The perineum is a very important part of a woman’s body and it plays a special role during childbirth. It is the area of skin and muscle found between the vagina and anus. During childbirth it stretches to allow the baby’s head through. As the birth approaches women may worry increasingly about the trauma and pain that might be experienced. They wonder how something as big as a baby’s head can really come out of what appears to be a relatively small hole!

How many women suffer perineal trauma?

In the latest statistics published in September 2004, one in three Australian women having a vaginal birth had no perineal tearing at all. Overall forty eight percent of women had some form of tearing when giving birth and around seventeen percent had an episiotomy (cut to the perineum).

What are the different types of perineal trauma?

Perineal trauma is usually divided into different types. The mildest form of trauma is called a graze. These are shallow splits in the skin that rarely need to be stitched. They can sting when you pass urine after the birth. Taking a urine alkaliniser such as Ural can help reduce the acidity of your urine and the stinging experienced.  A first degree tear is a small tear in the perineum and only involves the skin. These tears also rarely require stitches.

A second degree tear involves the skin and some of the muscles in the perineum. These are often stitched to help with healing. About forty percent of Australian women experience a first or second degree tear when giving birth. The most severe tears are third and fourth degree tears and they are quite rare (about 1 in 100). Third degree tears involve all that second degree tears do but also involve the anus. If the tear goes through the anus into the rectum then it is called a fourth degree tear.

Tearing is more likely when:

• Having your first baby
• Having a forceps or vacuum birth
• Having an episiotomy
• Pushing the baby out very fast or taking several hours
• Giving birth lying on your back, especially with legs in stirrups
• The baby’s head is in an abnormal position
• The baby is very big

Tearing is less likely when:

• Having your second or subsequent baby
• Giving birth in a side lying, kneeling or all-fours position
• Perineal massage has been done antenatally
• Your pelvic floor relaxed
• When you follow your own urge to push rather than being instructed to hold your breath and push

Perfecting the perineum during pregnancy

There are certainly things you can do to reduce trauma to your perineum. Making sure you have a healthy balanced diet is very important in pregnancy. This will keep your body in good condition and also help you to heal well if you do have a tear during the birth. Vitamins such as Vitamin E and Zinc are important for maximising the health of your skin. Regular exercise also helps maintain a healthy body.

Perineal massage is one of the best researched methods of reducing perineal trauma. It does not guarantee, however, that you will not tear. Two large research trials into perineal massage done during the pregnancy showed women could reduce perineal tears, particularly bigger tears and episiotomies. In one of the studies this was even more apparent in women aged thirty years and more.

Perineal massage can be done by yourself or your partner. Most women start around thirty four weeks of pregnancy. You can massage once or twice a day. Before you start make sure you won’t be disturbed and you feel relaxed. Some women prefer to have a bath or use a warm compress on the perineal area before they start in order to soften the tissues. You can do the massage semi-sitting, reclining against several pillows or standing with one leg on a chair or the toilet seat.

A mirror can help you to see what you are doing.

• You will need to use a lubricant (almond oil or water-soluble jelly). Make sure your or your partner’s hands are clean and nails are short and smooth.
• Rub the lubricant on the perineal skin until it is completely worked in and the circulation is stimulated (3-4 minutes). Try not to get too much oil in the vagina as it can disturb the normal balance.
• Place your thumbs shallowly into the vagina (no more than 3 to 4 cm) and press the perineal floor down towards the bowel and to both sides. Your partner can use their first and second fingers of one or both hands.
• Gently stretch the opening by pressing down until you feel a slight burning or stretching sensation. Maintain the pressure for about a minute and then rest for a minute or two.
• Repeat this action two or three times and concentrate on any previous episiotomy scars as they are especially inelastic.
• Avoid the urethral area (where the urine comes out) to reduce the risk of a urine infection. Avoid doing perineal massage if you have a vaginal infection or genital herpes.
• As well as doing perineal massage women should be encouraged to do pelvic floor exercises to help tone the pelvic floor muscles. This also teaches them how to relax the pelvic floor.

While commercial devices have been developed to simulate perineal massage they are expensive and not necessarily better.

Perfecting the perineum for birth

During the labour and birth there are also things you can do to reduce the likelihood or severity of perineal tearing. Using warm water for pain relief, such as a warm bath or shower, can also help to soften the perineal tissues. For many years midwives have used moist, warm packs on the perineum when women are pushing to help reduce pain and tearing as the baby’s head is born. I have just completed a large study into the use of warm packs and the results are very positive. Women certainly find warm packs help them to cope with the stinging sensation they experience when the baby’s head stretches the perineum.

Women who have epidurals for pain relief are more likely to have severe perineal tears. The reason for this is these women are more likely to have episiotomies and forceps or vacuum deliveries. We know from past research that both episiotomies and forceps and vacuum deliveries lead to more severe tearing.

The position women choose to give birth in can also have an impact on their perineum

Studies have shown a lower rate of tearing when women give birth in side-lying or squatting positions.  Lying on your back or in a semi seated position puts pressure on your tail bone and reduces the size of your pelvis. Women who give birth in stirrups have the worst perineal tears. Upright positions, like standing, squatting and kneeling, make the birth much easier. Birthing on your hands and knees is another good position. The very best birth position, however, is the one you are most comfortable in. If you have a particular birth position in mind or want to birth in water or on a birth stool then check with your care provider early on in the pregnancy. Some obstetricians will not deliver in any other birth position than lying on your back. Most midwives these days are happy to accommodate women’s choice of birth position.

Pushing is an instinctive thing for women. When the cervix is fully dilated and the head distends the lower part of the vagina, women get an urge to push. Unfortunately many caregivers instruct women to push by telling them to take a deep breath and push in a sustained way. This type of pushing is referred to as a Valsalva manoeuvre and it can increase the rate of perineal tearing during birth. It tends to tighten up the pelvic floor rather than relax it. It reduces the amount of oxygen the baby gets, sometimes causing the baby to get distressed. Also, it exhausts women faster. Sometimes women need guidance with pushing, especially if they have an epidural, as this takes away their urge to push.

The majority of women should be able to birth their baby by following the natural urge to push.

When the baby’s head stretches the perineum to paper thin most women feel an intense burning sensation. This is where warm packs can help. It is important at this point of the birth that the widest part of the baby’s head is eased out slowly. Women are often encouraged to pant or blow to slow the birth down and minimise tearing. As the baby’s head is born your caregiver usually places their fingers on the baby’s head to control the speed of the birth. A large study done in the United Kingdom showed some control is beneficial but this should not involve pushing the perineum over the head on putting fingers in the vagina to stretch it up further.

The evidence for restricting the use of episiotomy is very strong and leads to lower rates perineal trauma, particularly the more serious third and fourth degree tears. Not surprisingly women who have episiotomies take longer to resume sexual intercourse than women who don’t. Obstetricians are much more likely to cut episiotomies than midwives. Studies have shown privately insured women, who are usually delivered by obstetricians, have twice the rate of episiotomies as publicly insured women delivered by midwives.

Studies have also shown that good support in labour leads to less perineal trauma. This is an area that needs a great deal more research. The impact of fear is also largely unexplored. Where you know your midwife and have a good system of support during the birth we know women have less perineal trauma.

Research has shown that the way we repair perineal tears can also reduce pain. You should check that your caregiver will repair any trauma using products like Dexon or Vicryl. Vicryl Rapide is now available and has all the same advantages of the other two suture materials but dissolves even faster. It is also better if your caregiver uses a continuous suture rather than individual sutures. When repairing the skin a suture technique called ‘subcuticular’ should be used as this buries the stitches under the skin and is much more comfortable.

Perfecting the perineum after the birth

We know perineal trauma can affect women physically, psychologically and socially following the birth of a baby. From the research available we know the optimal perineal care is that which keeps the area clean and reduces swelling. Swelling can cause the stitches to break down before the wound is healed and it is very painful. Ice in the first 48 hours can reduce swelling. Regular pelvic floor exercises commenced in the day or two following the birth can also help reduce swelling and increase circulation.

This in turn improves healing. Regular pelvic floor exercises should be part of every woman’s life when it comes to perfecting the perineum. Changing pads regularly and having regular perineal washes helps keep the area clean and it will be less likely to become infected. It is important to not get constipate after the birth so a diet high in fibre and drinking at least two litres of water a day will help.

Using hair dryers to dry the wound or soaking in salt or disinfectant baths are all a waste of time and don’t improve healing. Not enough research has been done yet on the use of ultrasound on perineal trauma. Paracetamol is still the best choice of pain relief for mild perineal pain. If you need something stronger make sure you talk to your caregiver.

Women can resume sexual intercourse anytime they feel ready.

How soon you feel ready will depend on how much perineal trauma you experienced, how you have recovered from the birth and how much sleep you are getting during the night. Don’t put extra pressure on yourself about resuming sexual intercourse. Take things slowly the first time you do and use lots of lubricant and foreplay. Tell your partner foreplay begins at the kitchen sink with the washing up being done. The more support you get following the birth the easier it is to get in the mood! Women who are breastfeeding will find they experience more vaginal dryness and may need to use a water based lubricant. If it hurts having sex then wait a few days and try again. If intercourse continues to hurt three months or more after the birth then see your general practitioner.

Page revised on 16th December 2021