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Perineal tearing refers to a laceration or tear in the tissue between the vaginal opening and anus that occurs during childbirth. It can lead to a number of complications such as infection, prolonged healing, bowel or bladder incontinence, and pain. It is important to note that perineal tearing is quite common during a vaginal delivery, but if we are able to prevent severe tears (grade 3 and grade 4) a lot of the complications can be lessened or avoided.
Before we go into the ways to reduce perineal tearing, let’s briefly discuss the different degrees of tears that can occur.
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1st degree tear
A first degree tear affects the vaginal mucosa and may involve the perineal skin. First degree tears usually heal quickly and without treatment.
2nd degree tear
Second degree tears affect the skin, pelvic floor musculature, and perineal body. Second degree tears usually require stitches.
3rd degree tear
A third degree tear is a second degree laceration with the addition of the anal sphincter. Third degree tears are sometimes classified into three subcategories (A, B, C). A: Less than 50% of the anal sphincter is torn, B: Greater than 50% of the anal sphincter is torn, C: External and internal anal sphincters are torn.
4th degree tear
This is the most severe perineal tear. All the areas of a third degree tear are compromised with the addition of the rectal mucosa. Fourth degree tears tend to be associated with a number of complications such as fecal incontinence, bowel urgency, and painful sex.
So now that you’re officially freaked out, the good news is that there are several ways to reduce the severity of perineal tearing. It is strongly recommended that you discuss these options with your OB/GYN or midwife prior to starting.
1. Perineal Massage
Perineal massage may reduce your risk of tearing by prepping your tissue for stretch and allow you to feel more comfortable with the sensations during delivery. With clearance from your midwife or OB/GYN, patients generally begin perineal massage around 35 weeks (but sometimes sooner!). It can be difficult to reach your perineum in the later stages of pregnancy so asking your partner to help you is key.
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2. Preparing your pelvic floor for childbirth during pregnancy
The pelvic floor needs to be able to relax to allow the baby to enter and pass through the pelvis during labor and delivery. During pregnancy the pelvic floor is usually pulled tight to support the added pressure and weight of the growing baby. However, during delivery we need to be able to relax the pelvic floor through our breath, visualization, and positioning. Taking a big breath in and being able to allow the pelvic floor muscles to release is an important skill to have mastered prior to labor. This can be very difficult to learn on the fly! If you need support gaining awareness of your pelvic floor muscles, a prenatal visit with a pelvic floor physical therapist may be exactly what you need.
There are also somethings you can do DURING childbirth to reduce severity of perineal tearing:
3. Warm compress to perineum
Applying pressure or support on the perineum as the baby begins to crown is thought to minimize the severity of perineal tearing. A study performed by Aasheim et al. in 2017 found that fewer third and fourth degree perineal tears were reported in the warm‐compress group versus the control group (hands off and no compress).
4. Open glottis pushing
There has been some research to support open glottis pushing for decreasing severity of perineal tears. When most of us think of pushing during childbirth, it is usually the hold your breath and push, or purple pushing, technique. Open glottis pushing is another option that involves taking a deep breath in and bearing down while slowly blowing air out of your mouth at the same time. It is thought that open glottis pushing results in decreased pressure on the pelvic floor by allowing for a slower expansion of the perineum tissue during delivery. There has also been some research that shows patients who wait to push until they feel the urge to push experience fewer perineal tears.
5. Pelvic floor friendly pushing positions
If it is safe and you have flexibility in how you deliver your baby, pushing in positions in which the tailbone is free to move (aka not on your back) is ideal. As the baby’s head moves through the pelvic cavity, the sacrum and tailbone need to move out of the way, or posteriorly, to allow the baby’s head to pass. Positions that allow the tailbone to move include squatting, on hands and knees, or side-lying. However, we don’t always have the choice (for a variety of reasons including safety) of the position the baby is delivered in. Placing towel rolls under your sit bones, otherwise known as ischial tuberosities, also allows the sacrum some more freedom to move posteriorly when we are on our back.
It’s important to remember that the goal of these techniques is to reduce the risk of tearing during delivery and to decrease the risk of sustaining a higher degree tear. Sometimes a tear is unavoidable for a number of reasons that are out of our control. The good news is that our bodies are very good at healing from perineal tears and that’s one of the reasons why episiotomies are not performed as routinely as they once were.
If you experience a perineal tear a pelvic floor physical therapist can perform scar mobilization, assess the function of the pelvic floor, and make recommendations to promote healing.
Resources:
Ahmadi, Zohre, et al. “Effect of Breathing Technique of Blowing on the Extent of Damage to the Perineum at the Moment of Delivery: A Randomized Clinical Trial.” Iranian Journal of Nursing and Midwifery Research, vol. 22, no. 1, 2017, pp. 62–66.
Aasheim, Vigdis, et al. “Perineal Techniques during the Second Stage of Labour for Reducing Perineal Trauma.” Cochrane Database of Systematic Reviews, no. 6, 2017.
Edqvist, Malin, et al. “Midwives’ Management during the Second Stage of Labor in Relation to Second-Degree Tears—An Experimental Study.” Birth, vol. 44, no. 1, 2017, pp. 86–94.
Simpson, Kathleen Rice, and Dotti C. James. “Effects of Immediate versus Delayed Pushing during Second-Stage Labor on Fetal Well-Being: A Randomized Clinical Trial.” Nursing Research, vol. 54, no. 3, June 2005, pp. 149–57.