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You Can’t *Completely* Avoid Tearing During Birth, but These 10 Midwife-Approved Tips May Help Reduce the Severity

  • 6 days ago

It’s never your fault if you do, BTW!

As you head into your third trimester, you’re getting more and more excited to meet your baby. But some worries surrounding labor and delivery surface, too—and that’s totally okay! While your body is designed to give birth, the idea of pushing out a baby (or getting a C-section) can be intimidating. On top of that, there’s potential side effects to think about, like constipation, pain, or vaginal tearing. You may even wonder if it’s possible to prevent tearing during birth.

Vaginal tearing happens when the skin or muscle around your vagina and perineum (the area between your vagina and anus) rip because they can’t stretch enough. It’s pretty common (between 53 and 79 percent of people tear, per the American College of Obstetricians and Gynecologists (ACOG)), and can vary in severity depending on how deep it goes. Some different degrees include the following, per Penn Medicine:

  • First-degree tear (the least severe type of tear): only affects the perineal skin and often doesn’t require any stitches
  • Second-degree tear (the most common): affects both the skin and muscle of the perineum and requires stitches to repair
  • Third-degree tear: extends into the anal sphincter (the muscle that surrounds the anus) and repairs may require general anesthesia in an operating room
  • Fourth-degree tear (the least common, but most severe type of tear): extends from the vagina into the anal sphincter, but also into the rectum itself, and repairs may require care of a specialist

Sooo…can tears be prevented? Unfortunately, many (if not most) vaginal tears are unavoidable and are due to risk factors beyond your control (more on this later). Still, there are some things you can do during pregnancy and labor to try to prevent tearing (or reduce its severity).

KEEP IN MIND

Because there’s no guarantee that you can prevent vaginal tearing during birth, try not to beat yourself up if you do. Every body is different and will react differently to birth.

What to do before labor to avoid tearing

In preparation for labor, there are certain things you can try in pregnancy to help prevent tearing.

1. Try perineal massage

Your perineum is small (about 1.5 inches long on average), but it plays a big role in childbirth. The skin and tissues “down there” must be pliable enough to stretch and allow your baby to pass through the birth canal.

Some say that gently stretching your perineum—known a perineal massage—can help your body prepare for labor and lower your risk of tearing, says Marcy Crouch, PT, DPT, a pelvic floor physical therapist and co-host of the No Mama Left Behind podcast.

In fact, some research shows that “perineal massage may reduce serious tears involving both the vagina and rectum,” says midwife Karen Jefferson, DM, CM, FACNM, director of professional practice and policy at the American College of Nurse-Midwives. She points to an October 2023 systematic review in the Journal of Gynecology Obstetrics and Human Reproduction, which concluded that prenatal perineal massage protects the perineum from injuries in birth. The authors also said it can lessen the likelihood of fecal and gas incontinence (i.e., when you can’t control the release of your poops or farts) in the postpartum period.

Still, “the evidence that prenatal perineal massage helps prevent tearing is pretty limited,” says Nicole Rankins, MD, an OB/GYN and host of All About Pregnancy & Birth Podcast. She’s right: The data hasn’t been totally consistent. While some studies show perineal massage can reduce your risk of severe tears, others have found it makes little or no impact on tearing outcomes, according to the Cleveland Clinic.

The research is mixed because perineal massage is usually done at home, so it’s hard to know if everyone is doing it the same way. Plus, there are many other factors that can affect whether you’ll tear or not (like how big your baby is, how fast they crowned, and what interventions your doctor used). This is why it’s important to not blame yourself if you tear (it’s never your fault!).

Ultimately, the choice to try perineal massage is yours! It’s not a make-or-break decision, says Dr. Rankins. Don’t feel pressure to keep going if it’s uncomfortable (it’s not like a relaxing back massage, BTW) or if it’s not your thing.

But if you are interested in trying perineal massage, give it a try at around 34 weeks (to reduce your risk of third- or fourth-degree tears), Crouch says. Do these steps at least three to four times a week for five to 10 minutes at at time, per Crouch and the Cleveland Clinic:

  1. Wash your hands with a mild soap to prevent bacteria from entering your vagina. You’ll also want to make sure your fingernails are trimmed short to keep from scratching your delicate tissue.
  2. Lie on your back with your legs wide and knees bent, making sure that your back is supported the entire time.
  3. Apply a natural oil (like coconut oil or olive oil) or a water-soluble lubricant to your fingers, thumbs, and perineum.
  4. Place a single, lubricated thumb about 1 to 1.5 inches (that’s about to your first knuckle) into your vagina. Gently insert your other thumb.
  5. Press both thumbs on the back wall of your vagina toward your anus, applying enough pressure to feel slight stretching in your vagina. Hold this position for a minute or two.
  6. Move both thumbs slowly in a U-like motion so you feel a gentle stretch.

Note: If you have a vaginal infection, like thrush or genital herpes, you should avoid perineal massage because it can cause the infection to spread.

2. Choose the best medical provider for you

The things your medical provider does during labor can either reduce or increase your chances of tearing. For instance, you have a higher chance of severe tears with doctors who perform routine episiotomies (i.e., a cut made in the tissue between the vaginal opening and anus), per a November 2022 paper in Cureus.

But working with someone who’s “experienced in delivering babies with minimal intervention can significantly affect your birthing experience,” says Crouch. Interventions like episiotomies (or forceps or vacuum during delivery) should only be used when the health of you or your baby is in danger.

The best way to determine if your doctor’s right for you? Ask about their episiotomy and C-section rates at the beginning of your pregnancy. “These rates should be very low and these procedures should occur with consent in a situation where it is medically necessary,” Crouch says.

Your doctor should also be patient and give you time to let your perineum stretch slowly, when your baby is crowning, Jefferson says. The more gradually this area stretches, the less likely it’ll rip. “Providers who are patient and allow the labor process to proceed at a natural pace without rushing can help reduce the risk of tears,” Crouch agrees.

You may find a midwife fits all these requirements. In fact, an April 2016 review in the Cochrane Database of Systematic Reviews found that midwives tended to use fewer interventions (forceps, vacuum, and episiotomy). Plus, people under their care were more likely to feel satisfied with their birthing experience (a big plus).

3. Communicate with your team

“Keep the lines of communication open with your delivery team,” Crouch says. “Let them know your concerns about tearing and your desire to try positions or strategies that can help minimize the risk.” Ask your doctor or midwife what they do to prevent tears, and what they suggest you do to help prepare for delivery.

No matter who you choose—OB/GYN or midwife—it’s important you feel comfortable enough to voice your concerns. You want a provider who listens to your fears and respects and supports your birth plan. If you’re feeling rushed or dismissed, they may not be the right one for you.

4. Incorporate push prep

Just like you would train for a marathon, you can also train for giving birth. “Push prep,” in particular, can prepare your body for labor. This can potentially protect your perineum from severe tears. “Push prep involves training the pelvic floor muscles to relax and stretch, complementing the natural birthing process,” Crouch says. “It is especially helpful to train the pelvic floor muscles in specific positions you would like to try during birth.”

Wondering what that looks like? It’s doing perineal massage in different birthing positions (think: on your hands and knees, lying on your side, squatting, etc.) as well as practicing breathing techniques. “This awareness allows for more controlled and effective pushing, which can reduce trauma to the tissue,” Crouch says.

Keep in mind, though, “push prep is not universally defined, so it can be difficult to assess how well it reduces tearing,” Dr. Rankin says. Even so, it generally includes education about positions, pushing, pain management, and/or pelvic floor exercises, and all that is beneficial for birth, she says.

5. Invest in childbirth education

“In general, childbirth education is helpful to understand what is happening in your body during birth and to help you know what your options are (like different positions) so that you can better advocate for yourself,” Dr. Rankins says. For example, many people don’t know you don’t have to give birth on your back, Crouch says.

That said, “a lot of birthing classes are very focused on baby and not so much on the person giving birth,” Crouch says. You might have to do a little research to find a birth-prep program that centers around the birthing person’s experience. Crouch’s online birth prep and recovery course called Down There Done Right covers ways to reduce your risk of tearing and strategies to speed up your postpartum recovery.

6. Focus on a nutrient-dense diet

While eating fruits and veggies can’t prevent you from tearing, what you put on your plate can play a part in the health of your tissues. “Good nutrition is important for skin integrity and healing,” Jefferson says. Getting plenty of protein and vitamin-rich foods (already recommended in pregnancy for a healthy baby) can support your skin through all the changes it goes through in both birth and postpartum.

What to do during labor to avoid tearing

Here are a few things you can try during labor to potentially lower your likelihood of vaginal tearing.

1. Apply warm compresses

“Some say that applying a warm compress to the perineum during the second stage of labor (when you’re pushing) can help soften the tissue and increase its elasticity, potentially reducing the likelihood of tearing,” Crouch says. A June 2017 Cochrane Review supports this theory in certain cases. The authors found that people who got moist, warm compresses in labor had fewer third‐ or fourth‐degree perineal tears.

That said, evidence is limited. “It’s hard to say if this is a wives’ tale or not, though, because researchers can’t come to a consensus,” Crouch says. Case in point: While warm cloths may reduce the risk of severe tearing, the same 2017 Cochrane Review concluded that the effect of this practice on other outcomes (like first- or second-degree tears or the need for episiotomies) was unclear or mixed.

2. Practice controlled pushing

If your baby comes out of the birth canal quickly, you might have a higher chance of tearing. That’s because the tissues won’t have time to stretch. “Slow, controlled pushing, which is sometimes referred to as spontaneous pushing, allows the perineum to stretch gradually and can reduce tearing,” Dr. Rankins says. A slower pace allows “the tissues to adapt more effectively to the pressure and stretching that happens during childbirth,” she says.

Crouch seconds this: “When the baby’s head crowns, gentle, controlled pushing and breathing techniques can significantly help manage the pressure on the perineum and reduce tearing.”

But sometimes you may not have a choice to slow things down. “Don’t sweat this too much,” Crouch says. “The speed of labor is something we can’t really control.” In other words, if the baby is coming fast, and you need to push, you do you. Listen to your body and go with the flow.

3. Try certain birthing positions

Contrary to popular belief, you don’t have to labor on your back. There are many other optimal birthing positions. “It used to be common practice to put women flat on their backs and put their feet in stirrups,” Jefferson says. But this immobilized position “is not ideal for pushing, for the health of the baby, and for the perineum,” she says.

“Giving birth while lying down, particularly on the back (supine position), may [actually] increase the risk of vaginal tearing,” Dr. Rankins says. “It also makes it easier for doctors to do episiotomies, which increases the risk of tearing,” she adds.

According to Crouch, evidence has shown upright positions that “free the sacrum” (i.e., the triangular bone at the base of the spine that connects to the pelvis) may reduce tearing, she says. These positions give your baby more room to pass by your sacrum. According to a March 2016 review in the British Journal of Midwifery, this includes kneeling and being on all-fours.

Still, it’s not all cut and dry. The same systematic review also concluded that certain upright positions (sitting, squatting, and using a birth-stool) might increase your risk of perineal injury.

The takeaway: Though some positions might be more protective, there’s no perfect pushing position, and no guarantee you won’t tear. At the end of the day, listen to your body. Whatever position feels good and helps you progress is the right one for you.

Can you give birth in an upright position with epidural?

An epidural (a pain medication injected through a needle and catheter into the lower part of your back) is given during labor to number the lower half of your body. This can make it a bit more challenging to birth in upright positions, says Dr. Rankins. But it’s not impossible.

“Contrary to popular belief, you can use different birthing positions with a low-dose epidural,” Crouch says. Like the name implies, it’s a lower dose of an anesthetic. It provides pain relief but allows you to stay somewhat mobile. “You just have to stay in the bed,” Crouch says. With help from your care team and/or your partner, you can maneuver into different positions like kneeling or all-fours. Side-lying positions with an epidural might help protect the perineum, too.

4. Incorporate perineal massage

Perineal massage may help during labor, too. In the pushing phase, your medical provider can can place their middle and index fingers into the vagina to stretch the perineum from side-to-side, which may help protect your perineum. In fact, the same June 2017 Cochrane Review found that perineal massage during the second stage of labor resulted in more people with an intact perineum and fewer third- or fourth-degree tears.

But again, the data is inconsistent. The authors also noted that perineal massage didn’t appear to reduce first- or second-degree tears or episiotomies.

Another note: If your doctor or midwife wants to do perineal massage, “there should be consent first,” Dr. Rankins says. This means, they should ask whether it’s okay to touch your genitals. They should also explain any risks and benefits, so you can make an informed decision.

Who is more at risk of tearing during birth?

Tearing in birth is common. But certain people are more likely to tear than others. Some risk factors that increase your odds include the following, per the Cleveland Clinic:

  • It’s your first delivery.
  • Your baby was face up instead of face down during delivery.
  • Forceps (or a vacuum) were used during delivery.
  • You have a large baby (more than 8 pounds).
  • Your second stage of labor (pushing stage) was prolonged (or very short).
  • You’re of Asian ethnicity or descent.
  • You had an epidural.

Other possible risk factors include:

  • Your choice of care provider (some have higher rates of severe tearing and use of interventions like episiotomy, forceps, or vacuum)
  • Shoulder dystocia (when one or both of your baby’s shoulders get stuck inside your pelvis during a vaginal delivery)

How to recover from tearing

Vaginal tears often require stitches, which dissolve on their own after about six weeks, per the Cleveland Clinic. The tear itself, though, will often heal within two weeks (though it can take longer for severe tears). In the meantime, you might feel discomfort doing ordinary things, like pooping, coughing, or sneezing. Anything that puts pressure on your perineum can be pretty painful.

Fortunately, there are a few things you can do for relief. Try these tips for any type of tear, per the Cleveland Clinic:

  • Use a peri-bottle (a squirt bottle) to wash yourself clean after using the bathroom. Lukewarm water feels the best.
  • Gently pat yourself dry with toilet paper instead of wiping.
  • Apply ice packs or wear special sanitary pads that have a cold pack inside. These pads are often available in the hospital or at your local drugstore.
  • Avoid constipation by drinking plenty of water and using a stool softener.
  • Take a sitz bath. Fill your bathtub with a few inches of warm water and sit in it for a few minutes.
  • Sit on a donut pillow. This relieves pressure from your bottom, which can be especially helpful if you had a third- or fourth-degree tear.
  • Avoid exercises or uncomfortable movements that aggravate your perineal area. This could include squats or walking down steps.
  • Take an over-the-counter pain medication. Always check with your doctors beforehand if you’re breastfeeding, chestfeeding, or pumping.
  • Use a pain-relieving numbing spray like Dermoplast.
  • Line your sanitary pads with witch hazel pads like Tucks.

Potential complications of vaginal tears

While incredibly uncomfortable, most vaginal tears heal within two weeks. However, if your pain persists, and it’s accompanied by other symptoms, you might be dealing with an infection. Keep an eye out for these possible signs of an infection, per Penn Medicine:

  • Painful swelling
  • Redness
  • Unpleasant odor (or discharge)

You’re also more likely to have certain complications with third- and fourth-degree tears, which may include the following, per the Cleveland Clinic:

  • Bleeding
  • Painful intercourse (once you’re given the “okay” to have sex)
  • Fecal incontinence (leaking poop)
  • Ongoing pain and soreness
NOTE

Tearing during childbirth—and the continuing complications—can also be traumatic for some people, which can have a major effect on mental health. If you feel any of these issues, let your provider know ASAP. While fairly common, these problems are not normal, and you do not have to learn to live with them. Treatments are available (from pelvic floor physical therapy to talk therapy) to help.

The bottom line

Vaginal tearing during birth is not completely preventable. In fact, most people tear just a little. But doing certain things during pregnancy and labor may help reduce the risk (and severity) of tearing. Ultimately, it all depends on your body and birth experience; you can’t control the size of your baby, shape of your pelvis, or speed of labor.

Of course, it’s still important to prep. But if you do tear, remember: it’s not your fault. Try to focus on healing and recovery, and ask for help if you need it.