• Emily Reul, PT, DPT

Perineal Tears

Updated: Feb 18

Hi friends, today we’re going to talk about something a lot of individuals worry about during labor and delivery—perineal tears. One study found that more than 85% of women giving birth in the US and UK had some form of perineal trauma.


Let’s start by talking about what the perineum is. The perineum is the area between the vagina and anus. It has several layers which include skin, subcutaneous tissue (like fat), and the pelvic floor muscles.


The perineum is at risk for trauma or injury during birth due to the stretching of the vaginal opening to allow to baby to be delivered. The perineum can either tear on its own, or can be purposely cut by your provider through a procedure called an episiotomy. Episiotomies used to be performed routinely as they were believed to help reduce the risk of tearing; however, the American College of Obstetricians and Gynecologists now recommends that use of episiotomies be limited.


Somethings may put you at a higher risk of have perineal tearing. This can be instrument-assisted delivery (the use of a vacuum or forceps) or even the position you deliver in. The most common delivery positions in the US are the dorsal lithotomy or semi-reclined positions. In these positions, you are lying on your back either flat or slightly elevated (like in a recliner). Your knees are rotated outwards and pulled up towards your chest. These positions provide the best access for your provider to deliver the baby but can also put you at more risk of tearing. It can be very helpful to work with a doula or pelvic floor physical therapist who specializes in pregnancy to help find what positions may work best for you during labor and delivery.


Not all tears are created equal. There are four different degrees of tearing.

  • 1st degree: involves the outer layers of skin

  • 2nd degree: involves the skin and subcutaneous tissue (like fat); having an episiotomy will cause at least 2nd degree tears

  • 3rd degree: involves the skin, fat, and pelvic floor muscles

  • 4th degree: involves the skin, fat, and the pelvic floor muscles which are torn to the anus





Can perineal tearing be prevented? Perineal massage is recommended to help prevent perineal trauma (mainly by episiotomies) and to help reduce the amount of perineal pain you have postpartum. This massage is done 1-2 times per week starting at 35 weeks gestation. It can be very helpful to use lubricants with perineal massage, but not all lubricants are equal. Some of our favorites include coconut oil and Good Clean Love. This short YouTube video will show you how to perform a perineal massage.



So, what happens if you tear? Don’t worry, this isn’t the end of the world and please realize that it is not your fault! Things happen during delivery that are out of our control, no matter how much we prepare. While tears, especially 3rd and 4th degree can be associated with pain and incontinence, it’s likely not permanent if you receive proper treatment. This can include pelvic floor physical therapy and scar massage. Just like any other tears in the body, think of ACL tears or rotator cuff tears, your body needs time and rehabilitation to return to normal.

Once cleared by your provider, a pelvic floor physical therapist can help address any pelvic floor issues you may be having including pain with sex, incontinence (pee or poop), and so much more. It’s important to start to touch and massage your scar to allow the tissues to move freely. This can sometimes be uncomfortable and bring back many emotions, but over time this will get better. This can be done once the scar has healed and you get clearance from your provider. If you are having difficulty with scar massage, seeing a pelvic floor physical therapist can be very beneficial.


Jeanice has developed with an excellent self-paced course that will teach you how to massage your scar along with many other techniques to return to pain-free sex after delivery. The course is $39 and you will receive lifetime access. You can find the course here. You can also check out our new book Sex After Baby: How to Resume Intimacy with Confidence and Ease.


Whether you are getting ready to deliver, or have already had perineal tearing, here are some great resources:


What experiences or tips do you have that can help others? We’d love to hear them. Please join the conversation in the comments section below.  


Written by Emily Reul, PT, DPT


References

1. Seehusen DA, Raleigh M. Antenatal perineal massage to prevent birth trauma. American Family Physician. 2014;89(5):335-336.

2. McDonald EA, Gartland D, Small R, Brown SJ. Dysparunia and childbirth: a prospective cohort study. British Journal of Obstetrics and Gynaecology. 2015;122(5):672-679.

3. Frolich J, Kettle C. Perineal care. BMJ Clin Evid. 2015 Mar 10;2015:1401. PMID: 25752310; PMCID: PMC436152.

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