What we know about perineal tearing, and how to reduce it during childbirth

A common fear women have when contemplating having a baby is whether the birth will tear the tissues between the vagina and anus, also known as the perineum. How can something as big as a 3.5kg baby come out of something as small as a vagina without inflicting damage?

Fortunately, the vagina is designed to accommodate a baby. Hormones flood a woman’s body during pregnancy and labour, increasing blood supply and changing the stretchiness of tissues in that area.

Evidence shows appropriate use of heat packs along with other aspects of clinical care can improve comfort during the final minutes of giving birth, and reduce the risk of tearing in the perineum.

How common is tearing during childbirth?

Only 2% of women endure the most severe form of perineal tearing during birth, involving the vagina, perineum and sometimes the anus. Around 27% of women experience no tearing at all, while 23% have a very minor vaginal tear or graze that often does not require stitches and heals on its own. Around 26% of women have a perineal tear that may need to be stitched.

A surgical cut to the perineum called an episiotomy is performed on around 20% of Australian women during childbirth.

The rate of perineal damage during childbirth has increased over the past 100-200 years. While a quarter of women are tear-free during birth in Australia today, some data suggests 95% of women had no tearing in the 1800s.

Some reasons for this discrepancy may include 19th century women being younger at time of delivery, having many babies close together, birth taking place in an upright position and less medical intervention such as forceps, vacuum and episiotomy during delivery.

From ‘old wives tales’ to evidence-based care

Hannah’s interest in perineal care started when she was a student midwife in the UK. She witnessed a labouring woman who, although close to giving birth, seemed scared of letting her baby emerge. The supervising midwife - an older woman, and very experienced - quietly got up and left the room, and returned a few minutes later with a bowl of steaming water. She proceeded to put a cloth in the water, wring it out, and place it gently on the woman’s perineum.

The woman’s face relax noticeably, and she gave birth to her baby. When questioned about what was in the water, the senior midwife answered, “just soothing the ring of fire ducky” (taking the stinging out of the birth).

Hannah went on to undertake the largest randomised controlled trial - now known as the warm pack trial - examining whether placement of a warm pack on a woman’s perineum reduces perineal tearing and improves comfort.

A warm pack consists quite simply of a sterile pad soaked in very warm water (300mls boiling and 300mls cold tap water) and wrung out.

The results showed that warm packs reduce the most severe perineal tearing, as well as lowering women’s pain during the birth and the first couple of days afterwards.

The study also found urinary incontinence was reduced three months following the birth.

Perineal warm packs are now accepted as an approved technique for use during childbirth thanks to a validated review of approaches to reduce perineal tearing. The report concludes the use of perineal warm packs is associated with decreased occurrence of perineal trauma and is acceptable to both women and midwives.

Compassion matters during childbirth

Research led by Holly has examined the experiences of women who have endured the most severe form of perineal trauma. Women were able to clearly describe the way they were treated by health professionals throughout their labour, birth and postnatal period. This treatment experience shaped their recovery in both negative and positive ways.

Many of the women reported feeling they were not well supported, they were dismissed and disregarded, and at times they were treated “like a piece of meat”.

We found relationships with health providers and compassionate care were key in how women perceived the experience of sustaining a severe perineal tear. The women who felt the most supported throughout their experience were those who had received continuity of care by a known care provider (midwife or obstetrician).

They were more likely to be linked into services to give them support, and more likely to seek support themselves as they had been told what was normal and not normal when it came to post birth symptoms.

When asked what women considered to be ideal and most helpful, they identified information, continuity of care, compassion, understanding and support as critical. Compassionate, empathetic care should be provided to all women who are having a baby as a fundamental human right.

Factors contributing to the risk of perineal trauma

A number of factors influence the likelihood of perineal trauma associated with tearing or as a result of episiotomy:

Perineal trauma is more likely:

• Having your first baby
• Having a forceps or vacuum birth
• Being from certain ethnic backgrounds (such as India and China)
• Having a long second stage (pushing part) of labour
• Having an epidural
• Having an episiotomy
• Giving birth lying on your back, especially with legs in stirrups (lithotomy)
• The baby’s head is in an abnormal position
• The baby is very big, over 4kg in weight
• A private obstetrician is the care provider (specific to episiotomies)

Perineal trauma is less likely when:

• Having your second or subsequent baby
• Being active during labour and birth and avoiding an epidural
• Giving birth in a side lying or upright position
• Perineal massage has been done in the late stages of pregnancy
• Having warm packs applied to your perineum during the birth
• Birthing the baby’s head slowly or between contractions
• Having your baby in a birth centre or at home
• Being cared for by midwives

Midwifery has a history of using warmth applied to the perineum as a source of comfort in labour and childbirth. Modern evidence now supports the use of warm packs along with other aspects of care to reduce perineal tearing, to lower pain and to improve physical and mental recovery after giving birth.

Hannah Dahlen receives funding from NHMRC and ARC. She is affiliated with the Australian College of Midwives.

Holly Priddis does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond the academic appointment above.