I remember the screaming the most. It was the first time I had peed since giving birth to my firstborn son four years ago, and the urine soaked the stitches from my second-degree perineal tear. This caused one of the most intense burning sensations I’ve ever experienced—which my mother-in-law could hear me screaming about in the hallway outside my hospital room door.
Because I had an epidural, I didn’t feel the tearing during delivery or the postpartum stitches my OB-GYN gave me right after. But I definitely noticed the stitches as they burned every time I went to the bathroom until they came out a few weeks later.
The uncomfortable stitches also made postpartum bowel movements pretty unbearable, although I did take warm baths as often as I could to relieve the pain. This was one of the most unpleasant parts of childbirth for me. Luckily, current research has lots to offer in terms of tips and techniques to help lower your risk of severe perineal tearing during birth.
What is a perineal tear?
The perineum is “the diamond-shaped inferior outlet of the pelvis” in a woman’s body, which is at risk of trauma and tearing during labor occurring mostly along the posterior vaginal wall toward the anus, according to a 2018 study.
In 2015, researchers found more than 85% of women having a vaginal birth will suffer some form of perineal trauma, with spontaneous tears requiring stitches occurring in at least one-third of women in the U.K. and U.S. So, if you’ve experienced tearing during childbirth, know that you are not alone.
Degrees of perineal tears
There are four degrees of perineal tears:
- First degree tear: Superficial injury to the vaginal mucosa that may involve the perineal skin.
- Second degree tear: First-degree laceration involving the vaginal mucosa and perineal body.
- Third degree tear: Second-degree laceration with the involvement of the anal sphincter.
- Fourth degree tear: Third-degree laceration involving the rectal mucosa.
As you can imagine, third- and fourth-degree perineal tears are associated with “significant pain, discomfort and impact on quality of life and intimate relationships” according to a 2020 study.
What is an episiotomy?
An episiotomy is a surgical cut of the vagina and perineum, designed to prevent serious tears during childbirth. However, performing a routine episiotomy (in which a physician gives you one as a matter of course) guarantees the mother will have perineal trauma and sutures after delivery.
Should I get an episiotomy?
There are some benefits to an episiotomy. A 2005 study found women who have never given birth are more likely to experience tearing, but a mediolateral episiotomy may help lower the risk for anal muscle tears.
However, a 2004 study revealed that avoiding episiotomy increased the rate of intact perineum and only having minor perineal trauma, while lowering postpartum perineal pain. A 2017 study found that being more selective with episiotomies (as opposed to performing routine episiotomies) resulted in fewer women with severe perineal and vaginal trauma. These add to the growing evidence that routine episiotomies should be avoided.
Choosing whether or not to have an episiotomy should be discussed with your OB-GYN before delivery, as an episiotomy may not be necessary in most low-risk labor and deliveries.
How to prevent perineal tears
Some of the risk factors for perineal tearing are outside your control. A 2019 study showed that a high incidence of perineal trauma was linked to maternal age, the number of babies born (parity), the induction of labor, gestational age, fundal pressure, and nationality.
A 2020 study found common risk factors for third- and fourth-degree perineal tears included carrying infants who were large for their gestational age and having interventions used during labor and birth including instrumental deliveries. Another 2020 study found instrumental delivery, midline episiotomy and a persistent occiput posterior position during childbirth were associated with more severe perineal tears. Avoiding these things as much as possible could help prevent tears.
A 2021 webinar by Evidence Based Birth lists the following risk factors for severe tears:
- Care provider
- Giving birth for the first time
- Higher birth weight of baby
- Forceps or vacuum use
- Shoulder dystocia
- Prolonged or very short pushing phase
- Occiput posterior fetal position
- Family history
There are a few specific techniques pregnant women can utilize to prevent perineal tears.
Lateral or upright birthing positions
When giving birth in the hospital, I was directed to lie flat on my back with my feet in the stirrups. However, some studies have found that different birthing positions may lower your perineal trauma.
A 2012 study found that giving birth in the lateral position (lying on your side) resulted in less perineal trauma compared to childbirth in the lithotomy position (on your back with feet in stirrups). This position also resulted in fewer episiotomies. Giving birth in the upright position (standing or squatting, kneeling upright or on hands-and-knees, and using a birth seat) was also shown to reduce episiotomy rates.
Some evidence shows that applying a warm compress to the perineum area during labor may reduce third- and fourth-degree tears. Also, women who used warm packs on the perineum during labor had significantly fewer third- and fourth-degree tears, less pain during and after birth, and were less likely to have urinary incontinence, according to a 2007 study.
Perineal massage during labor may reduce third- and fourth-degree tears during childbirth, according to a 2017 study. A review study of perineal massage during labor—with most women having their midwives perform perineal massages in the second stage of labor (during or between pushing time) with the index and middle fingers using a water-soluble lubricant—found a significantly lower incidence of severe perineal trauma. Adding perineal massage to your birth plan is definitely worth considering.
Opt for a water birth to help lower your risk of perineal tearing! One study found that hospital-based deliveries with second-stage water immersion had a lower risk of perineal lacerations.
The hands-on technique for childbirth is used to control the fetal head during delivery, while the hands-off approach involves not touching the perineum during the crowning process. The hands-off technique has been shown to maintain intact perineum and reduce perineal pain and episiotomy use while not increasing the risk of severe perineal trauma, postpartum hemorrhage, or longer duration of second-stage labor compared to hands-on technique, according to a 2020 study.
A note from Motherly
Although no amount of perineal tearing or stitches feels good, lowering your risk for severe tears can make a huge difference in your labor and recovery experience. Talk to your OB-GYN or midwife about any of these techniques to see if they are an option for your birth plan.
Aasheim V, Nilsen ABV, Reinar LM, Lukasse M. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev. 2017;6(6):CD006672. Published 2017 Jun 13. doi:10.1002/14651858.CD006672.pub3
Abedzadeh-Kalahroudi M, Talebian A, Sadat Z, Mesdaghinia E. Perineal trauma: incidence and its risk factors. J Obstet Gynaecol. 2019;39(2):206-211. doi:10.1080/01443615.2018.1476473
Aquino CI, Guida M, Saccone G, et al. Perineal massage during labor: a systematic review and meta-analysis of randomized controlled trials. J Matern Fetal Neonatal Med. 2020;33(6):1051-1063. doi:10.1080/14767058.2018.1512574
Dahlen HG, Homer CS, Cooke M, Upton AM, Nunn R, Brodrick B. Perineal outcomes and maternal comfort related to the application of perineal warm packs in the second stage of labor: a randomized controlled trial. Birth. 2007;34(4):282-290. doi:10.1111/j.1523-536X.2007.00186.x
Dannecker C, Hillemanns P, Strauss A, Hasbargen U, Hepp H, Anthuber C. Episiotomy and perineal tears presumed to be imminent: randomized controlled trial. Acta Obstetricia et Gynecologica Scandinavica. 2004;83: 364-368. doi:10.1111/j.0001-6349.2004.00366.x
Dekker R. Evidence-Based Birth. The evidence on the top 5 ways to prevent tearing during childbirth. 2021 webinar.
Foroughipour A, Firuzeh F, Ghahiri A, Norbakhsh V, Heidari T. The effect of perineal control with hands-on and hand-poised methods on perineal trauma and delivery outcome. J Res Med Sci. 2011 Aug;16(8):1040-6.
Frohlich J, Kettle C. Perineal care. BMJ Clin Evid. 2015 Mar 10;2015:1401.
Goh R, Goh D, Ellepola H. Perineal tears - A review. Aust J Gen Pract. 2018;47(1-2):35-38. doi:10.31128/AFP-09-17-4333
Gupta JK, Sood A, Hofmeyr GJ, Vogel JP. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database Syst Rev. 2017;5(5):CD002006. Published 2017 May 25. doi:10.1002/14651858.CD002006.pub4
Huang J, Lu H, Zang Y, Ren L, Li C, Wang J. The effects of hands on and hands off/poised techniques on maternal outcomes: A systematic review and meta-analysis. Midwifery. 2020;87:102712. doi:10.1016/j.midw.2020.102712
Jiang H, Qian X, Carroli G, Garner P. Selective versus routine use of episiotomy for vaginal birth. Cochrane Database Syst Rev. 2017;2(2):CD000081. Published 2017 Feb 8. doi:10.1002/14651858.CD000081.pub3
Meyvis I, Van Rompaey B, Goormans K, et al. Maternal position and other variables: effects on perineal outcomes in 557 births. Birth. 2012;39(2):115-120. doi:10.1111/j.1523-536X.2012.00529.x
Pergialiotis V, Bellos I, Fanaki M, Vrachnis N, Doumouchtsis SK. Risk factors for severe perineal trauma during childbirth: An updated meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2020;247:94-100. doi:10.1016/j.ejogrb.2020.02.025
Poen AC, Felt-Bersma RJF, Dekker GA, Devillé W, Cuesta MA, Meuwissen SGM. Third degree obstetric perineal tears: risk factors and the preventive role of mediolateral episiotomy. BJOG: An International Journal of Obstetrics & Gynaecology. 1997;104: 563-566. https://doi.org/10.1111/j.1471-0528.1997.tb11533.x
Ramar CN, Grimes WR. Perineal Lacerations. StatPearls Publishing. 2021.
Sidebottom AC, Vacquier M, Simon K, et al. Maternal and Neonatal Outcomes in Hospital-Based Deliveries With Water Immersion. Obstet Gynecol. 2020;136(4):707-715. doi:10.1097/AOG.0000000000003956
Wilson AN, Homer CSE. Third- and fourth-degree tears: A review of the current evidence for prevention and management. Aust N Z J Obstet Gynaecol. 2020;60(2):175-182. doi:10.1111/ajo.13127