Birth is a complex interplay between a mother and baby and preventing significant tears is often at the forefront of the mothers mind when preparing her body for birth.
There are many factors that can influence a woman’s risk of tearing.
Factors that could increase risk of tears include:
Non modifiable:
- Being a first time mum
- Your age
- Having a large baby or large head circumference
- Anatomy of your perineum (length of that tissue)
- Previous perineal trauma (scar tissue)
- Shoulder dystocia (where baby’s shoulders get stuck)
Modifiable
- Position
- Laying on your back
- Laying on your back with legs in stirrups
- Squatting
- Synthetic oxytocin (Used in an induction)
- Coached or forced pushing
- Forceps
Factors that could decrease risk of tears
- Positioning
- All fours
- Side-lying
- Warm water
- Warm compress
- Flexibility of perineal tissue
- Instinctive behaviours
- Closing the legs
- Gasping / stopping pushing and slowing down delivery of baby’s head
- Holding own perineum / baby’s head
- Awareness of pelvic floor tone
Perineal pressure is a technique that can be used to reconnect to this part of your body, observe the effect of different positions on the tautness in this tissue, teach relaxation techniques in response to pressure and desensitise pain.
Traditionally perineal massage was taught as aggressively stretching the tissue with sweeping motions in order to improve its flexibility. The way I like to teach perineal massage adopts a more gentle approach and encourages the woman to connect with this part of her body and use breath techniques to soften her body in response to pressure held in different parts of the perineum and pelvic floor. This sustained pressure also allows pain desensitisation as the intensity of the sensation decreases with time.
I will usually go through these techniques in an in-person pregnancy consultation and teach a woman ways she can perform them at home on herself and with the help of her partner. The research shows that performing perineal massage can decrease a woman’s risk of perineal tears, particularly severe tears.
Understanding the impact of her position for both tautness in the perineum and the rate of babies descent can also help her prepare for birth. Having the knowledge of different positions can be particularly helpful in the case of an epidural.
Assessment of your pelvic floor during pregnancy can also be helpful for identifying where you sit on the spectrum of overactive to underactive. If the pelvic floor is really tight and overactive, you can imagine how it could increase the risk of tears. A recent study by Dieb et al compared a group that did perineal massage and pelvic floor exercises to controls and found that the perineal massage and pelvic floor group had reduced rate of episiotomy and perineal tears as well as reduced pain after birth!
In summary, to decrease the risk of tears during childbirth, women can consider various factors. Positioning plays a crucial role, with alternatives like all fours or side-lying being beneficial. Warm water or warm compresses can help, as can slowing down the delivery of the baby’s head allowing time for the perineum to gently stretch. Perineal pressure and pelvic floor exercises have also been shown to reduce rates of tears.