How can you reduce your risk of tearing during childbirth?

By Nicole Guitar

Most women who giving birth for the first time experience some form of perineal tearing. These tears can have long term consequences on a women’s pelvic floor and contribute to pain, incontinence, pelvic organ prolapse and sexual dysfunctions.

We’re asked all the time what we can do to reduce the risk of tearing. The best answer is to see a Pelvic Health Physiotherapist who can give you specific strategies for your individual situation. However, there are some general tips to keep in mind.

The following is an informative summary written by Nicole Guitar PhD(c), who is a member of our physiotherapy team. Nicole practices Orthopaedic and Pelvic Floor Physiotherapy at Compass Rose Wellness Inc in Komoka, ON. She is a researcher and PhD Candidate at The University of Western Ontario where she also works as a Teaching Assistant in The School of Physical Therapy. In addition to her physiotherapy training, Nicole holds a Master of Science in Neuroscience.

Most women who give birth for the first time experience some form of perineal trauma. The perineum is the area between the anus and vagina. During vaginal childbirth, the vagina and surrounding tissues stretch to help make room for the baby. It’s important to note that perineal tears are different from episiotomies. During an episiotomy the perineum is intentionally cut to facilitate childbirth.

Perineal tears can be graded from first to fourth degree, with fourth degree tears being more severe. In a first degree tear the tear is limited to superficial perineal skin and vaginal mucosa. In a second degree tear the cut extends past the vaginal opening to the perineal muscles and fascia. In a third-degree tear, the vaginal opening, skin, muscles and anal sphincter are torn. And in a fourth-degree tear all of the above, plus the rectal mucosa are torn.

All perineal tears can benefit from pelvic floor physiotherapy in order to prevent the development of persistent pain and to learn how to mobilize the scar tissue to prevent further complications like incontinence and prolapse. With more severe tears, it’s possible that the complications and symptoms you may experience as a result will also be more severe.

So… is there anything we can do to decrease our risk of tearing? Yes!

Before Childbirth

If you’re experiencing your first birth, practicing perineal massage during your pregnancy can reduce your risk of tearing. Approximately 25% of birthing people who used perineal massage during their pregnancy did not tear at all. This is in contrast to people who did not use perineal massage, where approximately 15% did not tear at all (Labrecque et al., 1999).

In addition, use of a Midwife is also known to reduce the risk of severe tears (Mizrachi et al., 2017). In one recent study of 15,146 birthing people, working with an experienced midwife during your childbirth was associated with a lower rate of third- and fourth-degree perineal tears. Of the 15,146 people studied, only 51 (0.33%) of birthing people experienced a third- or fourth-degree tear.

During Childbirth

In contrast to before your childbirth, there is no benefit to perineal massage during your childbirth. Studies have found that there’s no difference to your risk of tearing whether or not your provider performed perineal massage during childbirth (Edqvist et al., 2017). Let’s skip this one.

The application of a warm compress to the perineum; however, may result in fewer third- and fourth-degree tears during childbirth (Asheim et al., 20017). This data comes from a review of different studies with >15,000 birthing people! This is a simple and cost effective technique you can ask your health care provider to use.

Spontaneous pushing (i.e., pushing when YOU feel like it) and choosing your own pushing position are both associated with a decreased risk of tearing! Positions like side-lying, that allow the tailbone to move, and having your knees together and ankles apart are some of the best for reducing risk of tearing (Edqvist et al., 2017).

Lastly, using certain breathing techniques can reduce the length time you spend pushing, but are not associated with your risk of tearing. Exhaling as you push has been shown to decrease the length of time you spend pushing (Edqvist et al., 2017).

A Pelvic Floor Physiotherapist can work with you to help you learn these strategies and how to reduce your risk of tearing during childbirth.

About the Author, Nicole Guitar:
I am thrilled to be working as an orthopaedic and pelvic floor physiotherapist. I have clinical interests in working with women in prenatal and postnatal care and both men and women experiencing pelvic pain conditions, urinary incontinence, and pelvic organ prolapse. My goal is to *empower* you. I want your treatment to be *accessible* for you: so that means that together we’ll consider all of the bits and pieces of your life and figure out how we can incorporate physiotherapy treatment in YOUR life: not the other way around!
I have completed the three levels of training for pelvic floor physiotherapy, including “The Physical Therapy Approach to Male & Female Urinary Incontinence” and “Male & Female Pelvic Pain” and have additional training in cesarean birth and “The Role of Physiotherapy in Preparation & Recovery.” I am a member of the core development committee for Western University’s eMPWR (Electronic Multidisciplinary Pelvic and Women’s Rehabilitation) telehealth clinic, and I was a student physiotherapist at the clinic during its initial launch. I also have training and my Level 1 qualification in Manual Therapy from the Canadian Orthopedic Division of the Canadian Physiotherapy Association.
I am a Doctoral Candidate at Western University in the School of Physical Therapy, and I am set to receive my PhD in 2021. I have published 14 articles in peer-reviewed journals worldwide and have presented at multiple international and national conferences, including the Canadian Physiotherapy Association’s Forum. In addition, I hold a Master of Science in neuroscience and an Honours Bachelor of Science in psychology from Western University that helps me understand pain mechanisms and neuronal changes in the brain in patients living with chronic pain.
I am a member of Canadian Physiotherapy Association (including the Women’s Health, Seniors Health, Orthopedics, and Pain Sciences Divisions), The Canadian Association on Gerontology, and the International Society to Advance Alzheimer’s Research & Treatment.
Nicole is a member of the physiotherapy team at Compass Rose Wellness Centre, just West of London Ontario, and is accepting new clients.