If you’re pregnant, probably everyone you know who’s had a baby is telling you stories of their births. Some of these stories are empowering and warm, while others might make you worry. One of the things that’s often on the mind of expectant parents planning a vaginal birth is tearing of the perineum. The perineum is the bit of skin, muscles, and tissue between your anus and vagina, and it tears in the majority of vaginal births. In this blog post, we’ll discuss what perineal tearing is, as well as how you can best prepare and avoid tearing.
The first thing to know is that not everyone tears. Somewhere between 50 and 90 percent of birthing people will experience a tear, but the good news is that most of those tears aren’t severe.  Care providers divide tears into categories based on their severity. First degree tears are superficial and only involve the skin of the vagina and/or perineum. Second degree tears involve skin and muscle of the vagina and perineum. Third degree tears involve the anal sphincter, and fourth degree tears involve the anus and rectum. No more than 11 percent of tears are third or fourth degree, meaning the vast majority of tears are first- and second-degree tears.
When you experience a tear while you push your baby out, it may hurt, but it’s also possible that you may not even feel it, especially if you have an epidural. In my experience, the worst part of having a tear was the quick injection of anesthetic that my midwife used to numb my perineum in order to sew up my second-degree tear. It was a quick pinch, no more painful than any other shot, and then I couldn’t feel anything. Most people heal fine on their own or the care provider will use a few sutures to bring the skin together so it can heal itself. More severe tears require more extensive repair, but you’ll also likely be offered more significant pain medication. If you are in pain, ask your nurse or care provider for medicine.
All of that said, what are the things you can do to prevent tearing? The first thing is to choose your care provider and place of birth carefully. Evidence says you’re less likely to tear at a home birth.  And if you have a choice of obstetrician or midwife, talk to them about how they support the second stage of labor, also known as the pushing stage. Discuss how routinely they cut episiotomies—cuts to the perineum that some providers use because they believe that these cuts help babies get out faster—and how long they expect pushing to take. If someone routinely cuts episiotomies, this isn’t necessarily evidence-based. It’s also best to have a care provider that you trust, so that no matter what happens during your birth, you feel at peace with the outcome. And a recent study from Sweden showed that having more than one midwife at vaginal births prevents severe tearing by nearly a third, so ask your care provider how many people are in the room. 
Other things evidence-based ideas to prevent tearing include:
Perineal massage, which you or your partner can do during pregnancy or your care provider (doctor or midwife) can perform during pushing, is associated with a lower risk of third- and fourth-degree tears. To practice perineal massage during pregnancy sit with your legs apart and your back against something firm. Use an unscented massage oil, olive oil, or coconut oil on your fingers and put your thumb or finger about two inches into your vagina and press into one side (toward your left leg for instance). Then, keeping firm pressure, sweep your finger or thumb down toward your anus and then up toward your other leg. Continue sweeping back and forth for about five minutes. You or your partner can do this every night to help your perineum stretch.
Warm compresses applied to your perineum during pushing may also decrease the risk of tearing. Ask your doctor, midwife, or nurse if this intervention is something that they offer. If not, you can make your own warm compress with a washcloth and warm water. Make sure it’s not too hot.
Take care of your pelvic floor. Doing pelvic floor exercises (squatting, kegels, tensing and relaxing in time with your breath) are all good ideas during pregnancy. And a pelvic floor physical therapist can also help you prepare for physiologic birth.
- Ramar CN, Grimes WR. “Perineal Lacerations.” [Updated 2022 Jun 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing.
- Scarf, Vanessa L et al. “Maternal and perinatal outcomes by planned place of birth among women with low-risk pregnancies in high-income countries: A systematic review and meta-analysis.” Midwifery. (2018). doi:10.1016/j.midw.2018.03.024
- Edqvist, Malin et al. “The effect of two midwives during the second stage of labour to reduce severe perineal trauma (Oneplus): a multicentre, randomised controlled trial in Sweden.” (2022). doi:10.1016/S0140-6736(22)00188-X