perineal massage during labor is associated with significant lower risk of severe perineal trauma, such as third and fourth-degree lacerations’, but is not associated with a lower risk of 1st and 2nd-degree tears.
While there is evidence that having perineal massage can help reduce severe trauma if you go back to the earlier numbers, only 3% of women experience a 3rd or 4th-degree tear. This has to be balanced with the risks of tearing when in the lithotomy position (which is often required for perineal massage) along with the experience for women.
Warm compress or water
Warm compresses have been used by midwives for generations. And now we know why! A warm compress, simply a compress soaked in warm water, wrung out and applied to your perineum during crowning, may reduce the risk of third- or fourth-degree tears
Warm water – similar to a warm compress however being in a pool or bath also means that it’s much more difficult for other’s to get their hands involved.
Position during birthing
We already know that being in certain positions may increase the risk of tearing as they make the perineum tight and stretched (lithotomy, deep-squat and semi-supine, I’m looking at you!). What about positions that reduce the risk of tearing? Any positions that do not involve having your legs stretched wide, like side-lying or being on all fours, can help reduce the pressure on your perineum and therefore reduce the risk of tearing.
Why don’t you try it out for yourself now? Not the birth bit but the increased pressure on your perineum. Place one hand on your perineum as you go into a deep, wide-legged squat – notice the increasing tension in your perineum? Now try it on all fours – feel any different?
Not wanting to put your hand on your perineum to try it out? No worries – you can do the same experiment wearing a pair of non-stretch pants (no yoga pants). Try and do a deep wide-legged squat wearing dress pants – does the thought make you cringe for fear of tearing your pants? Can you easily move onto all fours or into a side-lying position without worrying about tearing your pants at the seam?
When it comes to birthing your baby, move into any position that feels best – maybe it’s leaning on the back of the bed, maybe you’re on all fours, maybe it’s in the pool or shower. Whichever position you choose, know that you don’t ‘have’ to birth your baby lying on your back.
Mother-directed pushing
Imagine someone telling you that it’s time for you to go to the bathroom and poo – regardless of whether you feel the urge to or not. Imagine them telling you to hold your breath and push to try and do so. And to keep pushing until you are told to stop. How do you think that will go? Will you have an easy time going to the toilet?
Of course not!
So why is that we expect a woman to have an easy time birthing her baby when someone is telling her when and how to push – even if her instinct is telling her otherwise?
If left to push on your own without direction, the intense sensations of crowning will often mean that you instinctively slow down. This is in contrast to having someone telling you to push with each contraction and with a force that you may not have used otherwise.
Listen to your body, push when it feels right to do so and in a way that feels right to you.
‘Hands Off’ technique
Before we look at the evidence let’s look at the difference between hands-on and hands-off techniques.
Hands-on technique is where the care provider uses their hands to support baby’s head and apply a slight pressure to control the head as the baby is crowning. In contrast, hands-off (or hands-poised) technique is exactly as it sounds – the care provider has their hands off as the baby crowns.
One literature review stated that “The hands-poised [off] technique appeared to cause less perineal trauma and reduced rates of episiotomy. The hands-on technique resulted in increased perineal pain after birth and higher rates of postpartum haemorrhage.’ In other words, tell everyone to keep their hands away!
Reducing the risk of tearing is less about doing things before birth or having things ‘done to you’ during birth than it is about trusting your body, trusting the process of birth and following your instincts. Your perineum is not a design-flaw!
Want to know more about how you can prepare your mind and body for labour and birth (including looking at some of those birth positions that can help reduce the risk of tearing)? My Hypnobirthing Australia classes will give you all the knowledge, tools, preparation and support to help you prepare for a calm, positive birth.
Kate Vivian is a self-professed pregnancy and birth geek who is finally learning to embrace the chaos of having 3 kids. It was the birth and ‘bringing baby home’ experience of her first baby, and the overwhelming guilt that went with it, that led her to start Bright Mums – and create a world where Mums matter.
A Certified Hypnobirthing Australia Practitioner, childbirth educator and birth and postpartum doula, Kate works with Mums-to-be not only supporting them through pregnancy, and birth but also teaching them to honour themselves at a time when the world is telling them their baby is the most important thing.
With almost 2 decades in adult education, Kate has the ability to create a safe space, a non-judgey space. A place where Mums can relax and feel supported regardless of what their journey looks like.
A keen traveller in a former (pre-kids) life, Kate dreams of the day her kids are big enough to take skiing and they can completely show her up while she is busy falling down mountains.
Find out more about Kate and how she can support you during your journey through pregnancy, birth and beyond.