How Pelvic Floor PT can help reduce risk and severity of perineal tears during childbirth
Perineal Tears: What are they?
First a little anatomy. If you go down on the outside of the vagina, so vestibular/ vulvar area, prior to reaching the anus, you run into a small area of tissue called the perineum. Because of how the muscles are structured in this area, on the surface, you may think it’s just skin or maybe even just one muscle. But, no! Ther perineum is an intersection of FOUR muscles, specifically, the superficial transverse perineum, the deep transverse perineum, the bulbocavernosus, and the external anal sphincter. Because there are multiple muscles that intersect here, that makes this small tissue area very dense. It’s muscle, so how do muscles behave? They have the ability to stretch, but being that this is a very small area, we’re looking for majority slow-twitch muscle fibers, and good coordination between all FOUR muscles groups to be able to relax at the same time.
What types of perineal tears can occur?
There are 4 degrees of tears. The 1st degree is a superficial injury to the vaginal mucosa that can involve the skin, as the tear would generally come from pressure on the inside of the vaginal canal. The 2nd degree is a first-degree laceration involving the vaginal mucosa and the perineal body. The 3rd and 4th degrees are considered OASIS injuries. The 3rd degree is a second-degree laceration with the involvement of the anal sphincter complex, which can be broken down further into: type A, involvement of <50% of the external anal sphincter; type B, involvement of >50% of the external anal sphincter; type C, external and internal anal sphincters are torn. The 4th degree is tearing of the anal sphincter complex and the rectal mucosa.
Type 1 generally does not need suture repair, however 2nd degree generally does, and Oasis injuries require skilled repair, generally under anesthesia.
You can imagine that experiencing a perineal tear, could make postpartum recovery difficult, as the wound could become irritated with both urinating and defecating, or simply having a moist environment from the lochia in your pad, sitting may be uncomfortable, and it may take longer to feel ready to engage in sexual intercourse as well.
What if I told you, there are ways to prepare your perineum (and other vulvar tissues, because tears can happen elsewhere as well) prior to childbirth, to help reduce the risks of tears, or at least drop the severity of them?
Prevention:
So, remember, I stated that the perineum is the intersection of muscles, these muscles have the ability to stretch, but they are slow twitch fibers (to promote long lasting contractions used throughout the day/ night). Therefore, we want slow gentle stretching. The best way to promote this type of lengthening, is through breath.
1.Did I say breath? Yes! When our pelvic floor is in sync with our diaphragm, it works it’s best. So when we inhale, our lungs fill with air, and that pushes our diaphragm down, which increases pressure in the abdomen, which then pushes down on the pelvic floor. So a good inhale, will cause lengthening of the pelvic floor muscles from the inside, the same direction that force from the baby is coming that can cause to overstretching and tearing of these muscles. If we spend the time to learn how to gently stretch them with our breath, we can combine the two during pushing, so not only having readily ample muscles, but using them appropriately to help deter injury.
2.The next option is actual stretching. This can be done during the third trimester, and is often called perineal massage. Massage is a misnomer. The act is purposeful stretch, which again should be done gently, but can garner further length than a breath. This can be done in the tub or shower (if you have good support), or even in your bed/ soft surface (with clean hands and lubricant). The idea is to insert your finger or tool (vibrator/ fridamom/ pelvic wand) just at the entrance of the vagina and to pull down the lower border- if it were a clock, you’re looking at 4- 7 o’clock. Hold in that direction for 15-30 seconds and breathe, before moving to next position and repeating. It should take about 5 min per session. If you’re having trouble reaching around your belly, you can use a tool, or perform in standing in the shower, and enter your finger from behind, or have your partner or pelvic floor therapist to help you with this task.
3.Perineal massage can be controversial in some circles, as some people believe that repeatedly stretching the tissues can cause microtears that can lead to easier tearing during birth. Healthy tissue should not be subject to micro tearing. If you are experiencing micro tearing, then there are other pelvic floor dysfunction issues at play, and in this case, you should be seen by a pelvic floor physical therapist to assess and assist you with this. Also, if you are regularly having sexual (penis or dildo in vagina) intercourse during your pregnancy, perineal massage may not be necessary, as you are regularly stretching these tissues.
4.Another technique is stretching your hip adductors, as these muscles share attachment sites with some of the perineum muscles. Performing deep, wide-legged supported squats can help stretch these muscles. Another helpful stretch is a frog stretch, where you’re on your knees, spread apart and coming back into a child’s pose type of position, however a deeper version of this stretch would be having only one knee down, and the other leg stretched out to side and then attempting to bring your behind back to your heel. While holding these stretches, focus on your breath, and imagine your pelvic floor lengthening and relaxing away from your body.
5.Also, a great way to prevent perineal tearing during childbirth is the position you chose to push in. Research states that pretty much any position other than pushing on your back helps prevent perineal tears. So, laying on your side, squatting, hands and knees, kneeling, positions that allow proper positioning of the pelvic outlet and allow gravity to assist in delivery give your perineum a chance to properly stretch/ relax.
6.Lastly, applying a warm compress to the perineum with some compression can help with allowing the tissues to relax and to help slow down rampant and forceful stretching in the area.
Recovery
So, If you didn’t get this information beforehand, and you’ve experienced a perineal tear, come see a Pelvic Floor Physical Therapist, so we can help you return function, decrease pain, and thrive in your postpartum… remembering that postpartum is for life!
1. Ramar CN, Vadakekut ES, Grimes WR. Perineal Lacerations. [Updated 2024 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559068/
2. Cochrane Database Syst Rev. 2017 Jun 13;2017(6):CD006672. doi: 10.1002/14651858.CD006672.pub3
