As a doula and childbirth educator, I have found that one of the biggest concerns of birth-givers is perineal tearing.
So, to help you avoid unnecessary perineal trauma, here are some techniques AND the research on their effectiveness.
But first: one of the most important things you can do is choose a medical birth professional who knows how to support your perineum! There is a wide range of expertise, and variety in approach, among medical professionals. So ask the medical members of your birth team about their practices. [For more about choosing the medical professionals for your birth support team, read my blog post: Who's Responsible? (1)]
You might pose questions like:
[WARNING: There are pictures below of actual perinea, perineal massage and a baby emerging. Stop here if you're not interested.]
So, to help you avoid unnecessary perineal trauma, here are some techniques AND the research on their effectiveness.
But first: one of the most important things you can do is choose a medical birth professional who knows how to support your perineum! There is a wide range of expertise, and variety in approach, among medical professionals. So ask the medical members of your birth team about their practices. [For more about choosing the medical professionals for your birth support team, read my blog post: Who's Responsible? (1)]
You might pose questions like:
- What techniques will you use to support my perineum when my baby's head is emerging?
- What is your episiotomy rate for first time birth-givers (or second, or third...)?
- Are you skilled in supporting people giving birth in a variety of pushing positions?
[WARNING: There are pictures below of actual perinea, perineal massage and a baby emerging. Stop here if you're not interested.]
If you have a partner, it would be very helpful to have this person be part of the conversation with the medical professionals on your team. Your partner is in a prime position, with good preparation, to be the "protector of your perineum". So share this blog with them.
Remember, you (and your partner) have the most invested in the outcome, so be prepared!
Support options
Perineal massage during the last trimester of pregnancy
The research on perineal massage during pregnancy shows mixed results. The effect, when there is one, is not very big (on the order of a 5% reduction in the incidence of tears that required stiches for FIRST TIME birth-givers). You can read a detailed discussion of the research on Lamaze’s web site Connect the Dots titled “What is the evidence for perineal massage during pregnancy to prevent tearing?” (2) The goal is to get used to the sensation of the stretch, and to increase elasticity in your perineum.
Here's a quick primer on how to do it:
If you are massaging yourself, place your thumbs up to about 2 inches inside the lower vaginal opening. Or, partners use your first and second fingers.
There are two stretches:
Remember, you (and your partner) have the most invested in the outcome, so be prepared!
Support options
Perineal massage during the last trimester of pregnancy
The research on perineal massage during pregnancy shows mixed results. The effect, when there is one, is not very big (on the order of a 5% reduction in the incidence of tears that required stiches for FIRST TIME birth-givers). You can read a detailed discussion of the research on Lamaze’s web site Connect the Dots titled “What is the evidence for perineal massage during pregnancy to prevent tearing?” (2) The goal is to get used to the sensation of the stretch, and to increase elasticity in your perineum.
Here's a quick primer on how to do it:
If you are massaging yourself, place your thumbs up to about 2 inches inside the lower vaginal opening. Or, partners use your first and second fingers.
There are two stretches:
- Gently press downwards (towards the anus)
- Gently press outwards
It is only a gentle stretch – it should not be painful.
You do it 1-2 times a week starting at 34 weeks. And that’s ALL! More often may actually increase your risk of tearing.
For more detailed, step by step directions on how to do these stretches, check out MamaNatural's article on Perineal Massage during pregnancy (3).
In sum, the evidence is that this maybe helps a little. So if you don't like it or don't want to do it, don't. If you feel like it’s helping you prepare for birth by getting used to the sensations of stretching, go ahead. It's YOUR vagina after all!
You do it 1-2 times a week starting at 34 weeks. And that’s ALL! More often may actually increase your risk of tearing.
For more detailed, step by step directions on how to do these stretches, check out MamaNatural's article on Perineal Massage during pregnancy (3).
In sum, the evidence is that this maybe helps a little. So if you don't like it or don't want to do it, don't. If you feel like it’s helping you prepare for birth by getting used to the sensations of stretching, go ahead. It's YOUR vagina after all!
Techniques for the pushing part of labor: Here's a summary of the World Health Organization (WHO) recommendations from February 2018 (4). They discuss two techniques: You can choose to do either or both or none at all.
During the second stage of labor the person doing the massage uses lubricant and inserts two fingers into the vagina and applies mild, downward pressure to the vagina towards the rectum, while moving the fingers with steady strokes from side to side. Massage in some studies was performed only during contractions in the second stage and in others was continued during and between pushes.
The photo on the right, below, may be mild or may not, I can't tell. But it's definitely more than two fingers!
- Warm compresses: High-certainty evidence indicates that warm compresses applied to the perineum during pushing (see the photo on the left below), reduce the incidence of 3rd or 4th degree perineal tears (these are the more severe kind). This was found in four research trials including a total of 1,799 women. The Relative Risk (RR) of a 3rd or 4th degree tear was 0.46 with a 95% Confidence Interval (CI) of 0.27–0.79. The absolute effect on 3rd or 4th degree tears was estimated as 24 fewer tears per 1000 (with a range of 9 to 33 fewer). That means that for every 1000 people for whom warm compresses were used during pushing, between 9 and 33 fewer people had a 3rd or 4th degree tear.
- Perineal massage during labor: High-certainty evidence indicates that perineal massage during the pushing stage (demonstrated in the photo on the right below) reduces 3rd or 4th degree perineal tears. This was found in five research trials, including a total of 2,477 women. The RR was 0.49 with a 95% CI of 0.25– 0.94. The absolute effect was estimated to be 5 fewer tears per 1000 (with a range of 2 to 22 fewer). That means that for every 1000 people for whom this technique was used during pushing, between 2 and 22 fewer people had a 3rd or 4th degree tear.
During the second stage of labor the person doing the massage uses lubricant and inserts two fingers into the vagina and applies mild, downward pressure to the vagina towards the rectum, while moving the fingers with steady strokes from side to side. Massage in some studies was performed only during contractions in the second stage and in others was continued during and between pushes.
The photo on the right, below, may be mild or may not, I can't tell. But it's definitely more than two fingers!
YOU are going to have to be the judge of whether the massage is MILD or not!
How does it FEEL???!!!! You can say STOP if it feels too vigorous to you!
How does it FEEL???!!!! You can say STOP if it feels too vigorous to you!
A note to your birth support team members: YOU (partner/family/friend/doula) may be the one most able, during the pushing stage, to be THE PROTECTOR OF THE PERINEUM. So, watch what is being done. Does it look gentle? Does it look like it hurts? Is the birth-giver giving signs that it hurts? A little? A lot?
If you think it's too rough, use the word STOP (5).
The research evidence supports only MILD pressure. Too much pulling and tugging can actually INCREASE the chances of perineal tearing. So if the birth-giver says it hurts more than just a little bit, that's too much. AND, the benefit of doing this is not very big. In fact, it's quite small. So if your partner/daughter/client wants them to stop, make them stop. Read more about how to do that here (5).
Note that warm compresses appear to be somewhat MORE effective than perineal massage during the pushing stage, with the added benefit that compresses usually FEEL GOOD.
Since the effectiveness of these techniques is pretty small, doing nothing is also a reasonable option.
If you think it's too rough, use the word STOP (5).
The research evidence supports only MILD pressure. Too much pulling and tugging can actually INCREASE the chances of perineal tearing. So if the birth-giver says it hurts more than just a little bit, that's too much. AND, the benefit of doing this is not very big. In fact, it's quite small. So if your partner/daughter/client wants them to stop, make them stop. Read more about how to do that here (5).
Note that warm compresses appear to be somewhat MORE effective than perineal massage during the pushing stage, with the added benefit that compresses usually FEEL GOOD.
Since the effectiveness of these techniques is pretty small, doing nothing is also a reasonable option.
What about episiotomies (cutting the perineum to enable the head to emerge)? We’ve known for at least 15 years that routine episiotomy does more harm than good. A review of the research on routine use of episiotomies published in JAMA in 2005 (6) concluded:
“Our systematic review finds no benefits from episiotomy. We identified fair to good evidence suggesting that immediate outcomes following routine use of episiotomy are no better than those of restrictive use. Indeed, routine use is harmful to the degree that some proportion of women who would have had lesser injury instead had a surgical incision.”
“Our systematic review finds no benefits from episiotomy. We identified fair to good evidence suggesting that immediate outcomes following routine use of episiotomy are no better than those of restrictive use. Indeed, routine use is harmful to the degree that some proportion of women who would have had lesser injury instead had a surgical incision.”
Breathing your baby out during crowning: Crowning is when your baby’s head is stretching your perineum, just before the head emerges. This is the time when you might feel ready to just get it over with; push with all your might and be done. However, giving your perineum the time it needs to stretch will lower your chances of tearing. This is the time for good coaching from your support team (OB, midwife, doula, partner, etc.). You want to resist the urge to push and instead, blow your air out, like blowing out a LOT of candles. Research has found this reduces the chances of, or severity of perineal tearing (7).
One more question to consider: Who's hands should be supporting your perineum?
Or, put another way: Who's vagina is it anyway????
One more question to consider: Who's hands should be supporting your perineum?
Or, put another way: Who's vagina is it anyway????
For a great discussion of that, read Hands Out of My Vagina (8).
Avoiding perineal tears is often a top priority for birth-givers. Protecting your perineum depends on what you choose to do, and what you allow to be done to you. It also depends on the techniques used by the people on your support team. Do your research. Prepare yourself and your team to protect your perineum.
Remember, if you don't know your options.... you don't have any!
Avoiding perineal tears is often a top priority for birth-givers. Protecting your perineum depends on what you choose to do, and what you allow to be done to you. It also depends on the techniques used by the people on your support team. Do your research. Prepare yourself and your team to protect your perineum.
Remember, if you don't know your options.... you don't have any!
References:
- Pregnant? Who's responsible for all this? From Dalia's Soap Box, online here.
- What Is the Evidence for Perineal Massage During Pregnancy to Prevent Tearing? By Rebecca Dekker, PhD, RN, APRN of Evidence Based Birth online here.
- How to do Perineal Massage - Diagram, Photos & Video, by Genevieve Howland, online here.
- WHO recommendation on techniques for preventing perineal trauma during labour. 17 February 2018. Online here.
- Permission to Touch: bodily autonomy during pregnancy and birth. From Dalia’s Soap Box, online here.
- Hartmann K, Viswanathan M, Palmieri R, Gartlehner G, Thorp J, Lohr KN. Outcomes of Routine Episiotomy: A Systematic Review. JAMA. 2005;293(17):2141–2148. doi:10.1001/jama.293.17.2141 online here.
- Ahmadi Z, Torkzahrani S, Roosta F, Shakeri N, Mhmoodi Z. Effect of Breathing Technique of Blowing on the Extent of Damage to the Perineum at the Moment of Delivery: A Randomized Clinical Trial. Iran J Nurs Midwifery Res. 2017;22(1):62-66. doi:10.4103/1735-9066.202071 online here.
- Hands Out of My Vagina, by Sarah Clark, published on September 4, 2014 online here
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