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Reduce the risk of tearing during birth
- thesmartdoula
- Aug 26
- 9 min read
Updated: Aug 29
'I tore from front to back'
In almost every childbirth horror story shared online, there is somebody in the comments saying they know someone who 'tore from front to back'. Quite understandably, this image is terrifying, makes us all cross our legs and shudder, and feel terrified about our turn to give birth.
In this blog, I am hoping to remove some of the fear associated with tearing during birth, help you understand the role of the perineum, and give you some strategies to reduce your chances of suffering a severe tear.
Two second-degree tears
I wanted to start this blog by sharing my own experiences of tearing during labour.
I have given birth twice, and both times I have 'suffered' from a second degree (more information on how they are classified later).
The first time I had hours of coached pushing on my back, I couldn't tell you that I 'knew' that I tore, there was no sensation to pinpoint, I had the tear repaired in theatre (with a spinal as my placenta was also retained).
The recovery was tough, as I had nothing to compare it to. I presumed the soreness I was feeling was from the tear; I was unable to sit for long periods of time, the sofa was 'too hard', and I needed lots of cushions.
The second time I gave birth standing, whilst experiencing the fetal ejection reflex, again I had a retained placenta, so I had it repaired with a spinal anesthetic in place.
But the recovery....oh my! There was no pain! I now know that the tenderness I was experiencing with my first, the swelling, the bruising, was likely due to the coached pushing, not the tear!
So the moral of the story - a tear is maybe not such a massive thing to worry about!
Incidentally, if you are interested in my experience of having two retained placentas, you can read about it here:
Where might you tear?
The most common place to tear is your perineum, the next most likely is your vaginal wall, then your labia, and last but not least towards your urethra or clitoris.
The amazing thing about your body is that the most common place to tear is also the place that is built to stretch, tear, and heal.
The perineum's tissues are spongy, full of collagen and elastin, which allow it to stretch far beyond the capacity of other skin when your baby is crowning.
The other thing that helps with the stretch is all those lovely hormones, relaxin and oestrogen, which soften and increase the stretch capacity of the tissues!
It is also made of multiple layers of overlapping muscle, helping distribute pressure.
Your preineum also has a great blood supply, meaning that if it does tear, it also heals quickly, and there is a direct highway for your immune system to protect the area.
It is rich in nerve endings... which at first might scare you a bit, if it is really designed to tear.... wouldn't it be better if it had none at all? BUT, those nerves provide you with a feedback mechanism, allowing you to move and reposition to relieve pressure, and at full stretch, these nerves can become so stretched that they are temporarily desensitised!
The ring of fire feeling is often before that full stretch point!
Grades of tears
First-degree tear
Involves the skin only; muscles are not involved, usually small, and heal without stitches.
Second-degree tear
Involves the skin and perineal muscles but not the anal sphincter.
Depending on alignment, bleeding, and informed choice, they may or may not require stitches.
The majority of repairs (stitching) will be done in the labour room with local anesthetic and gas and air.
Third-degree tear
Involves the skin, perineal muscles, and the anal sphincter.
Divided into:
3a: Less than 50% of the external anal sphincter is torn
3b: more than 50% of the external anal sphincter is torn
3c: external and internal anal sphincter torn.
These are repaired surgically with a spinal anesthetic.
Fourth-degree tear
Involves the skin, perineal tissue, internal and external anal sphincter, and the rectum.
Required surgical repair.
You may see third and fourth-degree tears referred to as OASI (Obstetric Anal Sphincter Injury)
How common are tears in birth?
You might have seen that in first-time mums, the statistic is that 9 in 10 will have some sort of tear (1st or 2nd degree)
Amongst all vaginal births, the risk of 3rd and 4th degree tears is 3 in 100 births; this increases to 6 in 100 for first-time mums.
Long-term outcomes
Although most first and second-degree tears heal well with no long-term issues, there can be some pain and swelling while they heal.
With OASI tears, there can be long-term side effects, including pelvic floor dysfunction and incontinence, plus chronic pain, sexual dysfunction, and the psychological impact of all of the above.
With any tear, there can also be a cosmetic impact, and healing can be impacted by granulation, which requires further treatment. Sometimes repairs require revision surgery down the line.
THE OASI Care bundle
As part of the Birth Trauma Inquiry, it was recommended that the OASI care bundle be rolled out across the UK in an attempt to reduce the incidence of third and fourth-degree tears and the number that are missed and therefore not treated.
Although wanting to put steps into place to reduce the incidence of these tears is a good idea, the roll-out of the bundle has been challenged by many as non-evidence-based, invasive, and perhaps damaging.
Antenatal Education - Discuss OASI with women during the antenatal period and what can be done to prevent them.
Manual Protection of the Perineum - whilst communicating with the woman to encourage a slow and controlled birth.
Mediolateral episiotomy - If clinically indicated at a 60-degree angle
Examination of the vagina and rectum after birth, even if the perineum seems intact.
Antenatal Education
In theory, this is a great idea; it's what I am doing now! BUT it all depends on how the information is delivered (a leaflet is not enough!).
Birth is not one size fits all; it cannot be reduced to a tick box of actions.
Manual Protection of the Perineum
Hands-on techniques have been shown to increase the risk of tears in women who have given birth before, and it hasn't been shown to make a difference in first-time mums. The authors of the OASI bundle themselves acknowledge this, and state that 'no evidence of an effect' does not equate to 'no effect'.
This may mean that if you are in a position where your perineum isn't easily reachable/observable during your birth, you may be asked to move into a different position.
Encourage a slow and controlled birth
In a physiological birth, most women instinctively slow down at this point; there is a fine line between 'encourage' and coached pushing, and we know that coached pushing actually increases the risk of severe tears!
If clinically indicated, a mediolateral episiotomy.
The problem with this one is that a 'hands-on' technique, as described in the previous step, has actually been associated with an increased rate of episiotomy.
An episiotomy is essentially a second-degree tear within itself, and although cutting one at a 60-degree angle does reduce the risk of tearing towards the anus, it's also linked to reduced sexual dysfunction for upto 5 years as it damages tissues of the clitoris.
Examination of the vagina and rectum
This has been brought in to help reduce the amount of severe tears that are missed (this was a major focus of the birth trauma inquiry). However, all of the women who shared their stories had flagged concerns and been dismissed prior to their injury being identified. Listening to women may be a more effective way to identify these tears, rather than subjecting all women to an invasive rectal check.
It is also very important that real informed consent is sought prior to this check, and it is not presumed that women know a rectal check is standard after birth.
The care bundle was trialed in the UK and achieved a 0.3% reduction in severe tears, which is described as 20% (3.3% reduced to 3%). This means that for 333 women who experience the care bundle, 1 severe tear is prevented.
What you can do to reduce your risk of tearing:
Choosing where to give birth
Some studies have found that those women who choose to give birth at home have a lower risk of perineal trauma and episiotomy.
Reduce your risk of tearing with Perineal Massage
For first-time mothers, or if you are having a vaginal birth after cesarean, perineal massage is an evidence-based way to reduce your risk of experiencing a tear.
Starting after 34 weeks and doing it 3-4 times a week, using a lubricant, you use your thumb to massage and stretch your perineum.
The jury is out on whether this creates any structural changes or just makes you more comfortable with the sensations!
Birth positions to reduce your risk of tearing
Lying on your back puts the most pressure on your perineum; upright AND forward positions are associated with less perineal trauma than lying on your back in a bed.
However, I am not going to write here that you should INSIST on being in a specific position during the birth of your baby; instead, I am going to suggest that you follow your body and your instincts and find the position that feels best for you!
The best way to enable you to do this is to avoid anything that reduces that feedback loop between your body and your baby, things like an epidural and opioid pain relief.
Avoid coached pushing to reduce your risk of tearing during birth
As we spoke about before, we know coached pushing increases the chance of tearing, holding your breath, pushing past a contraction, and someone shouting PUSH at you is not it!
In a physiological birth, your uterus will do the majority of the hard work for you, and you really want to be focusing on softening everything else, not tensing it up!
The push of the contraction will force the baby's head into your perineum, causing it to stretch, and once the contaction has stopped, the baby may well move backwards. This can feel frustrating, BUT it really is your body's way of creating the 'slow and controlled' birth that the OASI bundle is trying to achieve!
Reducing the risk of tearing during birth by using water
There is some evidence that giving birth in water can reduce your risk of certain tears:
However, the main benefit of water birth is that you are calm, relaxed, no one can get to your perineum to do a 'hands-on' technique, and you can assume any position you wish easily.
It is probably for that reason that giving birth in water reduces your risk of episiotomy as well!
Using a warm compress to reduce the risk of tearing
If you are not in water, a warm compress on your perineum has been shown to reduce the risk of tears and reduce the sensation of pain during crowning.
This can be held in place by you or a midwife, and is relatively non-invasive or disruptive
What if I do tear?
Hopefully, you are now feeling less fearful about the possibility of tearing, but if you do, there are plenty of things that you can do to help the healing process go more smoothly!
Although severe tears require surgical repair, with second-degree tears, there is a decision to be made about whether you accept stitches or not!
Should all second-degree tears be stitched?
Studies have shown that the long-term outcomes of sutured vs non-sutured second-degree tears are similar, with those that are repaired being more painful earlier on but healing more quickly overall.
The decision should be made with clinical input, depending on the amount of bleeding and if the edges are aligned.
If you choose not to have stitches, it is best to remain horizontal in bed in early postpartum to avoid disturbing the healing process. In some cultures, they used to tie a red ribbon around a woman's legs to aid with the healing process!
You can find more about my recommendations for postpartum healing here:
Hopefully, you are now less worried about tearing during birth, and you have some strategies to add to your birth plan to help you reduce your overall risk!
If you would like more individualized support for your specific situation, maybe you have had a severe tear before or want to know more about a specific strategy like birth biomechanics, you can book some one to one time with me or sign up for one of my virtual doula packages.
Who am I?
I am Charlotte, a Virtual Doula, providing bespoke evidence-based pregnancy support to families who want an empowering birth.
With 10 years + of clinical research experience, a biomedical science degree, and two hospital births under my belt, I use my knowledge to provide pregnancy support to help you make informed decisions about your pregnancy, birth, and postpartum.
I provide pregnancy support for all types of births, including hospital births, helping you to navigate NHS guidelines and have an empowering, positive birth.
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