Protect your Perineum: Part 1

Lisa Baker is a childbirth educator and mother of two in Calgary, Alberta. You can reach her by email at lisabakerlcce@gmail.com

One question that frequently pops up in my childbirth class is how to prevent perineal trauma during the birthing process, or as one mother gently put it, “is it possible to give birth without tearing?”

To begin, lets discuss what happens to your body if you develop a tear during childbirth. The perineum is a muscular area between the vagina and the rectum. Perineal muscles (the muscles you are flexing during your Kegel exercises) help to support the uterus, bladder, and rectum. The rectum contains a powerful ring of muscle called a sphincter that can open and close to release or retains feces. Tears to the vagina, perineum, and/or rectum are classified into four degrees based on how many structures are affected. I recommend viewing this slideshow created by The Mayo Clinic as it has very clear illustrations of the four degrees of tear and a description of each. The four degrees are as follows:

• First Degree – The tear involves only the skin surrounding the vagina. The tear typically does not need stiches and will heal on its own within a few weeks.
• Second Degree – The tear involves the skin surrounding the vagina and the perineal muscles. It typically requires stiches and will heal within a few weeks.
• Third Degree – The tear involves the skin surrounding the vagina, perineal muscles, and outer layer of the rectal sphincter. It requires stiches to repair properly and may take months to heal.
• Fourth Degree – The tear extends from the vagina all the way through to the inner layer of the rectum so that there is one continuous opening from vagina to rectum. This tear requires special repair and will take many months to fully heal.

Recovery is dependent on the severity of the tear. Swelling, pain, and a stinging sensation during urination are common. Severe tears bring with them the possibility of typically temporary complications such as painful intercourse and uncontrollable flatulence. If you experience a perineal tear it is important to talk to your doctor or midwife about care and comfort techniques, as each woman responds differently.

So is it possible to give birth without tearing and the associated complications that go with it? The short answer is YES. Ina May Gaskin and her team at The Farm Midwifery Center have proved this time and again with an impressive 68.7% of the mothers giving birth at their birth center maintaining an intact perineum (1).  This number is impressive because in studies that include hospital births, upwards of 50-77% of women require stiches to repair a tear and/or episiotomy (2).  At The Farm a further 19.4% of women suffered from a first degree tear, 3.2% from a second degree tear, 0.3% from a third degree tear, and .04% from a fourth degree tear. The bottom line is that although a tear can occur, it is possible to give birth without damaging the vagina, perineum, and rectum.

It is difficult to predict whether a particular woman will suffer from a tear as a result of childbirth. However, current research supports several factors that can reduce the risk and severity of perineal trauma. In this blog series I will highlight the following factors related to episiotomy and tears:

1)     Practice perineal massage;

2)     Avoid an episiotomy unless medically necessary for the health of you and your baby;

3)     Relax the pelvic floor muscles when pushing;

4)     Consider upright positions for giving birth; and

5)     Have the birth attendant apply warm compresses to your perineum during the pushing stage of labour.

In part one of this series we will examine perineal massage in further detail.

Perineal massage is a massage of the perineal tissues in the final 4-6 weeks of pregnancy. The American College of Nurse-Midwives has produced a great description of the method and benefits of perineal massage and is worth a look.  Either you or your partner can practice this massage technique in the comfort and privacy of your own home. Although mothers commonly describe an uncomfortable burning sensation in the first week of massage practice, the sensation typically weakens or disappears by week two or three (2).

When it comes to research, Cochrane reviews are considered to produce a very high standard of evidence. A Cochrane review of perineal massage published in 2009 supports the use of perineal massage by women in the weeks leading up to birth (2). The review shows that perineal massage reduces the likelihood of perineal trauma, mainly in the form of episiotomies, for women who have not given birth before.  This is important; as episiotomies can increase the risk of more severe 3^rd and 4^th degree turns (to be discussed in the next post of this series).

The mild burning sensation experienced during the first week of perineal massage is a great opportunity to practice deep breathing and relaxation of the perineum under a stressful situation.  Practicing relaxation under a mildly stressful situation can increase the chances of relaxing under more stressful situations such as childbirth.

The ability to relax the perineum during childbirth can reduce the need for an episiotomy, which again reduces the risk of more severe tears (see next blog post).

Tears and episiotomies can and do happen during childbirth. However, not all women will experience perineal trauma. Several factors are associated with a decreased risk and severity of perineal trauma. Perineal massage is one technique that women can try prior to labour to reduce the risk of episiotomy and tearing. In the next post we will explore factors during labour that can improve the chances of an intact perineum after childbirth.

(1)  Gaskin, Ina May. Ina May’s Guide to Childbirth. 2003.

(2)  Beckmann MM, Garrett AJ. Antenatal perineal massage for reducing perineal trauma. Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD005123. DOI: 10.1002/14651858.CD005123.pub2.