Perineal tearing is a common occurrence during vaginal childbirth, involving the tissue and muscles between the vaginal opening and the anus. This trauma can range from minor grazes to more extensive injuries that require suturing and longer recovery. Up to 9 in 10 first-time mothers who have a vaginal birth will experience some degree of tear or graze. Preparing the tissue and adopting specific techniques during labor can help minimize the risk and severity of these lacerations. Understanding how to support the perineum before and during delivery promotes a smoother birthing experience.
Preparing the Perineum Before Labor
The period leading up to labor offers an opportunity to enhance the flexibility of the perineal tissue, primarily through regular perineal massage. This technique involves gently stretching the perineum—the area between the vagina and the rectum—to help the muscles and skin become more pliable. It is generally recommended to begin this practice around the 34th week of pregnancy and continue three to four times per week until delivery. Studies show that this preparation can reduce the likelihood of needing an episiotomy and the chance of experiencing a severe tear, especially for those having their first vaginal birth.
To perform the massage, a natural oil like almond, olive, or coconut oil, or a water-soluble lubricant, should be applied to the fingers. The thumbs or fingers are inserted one to one-and-a-half inches inside the vagina, applying gentle, sustained pressure downward toward the anus and outward to the sides. The sensation should be a stretch or mild burning, which often lessens as the tissue becomes accustomed to the pressure. Each session should last approximately five to ten minutes, focusing on relaxing the pelvic floor muscles throughout the practice.
This regular stretching mimics the pressure of the baby’s head, helping the expectant mother become familiar with the sensation and learn to relax into it. Maintaining overall pelvic floor health through gentle exercises, such as Kegels, also contributes to tissue resilience and better muscle control. Hydration and a healthy diet further support the integrity of connective tissues throughout the body, including the perineum.
Pushing Techniques During Labor
The way a mother pushes during the second stage of labor has a significant impact on the stress applied to the perineum. The most effective approach for perineal protection centers on slow, controlled expulsion of the baby, allowing the tissue time to stretch gradually. This method contrasts sharply with the traditional, coached “directed pushing” technique, which often involves holding the breath and bearing down forcefully for long counts, known as the Valsalva maneuver.
Directed pushing can increase the speed and force of the baby’s descent, which may lead to rapid, uncontrolled stretching and tearing of the perineum. Instead, a more protective method is “spontaneous pushing,” where the mother follows her body’s natural urges to bear down. This involves pushing in shorter, more frequent bursts and often includes vocalizing or grunting, which prevents breath-holding and the excessive internal pressure associated with the Valsalva maneuver. This technique is often easier to execute without an epidural, as the natural urge to push is clearer.
Controlled pushing also involves focusing the effort in the correct direction, often described as pushing in a “J-shaped” curve, down and back toward the rectum, rather than straight forward. When the baby’s head begins to crown, the healthcare provider may coach the mother to slow or stop pushing entirely, often by instructing her to pant or blow through contractions. This crucial final step, known as the “fetal head crowning phase,” is where the greatest stretch occurs; slowing the delivery of the head allows the tissue maximum time to accommodate the head’s circumference.
Support and Positions for Delivery
Birthing positions and medical support minimize perineal trauma during delivery. Certain upright or side-lying positions naturally reduce the amount of direct pressure placed on the perineum compared to lying flat on the back. Positions like side-lying with a peanut ball, hands-and-knees, or standing/squatting allow gravity to assist the descent while distributing pressure away from the posterior perineal tissue. The side-lying position is often associated with the lowest rates of tearing, as it prevents the tailbone from restricting the pelvic outlet.
During the second stage of labor, the application of a warm compress to the perineum has been shown to be an effective measure for reducing severe tears. The warmth helps to increase blood flow and relax the tissue, thereby improving its elasticity as the baby’s head stretches the opening. Studies indicate that warm compresses can significantly lower the risk of second, third, and fourth-degree lacerations. Some care providers may also apply lubricating oils to the perineum to further reduce friction and aid the gentle stretching of the skin.
The healthcare provider’s hands-on technique, known as perineal support or guarding, is another mechanical defense against tearing. This involves the provider using their hand to apply counter-pressure to the perineum and manage the speed of the baby’s head as it emerges. While episiotomies—surgical cuts once performed routinely to supposedly prevent severe tears—are now generally avoided, they are reserved for situations where the baby needs to be delivered quickly or if there is a high, immediate risk of a severe anal sphincter injury.