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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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My Childbirth Experience (Perineum Discussion Part 1)

Dr. EeVon Ling, ND

Dr. EeVon Ling, ND

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

Injury to the perineum is cited as one of the most common fears that people have about giving birth. (I prefer to use the word “injury” rather than tear, as I feel “tear” in the context of childbirth can produce such a visceral response that can be disturbing for many people)

Ask any group of people of child-bearing capability “How many of you have felt frightened at the thought of tearing during childbirth for yourself or someone else?” Almost all will say yes. This fear is so impactful that it can influence the decision to not become pregnant at all.

So what is it really like to give birth vaginally?  What happens if you have a perineal injury? 

This is my account of what it’s like to vaginally birth and have a 2nd degree perineal injury. 

To give some background info, perineal injuries due to childbirth are divided into 4 categories, based on severity and tissue and organs that may be involved (It is not based on the number of stitches needed as many people believe): 

  • Intact perineum – no injury occurred
  • 1st degree – least severe, involves only the skin around the opening of the vagina. Depending on the nature of this, stitches may or may not be needed
  • 2nd degree – involves the muscles between the vagina and anus – usually needs stitches
  • 3rd degree – affects the muscles around the anus
  • 4th degree – the most severe, reaching the tissue lining of the rectum

3rd and 4th degree injuries require an OB to repair in the OR of a hospital (for example, if you have a midwife and a homebirth and a 3rd or 4th degree injury occurred, you would be transferred to the hospital and an OB would  be assigned to help you). 

Generally speaking, up to 80% of people birthing for the first time experience perineal injury. Of that number of people: 

1st and 2nd degree perineal injuries are most common

3rd and 4th degree occur in less than 10% of that number – when no preventative measures are taken. 

Upon digging into the research on this topic, I learned that there are a few factors and preventative measures that can help you significantly reduce your chance of having a perineal injury! If you want to go straight to the evidence, read Perineum Discussion Part 2: Besting Your Chances for Minimal Injury.

Back to my experiences. I had 2 wonderful home water births, about 2 years apart, with 2 very different perineal outcomes. 

First birth: “She flew out of me”

I woke up that morning with a sore back, causing me to curse the really long walk I did the day before. As the morning progressed, I realized it was labour starting. I had learned HypnoBirthing (YDD HypnoBirthing) in preparation for our planned home birth and the techniques helped me cope with the progressing labour. As we got into the evening, our midwife arrived, checked me and my baby and everything was healthy and going well. At some point I got into the birth pool and continued labouring there.  

As my labour really ramped up, the midwife asked me “Did your water break?”  I had been in the pool for a few hours at least and so I had no idea. The midwife suggested that she check my cervix, which I agreed to.  I got out of the pool and during the check it was discovered I was 8cm dilated but my water had not broken yet. Labour was really intense at this point and after having a short conversation, weighing my options (yes, you can still have a logical conversation weighing the pros and cons of an intervention in the thick of labour!), I agreed to have my water broken by the midwife (also referred to as “rupture of membranes”).  

Once that happened, things progressed extremely fast. My baby quickly descended and was crowning within just a few minutes. One moment I could just feel the tip of her head. The next moment I heard a “Floomph ” and I saw my husband and midwife fish our daughter out of the water and put her on my chest.  Our daughter literally flew out of me in 1 contraction. 

As a result I had a 2nd degree perineal injury. 

Because she was born so fast, I did not feel the commonly described “ring of fire” that many birthing parents report. Because she was born unexpectedly fast, my midwife didn’t have a chance to do anything to support my perineum. Would it have made a difference to my perineum had I not had my water broken (I believe that really sped up what was already a fairly fast labour)? Would it have made a difference if the midwife were able to actively support my perineum during crowning? I did perineal massage (link to perineal massage video), did that help reduce the severity of my injury? I’m not sure, but later I will discuss what can help in reducing perineal injury. 

My labour and birth were a great experience that I owe to having the birth pool and using the HypnoBirthing techniques. The repairing of my perineum? That SUCKED. 

For me, getting the stitches was the worst part of my birth experience. Why? During labour and birth I sort of knew what to expect based on what I learned in my naturopathic medical training and from the HypnoBirthing prenatal classes. I was sitting in a padded pool filled with warm water and listening to relaxation music and affirmations and breathing like a real pro. 

Getting the stitches, on the other hand, was quite the opposite of zen. I had to lay on my back on a bed. I was wet and cold (despite my husband’s best efforts to dry me off and our condo was an un-air conditioned 28 degrees in the middle of July). Before doing any stitches, the midwife injected local anesthetic. My perineum felt very raw and vulnerable and all the poking and sharpness of the repair process was harder for me to handle than the labour and birth. Luckily that part was very short, only a few minutes. I used my breathing exercises during that time. In hindsight, more distractions like music playing, having my husband close by (he was tending to the baby in a different room as the bedroom we used was very small) and having other coping measures available would have been very useful to reduce the intensity of that experience.  Would it have been helpful if someone disclosed the details of what it really feels like to get your perineum repaired (without an epidural)? I’m not sure, and I still grapple with this question when I teach HypnoBirthing Classes and our Confident Birth Prenatal Program to my parents. 

Recovering from a vaginal birth and 2nd degree perineal injury:  It took me about 2 weeks before I felt normal down there. It is very normal, and very alien-feeling, to have all that swelling and tenderness. A girlfriend, who gave birth a few months later and who has a very crass sense of humour, called it her “hamburger”.  

I didn’t pay much attention to my perineum before, but for the 2 weeks after birth I had 2 all-consuming jobs 1) feed the baby 2) look after my perineum.  I was quite diligent with the ice packs and sitz baths. I used 2 peri bottles filled with hot and cold water so I could do a mini hydrotherapy session each time I used the toilet. (I always remind my new parents to take the extra time to care for their perineum.) I think I spent those first couple of weeks horizontal as standing, walking and sitting made me really tired and caused my pelvis to feel heavy and dragging. It was helpful that I was sort of observing the Chinese tradition of “confinement”  – resting and staying indoors for 1 month after the baby is born. Meaning no going out to run errands or doing things that would further exhaust or deplete me. 

The stitches get itchy making you want to, but also don’t want to, scratch them. 

When your perineum starts to feel better, and you know you’ve rounded the corner on your recovery, it’s like the fog has lifted and you start to feel more like yourself. That said, please still take it slow as doing too much too fast can regress your recovery. After my perineum fully recovered, I did experience a bit of a lingering sensation. It wasn’t pain exactly, but a bit like a ‘pulling” sensation with sex and sometimes with peeing. I didn’t know much about pelvic floor physiotherapy at the time, although I wished I did and it’s something I recommend to my clients postpartum to help address any issues that remain after recovery from childbirth. 

Second Birth Experience: Much better

The birth of my second daughter about 2 years later was almost a rinse and repeat of my first experience. I say almost because I came away from it with an intact perineum (that and the labour was much faster).  What was different this time around? Experienced birthing parents do have a decreased risk of perineal injury  to begin with (almost 50% less chance), so the odds were in my favour. My second child was almost the same weight and size as my first, but the difference was the speed of her entry into the world. My midwives (different than the first) were very hands off and it wasn’t until my baby was crowning that they realized my water hadn’t broken yet! With the water intact maybe that helped slow down the crowning a bit.  Once they realized she was about to be born, they were able to guide me and my breathing so I didn’t push her out too fast and they provided perineal support. 

I did not have to go through the repair process. Thank goodness! 

Recovery from birth without a perineal injury is so much better (as you can imagine)! I felt like myself just days after giving birth. But there was still some swelling so I still made sure I took care of my perineum (a bigger challenge when you have a baby and another child). 

I feel pretty lucky that I didn’t have any lasting pain or incontinence issues after giving birth.  Unfortunately many people do develop chronic pain or some degree of incontinence after childbirth as a result of the perineal injury. Having serious perineal trauma can affect your recovery, your ability to care for yourself and your baby and can impact your mental health. Perineal injury can lead to problems with incontinence, pain with sex and chronic pain in general.  If there was some way to help avoid or at least reduce the severity of a perineal tear, we have a duty to inform those who are pregnant. 

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. 

To learn more, read Perineum Discussion Part 2: Besting Your Chances for Minimal Injury