7 Tips from a Pelvic Floor Physio to Prevent Tearing During Childbirth

preventing perineal tears

How can you prepare your vagina and perineum for birth?

A big concern for many women we see who plan to give birth naturally is the fear of a perineal tear.

What is a perineal tear?

The perineum is the area between the vagina and the anus. It has to stretch enormously to birth a baby.

A grade 1 tear, (often referred to as a graze) does not need stitches.

A grade 2 tear affects the vaginal skin and the muscles at the entrance to the vagina. The episiotomy cut that is made so the baby’s head can be birthed more easily, or to allow for forceps, is considered the same level of severity as a grade 2 tear.

A grade 3 or 4 OASI (obstetric anal sphincter injury) is a more significant tear that extends backwards into the anal sphincter muscle, which ordinarily keeps the back passage closed. An OASI occurs in 5% of first-time births.

What can you do to reduce your chances of a perineal tear?

Tip 1: Prepare your pelvic floor muscles

Your pelvic floor muscles need to contract and relax completely, have good strength and endurance, be supple and have enough length, be free of tight tender points, and be capable of relaxing with a push or contracting with a push, depending on the situation.

Tip 2: Learn perineal massage

A recently released Clinical Care Standard for perineal tears recommends that perineal massage be offered to all women during pregnancy. It is introduced at 34 weeks.

Tip 3: Ask for a warm compress

Ask for a warm compress (washcloth warmed under a hot tap is good enough) to be applied to your perineum as the baby’s head is crowning.

Tip 4: Aim for a slow controlled delivery of the baby’s head

Follow the instructions of your midwife. They may ask you to change your position, your pushing, or your breathing, or they may need to support your perineum with their hands.

Tip 5: Perineum massage during the second stage of labour

Perineal massage may be performed by your healthcare professional during the second stage of labour. You can include this in your birth plan if you feel comfortable with the idea.

Tip 6: Some birthing positions are better than others

Some birth positions (such a squatting) are more likely to result in a large perineal tear, whereas other positions (like being on your hands and knees) are protective.

Tip 7: An episotomy can help

An episiotomy (a cut from the back of the vaginal opening that is directed out to one side) may be suggested if it looks like you could tear in an uncontrolled fashion. An episiotomy is equivalent to a second-degree tear, and is done to protect the anal sphincter from a worse grade 3 or 4 tear. It will be stitched in the delivery suite after the baby is born. In Australia, 40-50% of first vaginal births are assisted with an episiotomy.

Note: if you choose a waterbirth at Nepean Hospital, hospital policy dictates that the midwives will be unable to touch or support your perineum. This means that if the perineum looks like it will tear, they will be unable to provide manual perineal support, and they will be unable to perform an
episiotomy. There is some evidence to suggest that an epidural actually protects the pelvic floor muscle, probably by completely relaxing it.

When should I see my pelvic health physiotherapist for help to prepare my perineum?

12-18 weeks:

This is a good time to see us if you have been experiencing any urinary leakage or excessive bladder urgency and frequency. You should also see us if you have been vomiting a lot, or of you have been experiencing constipation, as both of these things can weaken the pelvic floor and overstretch the connective tissue. Some women come to see us because they are unable to feel whether they are able to contract their pelvic floor muscles, even though they do not have symptoms. At this stage the emphasis will be on ensuring you can correctly activate and co-ordinate your pelvic floor muscles. You may be prescribed a strengthening program.

20-30 weeks:

See us anytime in the second trimester if you have pelvic girdle pain. Pain in the pubic area (sometimes called symphysis pubis dysfunction or SPD) can be associated with tight, non-relaxing pelvic floor muscles. Any emerging pains in the groins, sacroiliac area, hips, or low back are best treated now, to avoid them becoming more severe and difficult to manage later.

Around 22 weeks is a good time to assess if your pelvic floor muscles are able to relax properly. Women who cannot relax their pelvic floor muscles as they simulate a bearing down action will go on to have a longer second stage labour, and some small studies have even shown they are more likely to require the help of vacuum or forceps.

Another reason to see us in the second trimester would be if you are experiencing vaginal heaviness or bulging, as this could be a warning sign that a prolapse is developing. UK guidelines suggest you should see a pelvic floor physiotherapist at 20 weeks if you have a first-degree relative (mother, `sister) with pelvic floor dysfunction.

34 weeks:

This is a good time to start perineal massage. Your pelvic health physiotherapist can make sure you understand how to do this properly. Your physio can also assess the deeper parts of the pelvic floor for flexibility. There is emerging evidence that the second stage of labour will take longer if the levator hiatus (the gap between the left and right sides of the pelvic floor hammock) is smaller. Your pelvic floor physio can help find the best way to lengthen and release the gap in the pelvic floor muscle to make it easier for your baby to be pushed through.

36 weeks:

If you wish to use a birth training balloon such as the Epi-No, this is the right time to start. This is also a good time to assess the length of your perineal body. The perineal body is the gristly tissue of the perineum, between the back of the vagina and the anus. A short perineal body will increase your risk of a 3rd or 4th degree tear.

perineal tear grades 1-4
Credit: Australian Commission on Safety and Quality in Healthcare. Information for women – Third and Fourth Degree Perineal Tears Clinical Care Standard

Get Your Prenatal Physiotherapy Check Today

If you are pregnant, and want to prepare yourself and your perineum for birth, book in to see our Women’s Health Physiotherapists today. We are help pregnant women throughout their pregnancy including preparing you for the birthing process. Book online today for your pregnancy check today.

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