Today, Katie McGee, PT,  DPT, a physical therapist specializing in pelvic floor health for the childbearing year shares valuable information about tearing during childbirth.  From time to time on Connecting the Dots, they will be sharing information and resources that will be valuable to educators and the families they work with.  This series is called The Body in Birth.  I am grateful that the topic of pelvic floor health during pregnancy and postpartum is being discussed, as many people suffer in silence and without helpful resources.  To find all The Body in Birth articles,  click here. - Sharon Muza,  Community Manager, Connecting the Dots 

This article was written by Dr. Katie McGee with contribution from Laura Fry, MS.

Introduction

Tearing during childbirth is one of the most common concerns of pregnant people. While over 90% people birthing through their vaginas for the first time do develop some tearing, most tears are not serious and heal on their own or with a few stitches (Smith et al., 2013).  

But what about those more significant tears? It is true that large tears do happen. Fortunately, research has shown us that there are ways to reduce the risk of tearing during a vaginal birth. Some of these ways of preventing tears can be done before childbirth, while others are done during childbirth. 

Before childbirth 

1. Perform perineal massage.

Perineal massage is a type of stretching for the vagina to prepare for childbirth. Typically, a pregnant person does the stretching on themselves by using one or two thumbs to widen the opening of the vagina, although sometimes a partner helps. Here’s a link to directions on how to perform perineal massage. 

A 2020 review of research on perineal massage done prior to birth found that it:

• Reduced pushing time .

• Reduced the risk of perineal tears that reached the anus (grade 3 and 4).

• Reduced pain in and around the vagina after birth .

• Improved APGAR scores at one and five minutes after birth (Abdelhakim et al., 2020).

How much perineal stretching should I do? Perineal massage is often started eight to four weeks prior to the expected due date. It can be done daily, however, performing it just three times per week might be equally effective in preventing moderate and severe perineal tears (Leon-Larios et al., 2017). Daily stretching is associated with developing no tearing whatsoever (Leon-Larios et al., 2017). 

Pregnant people should check with their medical provider before starting perineal massage. Frequently, people on pelvic rest or at risk of early delivery are instructed not to perform perineal stretching. 

2.  Consider Kegels

One recent study found that pairing Kegels (also known as pelvic floor muscle contractions) with perineal massage aided in protecting the pelvic floor. People who did perineal massage and Kegels: 

1. Increased the chance of having no tearing at all from 6% to 17%.

2. Notably reduced the risk of perineal tears that reached the anus (grade 3 and 4).

3. Had less pelvic pain after delivery (Leon-Larios et al., 2017).

How many Kegels should I do? The study mentioned above prescribed 5-second Kegels repeated 10 to 15 times, twice per day, starting at 8 weeks prior to the expected due date. It is worth noting that pelvic floor exercises by themselves do not prevent perineal tears (Schantz, 2018). However, they can be helpful with preventing urinary incontinence during pregnancy and after birth (Woodley et al., 2020)! As with perineal massage, pregnant people should check with their medical provider before starting Kegels.

3.  Practice birthing positions ahead of time.

Certain positions are more likely to lead to larger perineal tears. In particular, these positions are ones where the sacrum (part of the low back) is pressed against another surface, such as a bed or chair (Jansson et al., 2020). Often, it is easier to remember what TO DO when it comes to birthing, versus what not to do. For this reason, I encourage birthing people to practice positions that will be less likely to cause tears (sacrum is freer to move). Here are some to practice before going into labor: 

1.  Sidelying

2. Kneeling

3. Squatting

Recent research suggests that upright positions in general are less likely to lead to tears (Rocha et al., 2020), while horizontal positions are more likely to lead to a birthing person having an episiotomy performed (Souza et al., 2020). Use of an epidural has not been found to increase the risk of severe perineal tearing (Loewenberg-Weisband et al., 2014). Labor induction studies on the risk of perineal tearing show mixed results.  

4. Make a perineal tear prevention plan.

Make a visit to the midwife or obstetrician to talk about ways they can help reduce the risk of perineal tearing during birth. It is much easier to include perineal tear prevention strategies in the birth process if they have been agreed upon before labor starts. Here are some of the common ways a midwife or obstetrician might try to reduce the risk of perineal tearing: 

1. Good visualization of the perineum during pushing (Sveinsdottir et al., 2019).

2. Warm compress on the perineum during pushing (Magoga et al., 2019).

3. Hand on back part of vulva during delivery of the fetus’ head (manual perineal support) (Sveinsdottir et al., 2019).

4. Controlled delivery of the fetus’ head (Sveinsdottir et al., 2019).

In addition, sometimes a carefully placed episiotomy can prevent the occurrence of a large perineal tear that injures the anus (Marty & Verspyck, 2018). Occasionally, birthing people will decide that an episiotomy is a safe choice for their vaginal delivery. Similarly, if given the option to choose, some birthing people know that they would rather have a Cesarean delivery than risk developing a large perineal tear through the application of forceps or vacuum extraction.

During childbirth 

5. Consider fewer vaginal examinations during labor.

Having five or more vaginal examinations is associated with a higher risk of a severe perineal tear, even when other factors are controlled for (Gluck et al., 2020). A birthing person might consider requesting the medical team to only perform medically necessary examinations. 

6. Get in the water for pushing.

Waterbirth has been associated with having fewer severe perineal tears (Sidebottom, et al., 2020). If a birthing person is interested in a water birth, they should be sure to check (a) that they have a provider who will honor their wish to birth in the water and (b) that a tub will be available. A tub may need to be rented or purchased depending on the birthing location. 

7.  Push with an urge and breathe through pushes.

Some birthing people are instructed to push right when they reach 10 centimeters of dilation, while others wait until they feel the urge to push. In one study, the combination of waiting for an urge to push, as well as breathing during pushes (as compared to holding the breath and pushing), was associated with a reduction in perineal tears (Simpson & James, 2005). More recent studies have also found that blowing during pushing is associated with a lower risk of perineal tearing, when compared to breath holding (Ahmadi, et al., 2017). If someone plans on doing delayed pushing without breath holding, it can be helpful to discuss this decision with the midwife or obstetrician ahead of time, so that the birthing person does not receive unwanted coaching. 

Conclusion

Keep in mind that regardless of the amount or type of tearing, the human body has a tremendous capacity for healing. This includes the ability to heal from tears and episiotomies. If a perineal tear does occur, with or without preventative measures being taken, it is not the birthing person’s fault. There are many forms of support for recovering from a perineal tear, from medical treatments to support groups. Regardless of the outcome, birthing people have options for feeling restored. These days, there are many specialists from pelvic floor physical therapists to medical doctors who are board-certified in female pelvic medicine and reconstructive surgery (FPMRS) and colorectal surgery. No one should have to suffer alone.  If you have a student, client or patient with a significant tear who needs support, please share the resource Life after Fourth Degree Tears.

References

Abdelhakim, A.M., Eldesouky, E., Elmagd, I.A., Mohammed, A., Farag, E.A., Mohammed, A.E., ... & Abdel-Latif, A.A. (2020). Antenatal perineal massage benefits in reducing perineal trauma and postpartum morbidities: a systematic review and meta-analysis of randomized controlled trials. International Urogynecology Journal, 31(9), 1735-45. PMID: 32399905 

Ahmadi, Z., Torkzahrani, S., Roosta, F., Shakeri, N., & Mhmoodi, Z. (2017). 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, 22(1), 62-6. PMID: 28382061/

Gluck, O., Ganer Herman, H., Tal, O., Grinstein, E., Bar, J., Kovo, M., ... & Weiner, E. (2020). The association between the number of vaginal examinations during labor and perineal trauma: a retrospective cohort study. Archives of Gynecology and Obstetrics, 301(6), 1405-10. PMID: 32328711

Jansson, M.H., Franzén, K., Hiyoshi, A., Tegerstedt, G., Dahlgren, H., & Nilsson, K. (2020). Risk factors for perineal and vaginal tears in primiparous women - the prospective POPRACT-cohort study. BMC Pregnancy and Childbirth, 20(1), 749. PMID: 33267813

Leon-Larios, F., Corrales-Gutierrez, I., Casado-Mejía, R., & Suarez-Serrano, C. (2017). Influence of a pelvic floor training programme to prevent perineal trauma: A quasi-randomised controlled trial. Midwifery, 50, 72-7. PMID: 28391147

Loewenberg-Weisband, Y., Grisaru-Granovsky, S., Ioscovich, A., Samueloff, A., & Calderon-Margalit, R. (2014). Epidural analgesia and severe perineal tears: a literature review and large cohort study. The Journal of Maternal-Fetal & Neonatal Medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians, 27(18), 1864-9. PMID: 24476386

Magoga, G., Saccone, G., Al-Kouatly, H.B., Dahlen G, H., Thornton, C., Akbarzadeh, M., ... & Berghella, V. (2019). Warm perineal compresses during the second stage of labor for reducing perineal trauma: A meta-analysis. European Journal of Obstetrics, Gynecology, and Reproductive Biology, 240, 93-8. PMID: 31238205

Marty, N., & Verspyck, E. (2018). [Perineal tears and episiotomy: Surgical procedure - CNGOF perineal prevention and protection in obstetrics guidelines]. Gynecologie, Obstetrique, Fertilite & Senologie, 46(12), 948-67. PMID: 30392991

Rocha, B.D.D., Zamberlan, C., Pivetta, H.M.F., Santos, B.Z., & Antunes, B.S. (2020). Upright positions in childbirth and the prevention of perineal lacerations: a systematic review and meta-analysis. Revista da Escola de Enfermagem da U S P, 54, e03610. PMID: 32935765

Schantz, C. (2018). [Methods of preventing perineal injury and dysfunction during pregnancy: CNGOF Perineal prevention and protection in obstetrics]. Gynecologie, Ostetrique, Fertilite & Senologie, 46(12), 922-7. PMID: 30392987

Sidebottom, A.C., Vacquier, M., Simon, K., Wunderlich, W., Fontaine, P., Dahlgren-Roemmich, D., ... & Saul, L. (2020). Maternal and Neonatal Outcomes in Hospital-Based Deliveries With Water Immersion. Obstetrics and Gynecology, 136(4), 707-15. PMID: 32925614

Simpson, K.R., & James, D.C. (2005). Effects of immediate versus delayed pushing during second-stage labor on fetal well-being: a randomized clinical trial. Nursing Research, 54(3), 149-57. PMID: 15897790

Smith, L.A., Price, N., Simonite, V., & Burns, E.E. (2013). Incidence of and risk factors for perineal trauma: a prospective observational study. BMC Pregnancy and Childbirth, 13, 59. PMID: 23497085

Souza, M.R.T., Farias, L.M.V.C., Ribeiro, G.L., Coelho, T.D.S., Costa, C.C.D., & Damasceno, A.K.C. (2020). Factors related to perineal outcome after vaginal delivery in primiparas: a cross-sectional study. Revista da Escola de Enfermagem da U S P, 54, e03549. PMID: 32187311

Sveinsdottir, E., Gottfredsdottir, H., Vernhardsdottir, A.S., Tryggvadottir, G.B., & Geirsson, R.T. (2019). Effects of an intervention program for reducing severe perineal trauma during the second stage of labor. Birth (Berkeley, Calif.), 46(2), 371-8. PMID: 30444289

Woodley, S.J., Lawrenson, P., Boyle, R., Cody, J.D., Mørkved, S., Kernohan, A., & Hay-Smith, E.J.C. (2020). Pelvic floor muscle training for preventing and treating urinary and faecal incontinence in antenatal and postnatal women. The Cochrane Database of Systematic Reviews, 5, CD007471. PMID: 32378735

About Katie McGee

Katie McGee, PT, DPT, (she/her + they/them), specializes in helping pregnant and postpartum people overcome pain and pelvic health conditions. Her approach includes thoughtful listening, targeted exercise, and hands-on techniques. Katie regularly coordinates with clients' healthcare team and doulas for optimal outcomes. Home visits are available throughout the greater Puget Sound region and virtual visits from anywhere. You can reach Katie through her website.

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