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Perineum Discussion Part 2: Besting Your Chances for Minimal Injury

Dr. Ee Von Ling, ND

Dr. Ee Von Ling, ND

Trigger warning: Discussion about vaginal birth and perineum. Discussion about perineal injury and tears. 

This post will go right into the discussion of how to reduce perineal tears and injury. To learn about the 4 different types of perineal injury and read my personal account of having a 2nd degree perineal injury, first read My Childbirth Experience

Is there anything you can do to help reduce perineal injury? 


The most important factor that influences your risk of a perineal injury will surprise you. 

Your care provider is one of the strongest factors of having an intact perineum: 

Having a homebirth with a midwife is the best way to help avoid a perineal injury. Second to this is having a birth centre birth with a midwife. The main reason is episiotomies and repairing a 3rd or 4th degree perineal tear are not within a midwives’ scope of practice, so they are skilled in helping birthing people avoid or minimize these injuries. 

Having an OB with a high 3rd or 4th degree perineal injury rate or has a high rate of episiotomy use will have the highest risk of developing a perineal injury. 

If you want to give birth in a hospital, get a midwife to help reduce your chance of a perineal injury. 

If you don’t have access to a midwife, ask your OB what their 3rd and 4th degree rate is (it should be 3% or less, if it is much more, it means they are not taking preventative measures). Ask  your OB how often they are doing episiotomy, or under what circumstance they are doing this. Fortunately, hospitals in the GTA have a no routine episiotomy policy, meaning, the OB should not be doing them as just a matter of routine.  Ask your care provider if they obtain consent from the client first if they are considering to do an episiotomy

Other tips to help reduce severe (3rd and 4th degree) perineal tearing: 

  • Be in an upright birth position (If you have no epidural)
  • Be in a side lying birth position with delayed pushing (If you have an epidural)
  • Warm compress against the perineum (Done by your care provider – this helps reduce severe tears and reduce pain)
  • Perineal massage by the care provider might help lower your risk of a severe perineal  trauma, increase your chance of having an intact perineum, or it might make no difference (They need your consent first!)

These other factors that can increase your risk: (Unfortunately, these factors are less under your control)

  • Size of baby (the bigger the baby, the bigger the risk)
  • Position of baby at birth (if baby is “sunny side up”, OP or face up at birth)
  • Very long or very short 2nd stage (pushing time)
  • Shoulder dystocia (difficulty with birthing the shoulders)
  • Use of forceps or vacuum
  • Family history of severe perineal tears

Among the research, there was a particular group of midwives with an amazing 73% intact rate! What did these expert midwives do differently?  

  • They performed slow, calm and controlled delivery of the baby’s head
  • They guided with non-valsalva pushing
  • They delivered the baby’s head between contractions

Additional tips from these expert midwives: 

  • When the baby is crowning, they warn clients to blow instead of push
  • Avoid coaching to push
  • Avoid pushing during crowning
  • Encourage hands and knees position
  • Allow the baby’s head to remain on the perineum for a number of contractions
  • Wait until baby has rotated before trying to birth shoulders

What about doing perineal massage? 

Studies conducted have shown that doing a minimal amount of perineal massage (1-2 times/week, 10 minutes each time, starting from 34 weeks of pregnancy) can help reduce the chance of perineal injury for people birthing for the first time. People who are birthing after the first time generally have a lower chance of perineal injury, and doing perineal massage has not shown to reduce the rate further. However, doing perineal massage has been shown to help reduce perineal pain from childbirth. Interestingly, there is no added benefit in doing more than the minimum amount. 

Also, no study showed that perineal massage made it worse for perineal health. Thus, I always recommend that you do some perineal massage to help prepare physically as well as mentally for childbirth (learn to relax and practice breathing exercises while doing it). 

Injury to the perineum is cited as one of the most common fears that people have about giving birth. The fear is strong enough to influence people to not have children. It is the unseen and unspoken part of birth.  We don’t properly educate the public on the ways that help reduce perineal trauma, leaving the power and decision making to the care provider. I hope that in sharing these evidence-based tips and my own personal experience that you feel more empowered to gain control of this part of the birthing experience. 


Perineal massage video

Evidence Based Birth: Perineal Massage

Evidence Based Birth: top 5 tips on protecting the perineum

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