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There are a lot of causes of tearing of the vaginal tissues during delivery. Sometimes, the causes of tearing are outside of our control but there are plenty of causes that can be avoided by being proactive with your body during pregnancy and being strategic during delivery. In this blog post, we will cover some of our most recommended strategies for preparing your vaginal tissues during pregnancy, as well as ways that you can support your body through your delivery to avoid tearing.
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What are the risk factors for tearing during birth?
First-time Parents, your tissues have never stretched like this before.
Operative or assisted vaginal delivery.
Midline Episiotomy as it may continue to tear downwards.
Large for gestational age baby >4000g or post-term delivery.
Malpresentation/compound presentation or more than one part.
Epidural Anesthesia or Induction of Labor
Low socioeconomic status or poor nutrition weakens tissue integrity.
Genetic or hereditary issues such as pelvic floor dysfunction or connective tissue deficiencies.
Labor/birth complications such as prolonged second stage, shoulder dystocia, and occiput posterior delivery.
Short perineal body or previous laceration.
Prenatal Tools for Preventing Tearing
Perineal Massage Antepartum (Abdelhakim et al., 2020)
Perineal massage is when two fingers are placed in the opening of the vagina with a gentle but firm pressure placed in the perineum with oil. This is typically done with a sweeping motion left and right to help stretch the tissues and help relax the pelvic floor and any existing scarring. The benefits are that it can help you practice breathing and pelvic floor awareness, and help reduce the risk of 3rd-4th degree tears. It can also aid in better wound healing and less pain during the postpartum period. The downside is that this can be uncomfortable and even difficult for some individuals.
Pelvic Floor Therapy (León-Larios et al., 2017)
Pelvic floor therapy is where you go see a specialist that works with the large muscle structure that controls your vagina and sexual function, urinary and bowel function, and plays a large part in childbirth. They will perform either an internal or external assessment and can advise on specific exercises to strengthen or relax individual muscles in your pelvic floor. The benefits are that it can improve the effectiveness of pushing with muscle control and can possibly shorten the 2nd stage of labor. It can reduce the risk of vaginal tears, improve urinary leaking, reduce pain with vaginal functions such as intercourse, and help you feel more prepared and educated to work with your body to push. The downsides are sometimes there is no access to a pelvic floor therapist, it can be expensive and not covered by insurance, and sometimes it is perceived as invasive if it includes a vaginal exam (this can always be declined).
Good Posture/Activity (Feria-Ramírez et al., 2021)
Good posture is essential from the beginning of pregnancy. This can help keep your core muscles engaged and aid in properly positioning the newborn in utero. It is also recommended to do 30 minutes a day of physical activity to stay active and to prepare your body for the marathon that is labor. Some exercises can improve your tissue stretching and reduce the risk of tearing, such as squats and pilates. After 37 weeks, beginning positions and movements such as the miles circuit to aid fetal positioning. The risks of doing these are minimal. Listen to your body and don’t overdo it or over-stretch. Your body has lots of the hormone relaxin, especially at the end which makes your bones and ligaments looser for birth but also can allow for injuries if pushed too far with exercise. Consider wearing a belly support band while exercising to add core support.
Tools for Preventing Tearing During Labor and Delivery
Supportive Birthing Position (DiFranco and Curl, 2014)
The position that you birth in can drastically affect how it impacts your vaginal tissues. It is recommended to change positions every 30 minutes to aid the baby in navigating the pelvis. During pushing, recommended positions include side lying, kneeling, hands and knees, and avoiding being directly on your back. These positions reduce the risk of tearing by helping give the sacrum room to move, changing the pelvic shape to help the newborn navigate the pelvic structure, and supporting pushing and slowing delivery. Risks include that the newborn may not tolerate the position change which would require moving again, and position changes can make contractions seem more intense for the initial contraction after the position change.
Warm Compress During Delivery (Modoor et al., 2021)
A warm compress is usually a washcloth soaked in clean warm water applied to the perineum while stretching occurs. This has been shown to reduce the risk of 3rd and 4th-degree tears and can provide pain relief while still allowing for manual perineal support as desired. The downsides are someone may not watch touched as it can feel overstimulating for some individuals, the water may feel too warm, or there may not be time to prepare a warm compress if the pushing stage happens quickly.
Manual Perineal Support (Herrell, H., 2018)
Many individuals want a hands-off birth, but there are some intentional ways touch and support can be used during the delivery of the baby to reduce the risk of tearing. These look like counter pressure on your perineum as it stretches, or your provider applying pressure with a clean gauze in certain places as different parts of the head deliver to support tissues stretching in the right places. Perineal massage can help to stretch the tissues as the baby is descending. The goal of the pressures is to help deliver the largest diameter of the head slowly and support the angle the newborns head is coming out, while aiding in delivery of the body to keep limbs and other structures close to the newborn to avoid catching other vaginal tissues and causing tears. Downsides to this are that is can feel invasive, some individuals can’t stand touch, may be worse for individuals with a history of trauma, if done improperly may hinder delivery or create tearing opportunities, it depends on working with the birther and their speed of delivery can’t always be controlled. Perineal massage is when two fingers are placed in the opening of the vagina with a gentle but firm pressure placed in the perineum with oil. This is typically done with a sweeping motion left and right to
help stretch the tissues and help relax the pelvic floor and any existing scaring. Benefits are it can help practice breathing and pelvic floor awareness and reduce the risk of 3rd-4th degree tears. It can also aid in better wound healing and less pain. The downsides are this can be uncomfortable, difficult for some individuals to do, could be difficult for individuals with trauma.
References
Abdelhakim, A. M., El-Desouky, E., El-Magd, I. A., Mohammed, A., Farag, E. A., Mohammed, A. E., Hamam, K. M., Hussein, A., Ali, A. S., Keshta, N. H. A., Hamza, M., Samy, A., & Abdel-
Latif, A. A. (2020). Antenatal perineal massage benefits in reducing perineal trauma and postpartum morbidities: A systematic review and meta-analysis of randomized controlled trials. International Urogynecology Journal, 31(9), 1735–1745. https://doi.org/10.1007/s00192-020-04302-8
DiFranco, J. T., & Curl, M. (2014). Healthy birth practice #5: Avoid giving birth on your back and follow your body’s urge to push. Journal of Perinatal Education, 23(4), 207–210. https://doi.org/10.1891/1058-1243.23.4.207
Feria-Ramírez, C., González-Sanz, J. D., Molina-Luque, R., & Molina-Recio, G. (2021). The effects of the pilates method on pelvic floor injuries during pregnancy and childbirth: A quasi-experimental study. International Journal of Environmental Research and Public Health, 18(13), 6995. https://doi.org/10.3390/ijerph18136995
Herrell, H., MD. (2018, April 16). Four tips for preventing perineal trauma: The grip. https://howardisms.com/obgyn/four-tips-for-preventing-perineal-trauma-the-grip/
León-Larios, F., Gutiérrez, I. C., Casado-Mejía, R., & Suárez-Serrano, C. (2017). Influence of a pelvic floor training program to prevent perineal trauma: A quasi-randomized controlled trial. Midwifery, 50, 72–77. https://doi.org/10.1016/j.midw.2017.03.015
Modoor, S., Fouly, H., & Rawas, H. (2021). The effect of warm compresses on perineal tear and pain intensity during the second stage of labor: A randomized controlled trial. Belitung Nursing Journal, 7(3), 210–218. https://doi.org/10.33546/bnj.1452
Ramar, C. N. (2023, June 26). Perineal lacerations. StatPearls - NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK559068/#:~:text=Risk%20factors%20for%20perineal%20lacerations,race%2C%20and%20increased%20fetal%20weight.
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