Overview

During the second (pushing) stage of labor, your perineum stretches as your baby is born. More than half of first-time mothers experience some degree of tearing during vaginal birth. The good news is that you can educate yourself so you understand both how to prevent tearing and how to promote healing if it happens. Find out what evidence-based strategies can reduce your risk of tearing. This episode examines the research on everything from perineal massage to breathing techniques and labor positions. To cover all aspects of this possibility, learn what to expect if you do experience a tear, along with simple, effective ways to ease discomfort and support healing postpartum.

Listen Now

Article and Resources

I’ve heard so many horror stories about tearing during birth, and honestly, it freaks me out! I really want to do whatever I can to lower my chances of tearing, but there’s so much mixed advice out there. Some people swear by perineal massage, others say it doesn’t help, and I’ve even heard that certain birth positions make a difference. Is there anything I can actually do now during pregnancy to prepare? And when I’m in labor, are there positions or techniques that really make a difference? I’d love to know what actually works based on evidence, not just random tips from my friend group.

-Jessica

Jessica, thank you so much for writing in. I do not blame you for getting freaked out about horror stories of moms tearing during birth. When I had my first baby, no one told me that tearing was common, and I felt completely blindsided. The good news is that you have a heads up that this is a possibility, so you can prepare to prevent this and know how to promote healing if this happens to you.

What is Tearing?

Your perineum is the area between your vaginal opening and your rectum. As this area stretches during the second stage of labor, when you are pushing your baby out, it is possible that the skin tears. Tearing is classified by degrees depending on the severity. First-degree tears only involve the skin around the vaginal opening or perineal skin. A first-degree tear may or may not require stitches and usually heals within a few weeks. Second-degree tears involve the perineal muscles that support your uterus, bladder, and rectum. A second-degree tear usually requires stitches given in the delivery room with local anesthesia and heals within a few weeks.

Third-degree tears involve injury to the perineum involving the anal sphincter complex (the muscles around the anus). Fourth-degree tears involve the perineal muscles, the muscles surrounding the anus, and the tissue lining the rectum. Third or fourth-degree tears can require repair in an operating room and can take months to heal. Some complications can be fecal incontinence and painful intercourse.

How Common is Tearing?

During the birth of your baby, it is very common to tear your perineum, especially for first-time mothers. This study shows that the rates of tearing with a first baby are 90% and decrease to 69% in subsequent births. According to the American College of Obstetricians and Gynecologists, the rate of some laceration during all vaginal births is between 53-79%.

Episiotomy

Another possibility related to tearing is a surgical incision to the perineum, called an episiotomy. This is done with local anesthesia and requires stitches. In the past, episiotomies were routinely performed because it was thought that a clean cut would be easier to repair and prevent a more significant tear from happening. In the 1960s around 60% of births in the United States included an episiotomy. As organizations like the American College of Obstetricians and Gynecologists and the World Health Organization shifted to recommend against the routine use of episiotomy, rates have dropped. The average national rate in 2023 in the U.S. was 4.6%.

While episiotomy rates have significantly decreased, the procedure is still used in certain situations. The most common reasons for an episiotomy are shoulder dystocia or operative vaginal delivery (with forceps or a vacuum) or if an issue arises where your baby needs to be delivered quickly.

Evidence-Based Prevention Strategies

Although the possibility of a tear or an episiotomy can be intimidating, the good news is that there are some things you can do leading up to and during your labor and birth to help prevent these.

Perineal Massage

The theory behind perineal massage is that stretching this area leading up to your birth will allow it to stretch more easily and without tearing when your baby is crowning. To massage your perineum, you begin with clean hands and a lubricant. You place your thumbs inside your vagina, about an inch in. Then, you press down towards your bottom and to the sides until you feel a slight stretching sensation. You hold that position for 1-2 minutes while slowly massaging the lower half of your vagina. Think of it in the same way you would if you were stretching a muscle; you want to feel the stretch but it should not be painful.

Overall, there isn’t a pile of evidence to support this, and no consensus on the ideal frequency or duration. I have seen anywhere from once or twice per day to once per week for about 10 minutes during the last 5 or 6 weeks of your pregnancy. A Cochrane review found the benefits decreased with frequency. Women who did this 1.5 times per week had a 16% reduction in needing sutures. Those who massaged 1.5-3.4 had only an 8% reduction. With perineal massage, there is no guarantee it can prevent a tear, but it may reduce your risk.

Applying Heat

Applying a warm compress to your perineum during labor can increase blood flow and soften the tissue and muscles. Warm water should have a similar effect if you are considering a water birth. A randomized controlled trial found that warm compresses on the perineum positively reduce second and third-degree perineal tear and pain intensity during the second stage of labor and after childbirth. If you would like to incorporate a warm compress during labor you will need to enlist the help of your partner, your doula, a nurse, your midwife, or your doctor since it may be difficult for you to do this on your own.

Lubricants and Oils

Using a lubricant, like warmed mineral oil, can help to decrease friction and may help your baby slide out a little bit easier. A systematic review and meta-analysis of randomized controlled trials found lubricants might reduce the incidence of perineal trauma, especially second-degree perineal laceration, and shorten the duration of the second-stage labor. Similar to applying a warm compress, you will need to enlist the help of your doula, a nurse, your care provider.

Perineal Massage During Labor

Another intervention that would require assistance is perineal massage during labor. A randomized controlled trial evaluated perineal massage in the second stage of labor and found similar results in the massage and the control groups for first and second-degree tears and episiotomies. There was a significant difference in the rates of third-degree tears. This was 3.6% in the group who did not perform any perineal massage during labor and 1.2% in the group who did. A systematic review and meta-analysis showed that perineal massage during labor could be effective in reducing the risk of severe perineal trauma, such as third- and fourth-degree tears.

Slow Pushing

Your initial thought is probably that you want to push your baby out as soon as possible. One benefit of slowing down pushing is giving your perineum more time to stretch. To slow down pushing, try to exhale pushing. This is where you slowly breathe in and slowly exhale. It may also help to make a low or deep sound as you push. This will make the pushing stage slower than taking a deep breath, holding it, and then pushing. When the baby starts to crown, you can switch to short, almost grunting, pushes. It can be hard to remember these techniques when you are in labor. Talk about this with your partner, your doula, and any staff who will present. They can remind you to do this and even help guide you through breathing and pushing. See this episode for more information on breathing during labor.

Labor Positions

We often think of the most common laboring position of being in a hospital bed on your back. There are some downsides to this position, including that it puts more pressure on your perineum. Labor positions in which you are upright, kneeling, or on all fours leverage gravity to help your baby descend and reduce the need for forceful pushing. Other positions like squatting and side-lying can open your pelvis and allow more room for your baby which could also reduce the risk of perineal trauma. See this episode for more information on labor positions.

How to Promote Healing After a Tear or Episiotomy

If you have an episiotomy or a tear, the wound will be sore for a few weeks, especially when you walk or sit. If the laceration is extensive, the tenderness can last longer. Your care provider may recommend prescription or over-the-counter pain medications. The LactMed database is an excellent resource on the safety of medications while breastfeeding. You can also take many simple steps at home to reduce discomfort and promote healing.

Going to the Bathroom

A hospital or birth center should send you home with a peri bottle. This is a small plastic bottle you use to squeeze warm water on your vagina while you urinate. It helps prevent stinging from urine coming into contact with a tear and helps keep the area clean.

Many new mothers are intimidated to make a bowel movement after birth. You should avoid straining, which could aggravate your healing perineum. It does not help that constipation is a common side effect of pain medications used during labor. As a result, some care providers may recommend a stool softener in the days after you have your baby.

Moving Around and Getting Comfortable

Sitting can be more comfortable than moving around while your perineum is healing, especially in the first few days. Your partner can help by minimizing the movement you need to make, whether bringing you a glass of water, changing your baby, or grabbing something you need. It may also be helpful to keep diaper-changing supplies, water, and snacks in multiple places in your home to minimize how much you need to walk around. Sitting on a pillow or padded ring can be helpful. Some breastfeeding pillows, like the Boppy breastfeeding pillow, can be pretty comfortable to sit on as you recover.

Cooling & Postpartum Healing Pads

Cooling can provide much-needed relief when your perineum is sore and tender after birth. Ice packs, chilled maxi pads, and witch hazel pads (typically used for hemorrhoids) can all help reduce swelling and discomfort. Witch hazel has astringent and anti-inflammatory properties, making it a popular choice for postpartum healing.

One of the most soothing DIY options is postpartum healing pads, also called padsicles. These are easy to make and feel amazing during the first few days of recovery. To make them, simply mix ingredients like witch hazel, aloe vera gel, or lavender oil, add to regular maxi pads, then freeze them. Layering them with aluminum foil prevents sticking, and freezing them in a bowl gives them a slight curve, making them more comfortable to wear. These are most helpful in the first few days postpartum when swelling and discomfort are at their peak. See this episode for detailed instructions and recipes for padsicles.

Sitz and Herbal Baths

A sitz bath or an herbal bath can also provide relief and promote healing. A sitz bath is a small plastic tub that fits over your toilet and can be filled with warm water for you to sit on. While the warm water is soothing, you can also add ingredients for additional benefits. These include Epsom salt, baking soda, witch hazel, herbs like plantain leaf, yarrow, calendula, and essential oils like lavender or chamomile. There are many recipes online with DIY options and easier pre-mixed sitz salts with herbs available online or in retail stores.

Weighing the Pros and Cons

Many of the interventions aimed at preventing tearing have little or no risk. The same is true for most strategies to promote healing. Some techniques, like perineal massage or controlled pushing, take a small time investment to learn or practice. Other interventions like a sitz bath or making padsicles may require a small cost to purchase supplies. It is up to you to decide whether the potential pros outweigh the cons. Even if a strategy only slightly reduces the risk of tearing or makes recovery more comfortable, it can make a meaningful difference in your postpartum experience.

Including Preventative Measures Your Birth Plan

Jessica, hopefully, you are less freaked out and more prepared after this episode. Once you decide which preventative measures you would like to utilize during labor, you may decide to include them in your birth plan. As you create your birth plan, it’s essential to work with your doctor or midwife to ensure they support your preferences. While you can manage techniques like breathing and labor positions independently, you will need assistance applying warm compresses, lubricants, or oils. To keep your birth plan concise, focus on key preferences, but consider including details like using a warm compress so your support team knows this is something you want during labor. The Pregnancy Podcast has many resources to guide you in creating a birth plan:

• Get a copy of Vanessa’s birth plan
• Your Birth Plan book
• Become a Premium Member for access to the entire back catalog of episodes ad-free and a copy of the Your Birth Plan book.

Additional Resources:

• Optimal Labor Positions for a Shorter and Easier Birth
• Perineal Massage to Prevent Tearing
• Vaginal Tears and Episiotomy: Prevention and Healing
• Breathing During Labor

Thank you to the amazing companies that have supported this episode.