Perineal Tearing: How To Reduce Your Chance of Tearing and Heal After Baby

As a pelvic floor physical therapist, I have many patients who have just had a baby. One of the most common issues I see in these patients is the effects of perineal tearing. A particular condition that wrenches my heart is when women share that they experience pain with sex and how often doctors dismiss it. Birthing parents are told, “Things are different,” “Take a warm bath,” “Drink a glass of wine,” or “Just try to relax.” There are several ways to treat pain with sex, and one is to address the tears. But wouldn’t it be even better if women could avoid or reduce the tearing to begin with? Let’s explore how to minimize your risk of tearing and prepare yourself for what to do if you tear.

What Is Perineal Tearing?

The pelvic floor muscles and vagina can stretch to more than three times their normal size during vaginal birth.⁴ The nerves that allow these muscles to move are stretched up to 35%.⁵ Under normal conditions, this would always result in injury; however, the hormonal shifts during pregnancy allow a birthing person’s skin and muscles to be stretched much more than normal.^6,7

During vaginal birth, the area at the bottom of the vagina can tear. Tearing can occur in the vagina, vulva, perineum, or the area between the vagina and anus or into the anal sphincter. A tear can be as limited as the skin of the vaginal opening or as deep as the anal sphincter.^8,9

Tears are graded from the first to the fourth degree.⁸ A first-degree tear only includes the skin and mucosa.^8,10 A second-degree tear extends into the muscles.⁸ First- and second-degree tears generally aren’t related to leakage of the bowels or bladder.^11,12 Third- and fourth-degree tears extend into muscles and anal sphincters and need surgical repair.⁸ Having a third- or fourth-degree tear may predispose you to leaking stool later, making rehabilitation even more important.^11,12

How Common Are Perineal Tears?

According to the American Urogynecologic Society, tears occur in up to 90% of women during their first birth and between 44% and 79% of birthing women overall.¹ Tears are related to the baby’s size (whether or not it’s your first delivery), situational factors during birth, and your genetics.^8,13

What Does a Tear Mean?

Any injury must lay down scar tissue to heal, which takes six to eight weeks.¹⁴ Yet scars are weaker than normal tissue and can cause pain and contribute to pain with sex and urinary or fecal incontinence.¹⁵ Also, in the early days of postpartum, tears can make peeing and pooping after birth much more uncomfortable.¹⁶ Luckily, there are ways to help ease that first time on the toilet, such as using a peri-bottle.⁸

4 Tips To Minimize Your Risk of Tearing

As a pelvic floor physical therapist, I teach a few strategies to help you have a better labor with less likelihood of perineal tearing:

1. Do Perineal Massage

Starting to massage the perineum between 34 and 36 weeks can help the tissues stretch better.² Research shows that it doesn’t cause any harm and may help reduce your risk of tearing.³ You can follow these steps to massage your perineum:

1. Start by applying a warm, wet washcloth to your perineum or take a warm bath.
2. Ensure you have clean hands and trimmed nails. Lay reclined and use a mirror if you would like.
3. Apply lubricant to your fingers. Make sure it’s a good lubricant without parabens or glycerin.¹⁷
4. Insert one or two thumbs about 0.5 to 1 inch.
5. Apply gentle pressure down and out diagonally for one to two minutes. Then, press straight down for one to two minutes. Use your fingers to make a “U” shape or smiley face shape.
6. Perform this a few times per week for three to five minutes.

2. Learn How To Push Correctly

When you go into the pushing stage, you use your diaphragm, abdominals, and pelvic floor to help with birthing.¹⁸ Your pelvic floor muscles have to open while your abdominal muscles and diaphragm create pressure from above to help your uterus push out your baby. Learning how to relax your pelvic floor and push correctly can help you open better during birth.

The pelvic floor muscles interact with our breathing muscles, and it’s important to make sure they’re working together well.¹⁸ Practicing deep diaphragmatic breathing can be helpful for pelvic floor relaxation as well.¹⁹ Everyone asks me about Kegels, but pelvic floor relaxation is key during labor and delivery! And knowing when to push is just as important as how to push.

3. Consider Your Positioning During Birth

Your position during birth can increase or decrease your risk for tearing and pelvic floor muscle injury.^10,13 For example, laying on your side or getting on your hands and knees leads to less damage to the pelvic floor.^20,21 If you choose an epidural, laying on your side with a partner or sling lifting your leg is a great option.²²

On the flip side, laying on your back can restrict the motion of your tailbone and is related to a higher rate of perineal tears. Squatting also leads to a large number of tears.²² In the United States, we don’t squat often enough to make it a natural birth position. In other cultures, people squat regularly (to have a conversation, eat, and empty their bladder).²³

4. Build a Great Team

Choose birthing professionals who will respect your wishes about positioning and pushing. If you have a doula, they can help reduce the likelihood of a C-section and having an operative birth. Ask your midwife or physician if they’re comfortable catching babies in whatever position you would like to try.

So You Tore, Now What?

My advice to most pregnant people is to prepare for a perineal tear and healing because, statistically, it will happen. In the short term, make sure you have a pain management plan. Typical pain management can include having ice packs, sitz baths, medications, and padsicles and preventing constipation.⁸ Also, prepare yourself for your first poop and pee — the first time you go can be painful even if you didn’t suffer a tear.^24,25 Here are some tips for if you do tear:

Prepare for the Long Term

Once healing has taken place, think about retraining your pelvic floor muscles and core. Regardless of how you gave birth, the pelvic floor and abdominal muscles were distended by your growing uterus and need rehabilitation.²⁶ In France, all birthing people see a pelvic floor therapist, which I’d love to see catch on in the U.S.²⁷

If you have any scars from giving birth vaginally or via C-section, you can massage the scars by yourself or with the help of a professional or partner.¹⁵ Scars take six to eight weeks to close and about 12 weeks to finish healing.^14,28 After the scar heals, massaging it directly can help the tissue remodel so the haphazard and weak collagen of scar tissue is broken down and strengthened.¹⁴

Scar tissue is often uncomfortable and may cause negative emotions. Scars can affect how much you leak and lead to pain with sex.^8,15 Some people need to start very gently with a warm washcloth in the shower. Remember, nerves take longer to heal than skin and muscle. Any superficial skin nerves that were cut or torn through may feel like tingling, burning, and/or pain.

Disclaimer: This does not constitute or replace medical advice or evaluation.

Find a Pelvic Floor Physical Therapist

Here are some online resources for finding a pelvic floor physical therapist near you:

1. https://www.aptapelvichealth.org/
2. https://pelvicguru.com/
3. https://pelvicrehab.com/

I had the pleasure of chatting with Dr. Julianna Allen about this topic! Watch to see what she recommends women to do during pregnancy and childbirth to reduce their chances of tearing during birth:

The Bottom Line

Perineal tears are pretty common for birthing women, so it’s essential to educate yourself before you give birth to help reduce your risk of tearing. However, even if you do tear, rest assured that there are ways to manage the pain. Also, be sure to see a pelvic floor physical therapist to help treat your symptoms. You’ve got this, mama!