Can we prevent tearing during birth?

When we talk about childbirth there is one thing that is guaranteed to make women wince – conversations about tearing.  

Despite our queasiness, this is a conversation we can’t avoid as the research suggest that most women will sustain some damage to their perineum during birth (AIHW, 2018).  

Currently there is a lot of effort and money being invested in trying to establish ways to reduce the incidence of tearing. An example of this is the introduction of the Perineal Bundle to many leading Australian hospitals (If you want to know more on this we suggest checking out Season 1, Episode 6 of the Midwives’ Cauldron – Perineal Bungles).  

Consistent with the current birth climate, these strategies often view women’s body’s as the source of dysfunction, attempting to find interventions to minimize risk and protect the perineum. This has led to an explosion of interventions, tools, tips and techniques to try to prepare the perineum for birth in order to prevent tearing.  

While this sounds promising, it’s important to acknowledge that the evidence suggests that there is very little you or your care provider can do to prevent tearing. Infact, the only thing that has proven to consistently and dramatically reduce tearing is having an undisturbed physiological birth. However, with these kind of births representing only 1-3% of all births in Australia, for many women, this knowledge does not provide much reassurance.  

For women seeking something tangible to help reduce their risks, this article will explore 4 of the most commonly suggested method’s for protecting the perineum and reducing tearing.  

1: Perineal massage:  

What is it?  

Perineal massage is one of the most commonly recommend methods of ‘preparing the perineum’ for birth. It is performed antenatally and involves stretching and manipulation the perineal tissue around your vagina. It is usually performed using 1 or 2 fingers and can be done by you, your partner, or your health care professional (or maybe a good friend after a few wines?). Though the optimal frequency is unknown, guidelines commonly recommend starting perineal massage between 34-35 weeks and performing it between once or twice per week. Perineal massage is generally not recommended for women who are less than 34 weeks, have active infections such as genital herpes or genital candidiasis, ruptured membranes or vaginal bleeding so it is important to talk to your care provider.  

To find out how to perform perineal massage see Australian Birth Stories free Perineal Massage guide: https://www.australianbirthstories.com/massage 
 
Does it work?  

While many guidelines suggest the use of perineal massage during pregnancy, the most recent Cochrane review (our highest quality evidence available) found that regularly performing perineal massage did not reduce the incidence of first or second degree tears. While research suggests that perineal massage reduces the “incidence of trauma requiring suturing” this is attributed almost entirely to lowered rates of episiotomy. This is problematic due to the human factor in episiotomy (ie. The woman giving or withholding informed consent and a care provider making the decision whether an episiotomy is necessary to begin with). Furthermore, perineal massage was found to be even less effective at preventing tearing in women having their second (or subsequent) baby.  

To read the Cochrane review on Antenatal perineal massage for reducing perineal trauma see: https://www.cochrane.org/CD005123/PREG_antenatal-perineal-massage-for-reducing-perineal-trauma  

2: EPI-NO  

What is it?  

This device is used throughout pregnancy in order to “prepare the perineum for birth.” Manufacturers suggest that women should begin using it in week 36 of pregnancy and should continue until birth. To use it, you insert the device (which looks like a small balloon) into your vagina and gradually inflate it in a manner which aims to stretch the pelvic floor tissue. The ultimate goal is to make the tissue more flexible and elastic to allow for easier stretching during birth, and to prepare you for the sensations that come with pushing a baby out (though it’s important to note that perineal stretching is far from the only uncomfortable sensation that women experience in labour).  

To view the product visit: https://www.epino.de/en/epi-no.html  

Does it work?  

A large RCT by Atan et al. (2016) found that “antenatal use of the Epi-No is unlikely to be clinically beneficial in the prevention of anal sphincter or perineal trauma.” Translation, using the Epi-No is unlikely to reduce your risk of sustaining a tear to the vagina or anus during birth. There is also a lack of high quality evidence on how this unnatural and repeated stretching of the vagina effects a woman’s long term pelvic floor health.  

Read the full study here: https://pubmed.ncbi.nlm.nih.gov/26924418/  

3: Warm compress during labour:  

What is it?  

This technique has long been used by midwives and birth attendants as a means to reduce tearing during birth. It involves placing a warm compress (often a pad, swab or gauze soaked in warm water) on the your perineum while the baby is crowning.  

Does it work?  

A Cochrane review that looked at perineal techniques during the second stage of labour for reducing perineal trauma found that warm compresses did not increase the chance of having an intact perineum, decrease 1st or 2nd degree tears, decrease the risk of episiotomy or decrease the chance of suturing. Translation, using a warm compress did not make you less likely to tear or require stitches. While there is some evidence to suggest that it did reduce the chance of  severe (3rd or 4th degree tear), a woman’s comfort and ability to birth in a position of her choosing should take precedence as these are more likely to prevent tearing.  

Read the Cochrane review here: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006672.pub3/full  

4: Directed pushing  

What is it?  

Directed pushing involves a care provider (usually a midwife or obstetrician) advising you when to push (and with how much intensity), when to pause, and when to breathe as the baby is crowning. The ultimate goal is to control/ slow down the delivery of the head to allow your perineal tissues (vagina) to stretch in order to avoid tearing. Often this sounds like; 
 
– “Stop pushing”  
– “Okay now give me a big push”  
– “Breathe, breathe”  
– “Just pant” 
– “Okay when you get your next contraction I want you to give me a big push into your bottom” 

Does it work?  
 
When women birth instinctively, the intense sensation of crowning will usually cause them to make adjustments that naturally (and very effectively) prevent tearing. This may include closing their legs, holding the baby’s head, holding their vulva and/ or changing their breathing/ pushing pattern. Baby’s also play a critical role in this process by regulating the speed of birth and pressure on the perineum. An example of this is the natural pause that often (but not always) occurs between the delivery of the head and the rest of the body.  

For women who utilize pharmacological pain relief such as an epidural, these sensations can be dulled or inhibited, limiting the mother’s ability to push safely and effectively. In this situation it may be necessary for a care provider to provide instructions on how and when to push in order to ensure timely delivery of the baby and to help reduce perineal trauma.  

However, if possible you should follow your instincts over the care providers instructions in order to prevent tearing.  

So is it hopeless?  

Not quite.  

Vaginas are designed to stretch, tear (when necessary) and heal. They do it with remarkable efficiency. There are more than 7 billion people on this planet, so maybe it’s by design that this area both releases (tears) when necessary and then heals, with surprising success.  

Where possible to avoid tearing choose options which support you to have an undisturbed physiological birth. While there are many terrible stories of extensive trauma inflicted on the perineum during vaginal births, rarely do these occur during undisturbed physiological birth. So while there simply is not enough evidence to truly understand the rates of tearing in normal physiological birth, this is the single most important factor in reducing tearing that we know of. 

However, regardless of how your birth unfolds, take comfort in the knowledge that your body was perfectly designed to birth your baby.  

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