If you’re reading this, my guess is that you’re pregnant and might even be thinking:
“I’m really scared I’ll tear during birth!”
That’s totally valid! The idea of getting a tear in your vag probably doesn’t sound too fun and you’re definitely not alone in hoping there’s a way to prevent it.
In this blog post we’ll cover:
The types of perineal tears that can happen during delivery
How do perineal tears happen? During a vaginal birth, as baby makes their way through the vaginal canal, the pelvic floor muscles and tissue around the vagina have to stretch A LOT for the baby to come through. Sometimes that stretch becomes too much, and the only way for baby to make it through, is for that tissue to tear.
Perineal tears are measured in terms of degrees on a scale from 1-4:
Image used with permission from Pelvic Guru®, LLC as a member of the Global Pelvic Health Alliance Membership (GPHAM)
A 1st degree perineal tear is considered pretty mild and isn’t a tear into the muscle itself. You might a need a stitch or two, or even none at all!
A 2nd degree perineal tear does partially go into the pelvic floor muscles. These are the most common types of tears and while they can at times cause future problems such as pain with intercourse or discomfort, they are still considered less severe.
A 3rd degree perineal tear goes through the perineum and into part of the anus. This type of tear is more severe and sometime requires a repair in the operating room.
4th degree perineal tear is a full tear that goes through the perineum and all the way through the anal sphincter. This is the most severe type of tear, requires a surgical repair, and can have more complications.
(In case you're in a complete panic at this point, keep reading!!)
The Risk Factors for Perineal Tears During Birth
Here’s the good news and the bad news: while you CAN reduce the risk that you’ll tear during birth, unfortunately there’s nothing you can do to completely prevent perineal tears. In fact, there are estimates that anywhere from 75-90% of first time vaginal births end with some degree of tearing, which means that although we can't totally prevent them, we do want to reduce the risk of more severe 3rd and 4th degree perineal tears.
(And the great news is that if you do run any issues with even a 2nd degree perineal tear such as pain with sex or pelvic pain, pelvic floor therapy can help!)
According to the research, there are some factors that do increase the risk of tearing. Things like: baby’s position and head size, the speed of labor, whether or not birth is spontaneous or induction, the use of instruments such as a vacuum assist, and previous pelvic floor dysfunction can all impact the risk of tearing. A lot of these things (like baby head size), we do not have complete control over.
But a risk factor that we can in fact impact is pelvic floor dysfunction! What is "pelvic floor dysfunction"? It's a fancy way of saying pelvic floor problems. Issues such as chronic constipation, urine leakage, or pain with sex all fall under this category. This is why pelvic floor therapy (also known as pelvic floor occupational therapy or pelvic floor physical therapy depending on the licensure of professional you see) is a great option during pregnancy if you have a history of pelvic floor problems.
Note: If you're not sure whether you fall under the category of having pelvic floor dysfunction, we have a great screening tool here.
Strategies to Reduce the Risk of Tearing During Childbirth
Other factors that can reduce risk of tearing include: the position you’re in when pushing, perineal massage, and a warm compress at the perineum when baby is crowning. Let's take a deeper dive into these topics.
Positions. There is some research suggesting that positions that allow the sacrum to move more optimally and also being more upright decrease the risk of the more severe 3rd and 4th tears. Being on your back can increase the risk of more severe tears, because it does not allow your sacrum to move as well and because it can also increase the risk of vacuum or forceps assistance. Now, this doesn’t mean being on your back is bad, especially if this is the position that you’re having the most effective pushing in, but it is problematic that in many hospitals it's still the standard to only allow the lithotomy position (being on your back) during pushing.
Side note: how much your care team will support you pushing in different positions greatly varies from hospital to hospital which is why we recommend thoroughly vetting where you decide to go!
Perineal massage is the strategy of providing gentle stretch at the perineum around 35 weeks of pregnancy to prepare the pelvic floor muscles around the vagina. This can be done a few times per week and can reduce the risk of more severe tears, especially in a first-time birth.
Does perineal massage literally make tissues "looser" or stretchier? No, probably not, but learning how connect to your pelvic floor and let it relax under stretch can be extremely helpful practice for giving birth.
(Note: Make sure to keep reading and grab our free perineal massage guide at the bottom of this page!)
Warm compress. A warm compress held at the perineum during pushing has also shown some benefit in reducing the risk of perineal tears. This one is pretty straightforward, and something you can ask your prenatal care team about . Please note: this is NOT the same as your provider using their hands to "massage" the perineum when baby is crowning. This can actually increase risk tearing.
To recap:
Unfortunately perineal tearing is a part of the childbirth process and not something we can completely prevent but we CAN reduce the risk of more severe tears.
Things that increase risk perineal tearing are things like baby’s head size, birth position, speed of labor, and previous pelvic floor issues. If you’re pregnant and have a history of pelvic floor dysfunction or are currently experiencing symptoms, this is your call to address it with pelvic floor OT/ pelvic floor PT sooner rather than later.
Other strategies that can reduce the risk of tearing are perineal massage, a warm compress at the perineum, and birth position.
We hope you found this information helpful. If you’re pregnant and want to learn how to perform perineal massage, make sure to download our free guide here!
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