Your Guide to an Intact Perineum (Avoiding Tears and Episiotomies)

When we discuss fears of labor, one of the most common concerns that expectant parents bring up is a fear of tearing and it almost always elicits a cringe from partners at the mere mention.  To think that such a sensitive area - already stretched in response to the emerging baby - has the potential of tearing to create more space is enough to make anyone's eyes roll into the back of her head.  But there's a little known secret out there - tearing and episiotomies don't have to be the norm and actively minimizing perineal trauma is possible.

This amazingly resilient yet stretchy area between the vagina and the anus is called the perineum (the "taint" in more familiar terms).  This fibromuscular structure is part of the pelvic floor and is known as the central tendon of the pelvis because many of the pelvic structures intersect here (Ritchie).  Throughout the labor process and especially during the pushing phase of labor, the perineal area is flooded with blood and the hormones relaxin, which softens the ligaments and tissues, and progesterone which encourages smooth muscle relaxation.  These hormones allow the area to stretch and become even more elastic to accommodate the baby's slowly crowning head.

Let's do a quick anatomy lesson - get the lay of the land so to speak - so we can understand why minimizing or eliminating damage to the perineal area is a good idea and also why a natural tear is not always the traumatic thing we so greatly fear.  If you're not so into the why, feel free to jump ahead a few paragraphs for the tips and tricks on reducing perineal damage.

We'll begin with the basics of the pelvic floor.  The three layers of muscle of the pelvic floor are responsible for keeping the structures above it, such as the bladder, uterus, and rectum, in place.  The three layers are the superficial perineal layer, the deep urogenital diaphragm layer, and the pelvic diaphragm.  (Beyond Basics).  For our purposes, we will be discussing the superficial perineal layer, the group of structures providing support to and coming together at the fibromuscular mass between the vagina and the anus, called the perineal body.  The perineal body or perineum anchors several muscles including the levator ani (helpful in providing support and function for the anal sphincter) and the external anal sphincter.  The superficial transverse perineal muscle starts at the sit bones and connects to the perineal body, reinforcing the deep transverse perineal muscle to further stabilize the perineal body.  The deep transverse perineal muscle, starting at the inner part of the ischiopubic rams and connecting to the perineal body and external anal sphincter, is responsible for keeping the perineal body in place as well as supporting the function of the levator ani and the urethra sphincter, which controls the flow of urine.  The perineal membrane, a fascial thickening (connective tissue fibers) as opposed to muscle, starts at the pubic symphasis and attaches to the ischial spines, providing additional support to the perineal body (Ritchie).  The bulbospongiosus arises at the perineal body, wrapping around the vagina, inserting at the clitoris (O'Rahilly).  A great diagram of all of these muscles can be viewed at this link from www.netterimages.com.  What is the take away from all this great info?  The perineal area is pretty darn important when it comes to supporting the entire pelvic floor, vaginal, and anal region.  So let's get an idea of why we should take good care of it.

The Royal College of Obstetricians and Gynaecologists in the UK estimates that 85% of people with vaginal births will have some degree of tearing yet statistics from "Birth Matters: A Midwife's Manifesto" show that the rate of tearing at the birth center on the Farm in Tennessee, where midwives have attended close to 3000 births, is about 31.3%.  As a unified nation, the United States does not have accurate statistics on tearing as standards for reporting vary from state to state.

Perineal tears are classified into first, second, third, and fourth degrees.  
First Degree: the fourchette (where the labia minora meet at the perineum) and vaginal mucosa are damaged and underlying muscle is exposed but intact
Second Degree: the posterior wall and the perineal muscles are torn but the anal sphincter is intact
Third Degree:  tear extends to the anal sphincter but the rectal mucosa is intact
Fourth Degree: anal canal is opened and tear may spread to the rectum

General complications from perineal trauma can include pain which can interfere with bonding and the establishment of breast/chestfeeding, increased risk of postpartum depression, infection, and even problems with fainting after urination and defecation (Tidy).  Minor perineal damage from tearing can include extended healing time and discomfort from stitches and healing while complications from an episiotomy (a cut through the perineal area to enlarge the vaginal opening) can include longer healing time, more sutures, and a greater likelihood of third and fourth degree tearing.  Third and fourth degree tears are associated with being more than twice as likely to experience fecal incontinence (Borello-France, et al.) with the potential of lasting five to ten years after birth (Evers, et al.).  Tearing as compared to an episiotomy has a lower risk of posterior perineal trauma, lowered risk of needing suturing for perineal trauma, and lower risk of healing complications at seven days postpartum.  The only disadvantage to tearing over having an episiotomy is an increased risk of anterior perineal damage.  However, this research was done with laboring people in a supine (reclined) position which increases the pressure from the baby's head on the anterior perineum.  

In the 1970's, almost all vaginal births were accompanied by episiotomy without any research showing better outcomes; the research simply showed a lesser likelihood of tearing if an episiotomy was cut (let's think about that - if the area has already been cut, common sense would tell us that aside from the extreme of a third or fourth degree tear, the area is unable to tear because it has already been separated).  It was standard to cut an episiotomy on first time parents and then on those whom had previous episiotomies, which adds up to about 100% of birthing people.

The most accurate current episiotomy rates we have come from the UK, a country whose reporting standards are far more accurate and consistent from region to region than those of the U.S.  According to the Royal College of Obstetricians and Gynaecologists (RCOG) guideline from 2007, rates vary greatly from country to country; episiotomy rates are 8% in Holland, 14% in the UK, 50% in the U.S., and 99% in Eastern Europe (Tidy).  Rates also vary greatly from midwives to obstetricians, with 3.6% of midwives compared to 25% of obstetricians cutting episiotomies in the U.S. (American College of Nurse-Midwives).

Now that we know some of the basics, let's get to the meat of it.  What are some proven ways to lessen the chances of perineal trauma?

Know Your Rights: It must be stated first and foremost that knowing one's rights in the laboring room is the most basic step in becoming an informed decision maker during the laboring process.  Knowing your rights will help you build confidence in advocating for yourself and decreasing the likelihood of unnecessary perineal trauma.  Check out a great list of your rights here.

Nourish Your Body with Optimal Nutrition:  "Good nutrition is vital to your body's work in preparing the perineum for stretching during birth. Hormonal changes during pregnancy cause the tissues of your cervix and perineum to become extremely thick and elastic. Crucial to this process is an adequate intake of protein, vitamin E, and short-chain fatty acids, which consist of two types of 'good' fat, Omega-3 and Omega-6.  Short-chain fatty acids are found in nuts and seeds, cold-pressed oils, all types of beans, and fish such as salmon and tuna" (Griffin).  Vitamin C intake is also helpful for increasing tissue health and elasticity so eating plenty of citrus, kiwi, peppers, broccoli, strawberries, cantaloupe, potatoes, and tomatoes can all help you reach your minimum 85mg daily recommendation (Vitamin C).

​Prenatal Perineal Massage:  Massaging the perineal area once or twice per week for at least four weeks before labor begins has been shown by research to decrease the likelihood of episiotomies and possibly reduce the likelihood of tearing (Beckmann).  However, it must be done past the point of burning and, as it creates small tears in the tissues, does have the potential for infection.  In addition, the research shows that it mainly decreases the likelihood of episiotomies which brings up several variables that could influence the results (because the client has shown an interest in being proactive in reducing tearing/episiotomy, it would not be a stretch to suggest variables such as the client's choice of provider, client's discussion of prenatal massage with provider, and client's refusal of episiotomy all are at play).  As midwife Gloria LeMay states "Advising a [person] to do perineal massage in pregnancy implies a lack of confidence that her tissues have been designed perfectly to give birth to her infant."  So take this one or leave this one, whichever feels right to you.

Second Stage of Labor Perineal Massage:  Research suggests that a provider massaging the perineal area during the pushing phase decreases the likelihood of third and fourth degree tears as opposed to providers taking a "hands-off" approach.  However, as stated in the meta-analysis done by the Cochrane Review, "hands-off" is a term that varies in it's definition from study to study (Aasheim) and the likelihood of third and fourth degree tearing without an episiotomy is very small (about 1%).  It is also very important to note that these studies did not include any information about whether people had pain relief (which will decrease the amount of blood and hormones filling the perineal area and assisting with natural stretching), the position in which they birthed, and the nutrition of the participants during pregnancy.  In addition, the type of lubricant used for massage may also have an effect on outcomes; vaseline or topical lubricant provides a slippery surface while food-grade oils such as coconut or almond oil are absorbed by the tissues and encourage elasticity. According to Simpson in her article "When and How To Push...", "No evidence suggests that manual massaging or stretching the perineum is beneficial, and many [people] find this technique uncomfortable."

Hands-Off Providers:  In an unmedicated birth, the perineal area is engorged with blood and hormones that encourage stretching and elasticity during the second stage of labor which means that in that scenario, any external increase in pressure or stretching (as in perineal massage by the provider) has the potential to increase the risk of bruising, swelling, and tearing (LeMay).

Warm Compresses:  A warm compress held gently against the stretching perineal area at the point of crowning can help reduce tearing (Aasheim).

Avoid the Stranded Beetle:  Also known as "keep your legs together!"  The perineal area stretches side to side when the legs are kept open; this gives the area less ability to stretch front to back in response to the pressure from the crowning head.  And keeping the legs from being pressed out side to side will actually create more space between the sitz bones, easing the baby's way out!

Push Instinctively:  Coached pushing keeps laboring people from listening to their bodies' natural inclinations to start or stop (Aderhold).  A desire to "hold back" when the baby is crowning and emerging is actually a quite common and natural protector of the perineum (Reed).  In addition, directed pushing may increase the likelihood of long term pelvic floor issues (Calais-Germaine).

Embrace Your Ring of Fire:  At this intense moment when the baby begins to emerge from the vagina and the perineal area begins to sting, the body is saying "Whoa!  Slow down!"  If you push right through this burning, the tissues don't have a chance to slowly open with the pressure from the baby's head.  If you give little pushes or hold off - blow air out or do horse-lips - then the pressure from the baby's head will slowly stretch the area.  Once it goes numb, if the area does tear, it is unlikely it would even be felt.  In addition, according to LeMay, many people will instinctively reach down to support their baby's head at this point, further slowing the emerging and reducing the risk of tearing.

Birth in an Upright Position:  Multiple studies show that lateral and hands and knees positions decrease tearing and episiotomies while supine, squatting, and lithotomy positions increase the chances (Reed).  However, squatting is a common position for birthing world-wide (Kitzinger); understanding the bones of the pelvis and their relationship to one another in creating space and stretching soft tissue is important....and brings us to the next point!

Squat Optimally:  If choosing to squat when the baby crowns, doing so in a way where the sacrum is lifted and the perineum directs towards the floor may decrease the risk for tearing as compared to a deep "resting" squat.  More research needs to be done into the benefits of sacral nutation (forward tilting) on decreasing the likelihood of tearing.  If you are interested in more discussion and demonstration of optimal positions for reducing discomfort in labor, decreasing tearing, shortening labor, and preventing baby position-related complications, check out the pelvic workshops I facilitate - Moving Through Labor for expectant parents and Creating Space for birth professionals!

Change Position Frequently:  Anyone who has heard me speak about easing the birth process, has heard me expound the benefits of frequent position changes (Balaskas).  Changing the pelvic space allows the baby to make small head adjustments that can make for a more optimal position and smoother dilation and pushing stages of labor, all encouraging the smallest head diameter to make it's way out through the vaginal opening (keeping the perineal area intact!).

The perineal area is such an important part of pelvic floor health and offers the amazing ability to stretch and become elastic for the birth of your baby!  Understanding its complexity and how to keep the area intact and minimize perineal trauma is an important part of many people's birth priorities and should be knowledge that all birthing people take with them into their laboring space.  Here's to happy and healthy perineums!

*updated 2018*
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Sources:
Aasheim V, Nilsen ABVika, Lukasse M, Reinar LM. "Perineal techniques during the second stage of labor for reducing perineal trauma."  Cochrane Database Syst Rev. (2011): n. pag. Web. 27 Sept 2015.

Aderhold, Kathleen J. and Roberts, Joyce E.  "Phases of Second Stage Labor: Four Descriptive Case Studies." Journal of Nurse-Midwifery. Volume 36, Issue 5 (September–October 1991): 267-275. Print.

American College of Nurse-Midwives. Midwifery: Evidence-Based Practice. 2012. PDF file.  

Balaskas, Janet. Active Birth: The New Approach to Giving Birth Naturally.  Boston, Massachusetts: Harvard Common Press, 1992. Print.

Beckmann MM, Stock OM. "Antenatal perineal massage for reducing perineal trauma." Cochrane Database Syst Rev. (2013): n. pag. Web. 27 Sept 2015.

Beyond Basics Physical Therapy. "Anatomy of the Pelvic Floor." Beyond Basics Physical Therapy. 2015. Web. 27 Sept 2015.

Calais-Germaine, Blandine. The Female Pelvis: Anatomy and Exercises. Eastland Press, 2003. Print.
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Griffin, Nancy. "Avoiding an Episiotomy." Mothering Magazine Summer 1995: 60. Print.

Ina May Gaskin. Birth Matters: A Midwife's Manifesto. NY: Seven Stories Press, 2011. Print.

Kitzinger, Sheila. Rediscovering Birth. NY: Pocket Books, 2000. Print.

LeMay, Gloria. "Midwife's Guide to an Intact Perineum."  Midwifery Today Issue 59 (Autumn 2001): Web. 12 Oct 2015.

O'Rahilly, et al. Basic Human Anatomy. Dartmouth Medical School. Print.

​Reed, Dr. Rachel. "Perineal Protectors?" Midwife Thinking. Midwife Thinking, Mar 2015. Web. 27 Sept 2015. 

Ritchie, Laura. "Pelvic Floor Anatomy." Physiopedia. Web. 27 Sept 2015.

Simpson, Kathleen Rice. "When and How To Push: Providing the Most Current Information About Second-Stage Labor to Women During Childbirth Education." The Journal of Perinatal Education. Web. 26 Aug 2018.

Tidy, Dr. Colin. "Episiotomy and Tears." Patient. 16 Apr 2014. Web. 27 Sept 2015.  

"Vitamin C."  National Institutes of Health. 24 June 2011. Web. 11 Oct 2015.