Decreasing Perineal Tearing and Episiotomies During Childbirth

What Causes a Perineal Tear or Episiotomy?

A perineum that can’t stretch to let the baby’s head out of the birth canal will undergo perineal trauma and either tear, or be cut by a health care professional in an episiotomy, especially in first-time moms. These perineal tears or cuts require suturing to heal, and they often cause scarring and pain after childbirth, which can negatively impact sexual function. Some tears can even result in incontinence of gas, urine, or feces.

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What is Perineal Massage?

Perineal massage during pregnancy involves the gentle, manual stretching of the perineum. The goal of perineal massage is to stretch and relax a woman’s birth canal in preparation for vaginal delivery. Research shows that when performed regularly during the last several weeks of pregnancy, perineal massage decreases the rates of perineal trauma, episiotomies and postpartum pain.

Just 5 minutes a day of perineal massage can reduce chances of tearing during delivery!

Why Should I Do Perineal Massage?

A recent meta-analysis on the effectiveness of perineal massage during pregnancy offered the strongest evidence yet that this simple, home intervention allows the mother’s birth canal to stretch more easily during childbirth resulting in less trauma and need for stitches, and less pain up to three months later. For reference, a meta-analysis is an analysis and summary of all of the studies in an area of medicine, looking at the quality of the data.

Medical interventions that show a benefit in a number of studies with well-designed experiments are said to have “Level 1” evidence. This is the highest scientific support for effectiveness of a medical procedure. Perineal massage during pregnancy has Level 1 evidence showing its medical value for preserving the health of the mother’s genital tissues during childbirth.

What Are My Chances for Success?

Perineal massage is a safe procedure that could benefit millions of women, and yet many people don’t know about it, and even many health care professionals are unsure how to guide women about how to use this technique to optimize healthy birth outcomes.

The lack of knowledge about perineal massage, is due in part, to the fact that the anatomy inside the human pelvis can’t be seen, so it is hard to understand the structures involved. Also, the incorrect language we often use to discuss female reproductive and pelvic anatomy further confuses teaching about perineal massage.

For comparison sake, let’s look at a few common medical interventions to see how they compare to perineal massage during pregnancy in effectiveness:

  • Perineal massage during pregnancy is 5 times more effective in decreasing perineal trauma at childbirth than steroid inhalers are for helping asthma patients avoid a major episode
  • Perineal massage during pregnancy is 12 times more effective in decreasing perineal trauma at childbirth than daily aspirin is for preventing strokes
  • Perineal massage during pregnancy is 60 times more effective in decreasing perineal trauma at childbirth than cholesterol lowering statins are for preventing a heart attack in people without previous heart disease

In short, medical evidence shows that perineal massage during pregnancy is very effective in giving women their best chance for an intact perineum while having a baby.

Short and Long-Term Complications of Perineal Trauma

Perineal trauma is classified by health care providers in degrees: first degree trauma involves just the perineal skin and vaginal lining; second degree trauma involves the skin, perineal muscles and connective tissue; third degree trauma involves the perineal muscles through to the anal sphincter; and fourth degree trauma involves opening the entire perineal area into the rectum itself. To view images of the different types of tears, check out

Perineal trauma includes both tearing and episiotomy. Episiotomy is a medical procedure where the perineum is cut to allow the baby to be delivered faster. Because an episiotomy often cuts deeper than a perineal tear would have gone, and because it cuts through nerves and muscles that may be spared during natural tearing, many health care providers don’t use episiotomies as often as they used to. It is still a valuable medical procedure in some settings, but the stature of this “man-made” perineal trauma has fallen for normal births.

Both tears or episiotomies can be sutured or stitched after childbirth to facilitate healing. No matter what the cause, perineal trauma increases healing time and postpartum complications. Perineal pain from trauma after childbirth is high with:

  • 40% of women reporting pain during the first two weeks after giving birth (is that really all!)
  • 20% reporting pain at two months
  • 9% still feeling pain at three months.

Women who have an intact perineum report significantly less pain than women who have experienced perineal trauma.

Painful sex is also common in women after having a baby, with 60% of women reporting it at 3 months, 30% at six months and 15% after three years. Women with perineal trauma from childbirth report higher levels of pain during sex. In contrast, women with an intact perineum after childbirth resume intercourse earlier; report less pain during intercourse; have greater sexual satisfaction; greater likelihood of orgasm and more sexual sensation then women who had perineal damage.

Concern about perineal trauma during birthing is also increasing the requests for C-sections by some mothers. Overall, C-section rates in the US are double the World Health Organization recommended rates. There are many reasons for this increase, and perhaps most concerning is women choosing an elective C-section to avoid perineal trauma. There are many risks moms and babies may encounter following C-Section such as decreases in nursing success and increases in postpartum depression, as well as possible increases in lifelong disease for these babies (e.g. asthma, diabetes, and obesity). Of course C-sections can be lifesavers, but the US C-section rate has increased by 500% since 1970 (see 2014 Consumer Reports “C-Sections increase risks for mothers and infants”). Fear of perineal trauma should NOT be a deciding factor for choosing a C-Section in most women. Especially when perineal massage offers such great outcomes.