Perineal Tears during vaginal delivery: What. Why. and How to reduce risk and severity.

Vaginal birth is an incredible and empowering experience, but it can also come with challenges—including perineal tearing. While some degree of tearing is common during delivery, especially for first-time mothers, there are effective strategies to reduce the severity or avoid tearing altogether. 

The perineum is the area between the vaginal opening and the anus. During childbirth, especially as the baby’s head crowns, this area stretches significantly. If the tissues can’t accommodate the pressure, a tear may occur. 

Why Does Tearing Happen? 

• Fast or forceful pushing 

• Prolonged pushing 

• Larger babies 

• Assisted deliveries (forceps or vacuum) 

• First-time vaginal deliveries 

• Poor tissue elasticity or tight pelvic floor muscles 

Perineal tears are categorized by severity: 

1st Degree Tear 

• Involves the skin only 

• Often heals naturally or with minimal stitches 

• Mild discomfort 

2nd Degree Tear 

• Involves skin and muscles of the perineum 

• Requires stitches 

• More discomfort postpartum, but typically heals well 

3rd Degree Tear 

• Extends through the perineal muscles into the anal sphincter 

• May require more stitching or a surgical repair 

• Longer recovery, increased risk of complications  

4th Degree Tear 

• Extends through the anal sphincter and into the rectal mucosa 

• Requires surgical repair 

• Longer recovery and increased risk of complications 

How to Prevent Perineal Tearing During Delivery 

While tearing can’t always be prevented, there are proven methods that reduce risk and severity. 

1. Perineal Massage 

Perineal massage helps stretch and soften the tissues in the perineum during the final weeks of pregnancy (typically starting around week 34–35). 

How to Do It: 

• Use clean hands and a water-based lubricant or natural oil 

• Insert one or two fingers about 1 inch into the vagina 

• Apply gentle pressure downward and outward (like making a U-shape) 

• Stretch the tissue slowly, breathing deeply 

Benefits: 

• Increases elasticity of tissues 

• Helps moms become familiar with sensations of stretching 

• Reduces risk of 3rd and 4th degree tears, especially in first-time births 

2. Warm Compresses During Labor 

Applying a warm, moist compress to the perineum during the pushing stage can: 

• Increase blood flow 

• Improve tissue flexibility 

• Reduce the chance of tearing 

You can request it during your birth plan. 

3. Optimal Labor & Birthing Positions 

Positioning plays a critical role in minimizing pressure on the perineum and allowing the pelvis to open naturally. 

Best Positions to Reduce Tearing: 

• Side-lying: Reduces strain on perineum, allows gradual crowning 

• Hands and knees: Takes pressure off the perineum 

• Supported squatting: Encourages pelvic opening (if done slowly and with control) 

• All fours or leaning forward: Promotes optimal fetal positioning 

Lying flat narrows the pelvic outlet and increases perineal pressure—making tearing more likely. 

4. Controlled Pushing and Breathing Techniques 

“Purple pushing” (holding breath and bearing down forcefully) can increase the risk of severe tearing. 

Instead, try: 

• Exhaling while pushing (“open glottis” breathing) 

• Short, gentle pushes as the baby crowns 

• Following your body’s natural urge to push 

• Listening to your provider’s cues to slow down pushing 

Pelvic Floor Physical Therapy to Prevent Tearing 

A prenatal pelvic floor PT program is one of the most proactive steps you can take to reduce tearing and prepare your body for childbirth. Pelvic floor physical therapists can guide you through: 

Perineal Mobilization 

• Gentle manual techniques to increase tissue flexibility 

• Loosens fascial and muscular tension in the perineum and vaginal walls 

• Prepares the pelvic outlet to accommodate baby’s head without trauma 

Push Preparation (Push Prep) 

• Teaches the most effective pushing strategies for your body 

• Coordinates breathing and pelvic movement 

• Reduces forceful pushing and strain on perineal tissues 

Breathing and Diaphragm Coordination 

Your diaphragm and pelvic floor work together—when one moves, the other responds. 

Learning how to: 

• Inhale to open the pelvic floor 

• Exhale to coordinate a gentle downward movement 

• Use breath instead of force helps decrease internal pressure and strain 

Labor and Delivery Position Training 

Your therapist can help you practice labor positions tailored to your anatomy and comfort, including: 

• Side-lying 

• Kneeling 

• Squatting (with support) 

• Using tools like birthing balls or stools 

This way, you’re confident and prepared when labor begins. 

Women can begin pelvic floor physical therapy any time during their pregnancy for multiple symptoms or concerns.  More focus will be on perineal prep and push training in the third trimester (around 32–36 weeks). 

A prenatal PT program is especially recommended if: 

• You’re a first-time mom 

• You had tearing or pelvic floor trauma in a previous birth 

• You have pelvic floor msucle tightness or pelvic pain 

• You’re planning an unmedicated or minimally medicated birth 

Other Tips to Reduce Tearing Risk 

• Hydrate well in the weeks leading up to labor 

• Stay active with walking, yoga, or prenatal exercises 

• Communicate with your provider about your birth preferences 

• Choose a supportive birth team experienced in perineal protection 

What Happens If You Do Tear? 

Most perineal tears heal well with proper care, especially 1st and 2nd degree tears. 

Recovery Tips: 

• Use ice packs in the first 24–48 hours 

• Take sitz baths to soothe and clean the area 

• Use a peri bottle after bathroom use 

• Avoid straining or constipation (fiber and hydration help) 

• See a pelvic floor therapist postpartum for healing support and especially if you had a 3rd or 4th degree tear 

While perineal tearing is common, it’s not inevitable—and there’s so much you can do to reduce your risk.  From perineal massage and breathing techniques to labor positions and pelvic floor physical therapy, the key is preparation and support. 

Talk to your pelvic floor physical therapist about creating a plan tailored to your needs and goals. You deserve a confident, supported birth experience. 

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Disclaimer: This blog is here for your help. It is the opinion of a Licensed Physical Therapist. If you experience the symptoms addressed you should seek the help of a medical professional who can diagnose and develop a treatment plan that is individualized for you.