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Can you Prevent Tearing During Birth?

Many women will experience some trauma or injury to their genitals during birth, and this is a common fear during pregnancy. The Royal College of Obstetricians and Gynaecologists (RCOG) state that as many as 9/10 first-time Mums can sustain some level of trauma to the perineum (area between the vagina and anus) during childbirth. Sometimes, women may have injuries to other areas of their genitals including the inner or outer labia, vaginal wall, or less commonly, clitoris or urethra. The good news is that for most women, this trauma heals well but even better than that, there are steps you can take throughout your pregnancy and labour to help reduce the chance of sustaining tears. This post focuses mostly on perineal trauma, as this is the most commonly sustained tear in childbirth.




So here are 8 ways you can help to prevent or reduce the chance of tearing during your birth...


Choose Your Birth Place Carefully

This may seem like a strange thing to discuss in this particular article, but where you have your baby is a really important decision and can have huge influence on what happens during the course of your labour and birth. Giving birth in a less medicalised environment such as at home or in a Midwife-led birth centre is associated with reduced rates of perineal trauma. In fact, choosing to have a homebirth means you are 55% less likely to have an episiotomy and 40% less likely to sustain a 3rd or 4th degree tear! (Reitsma et al, 2020)


Perineal Massage

This involves using massage techniques to stretch your perineal muscles. Use some water based lubricant and gently putting pressure with 2 thumbs on the vaginal wall. This helps to increase blood flow to the area, and improve elasticity helping the perineum to stretch when your baby is being born, therefore reducing the chance of tears happening. It's usually recommended that you start perineal massage from around 34 weeks of pregnancy for 2-3 minutes each day until you give birth. You can read more about Perineal massage here.


Pelvic Floor Exercises

There is limited evidence to suggest that pelvic floor exercises alone can reduce the chance of tearing during birth, but some research has suggested that if done as part of a regime which also involves perineal massage, the risk of tears is lower (Leon-Larios et al, 2017). Exercising your pelvic floor helps to improve muscle tone, circulation and give you greater control over the muscles. This is not only useful for aiding birth, but will help promote recovery afterwards.



Controlled Birth of Your Baby

When you're in control during childbirth, you're able to listen to your body's cues and birth your baby at a pace that feels right for you. This helps to prevent putting too much strain on your perineal area, which can reduce the chances of tearing. Plus, staying in control allows you to find comfortable positions that can align your baby's head better and ease pressure on your perineum. Feeling confident and empowered during labour helps you relax your pelvic floor muscles, making it easier for your baby to move through the birth canal without causing tears. So, remember, staying in control of your birth process can lead to a smoother delivery and minimize the risk of perineal tears.


"UFO" Positions

If this is the first time you've come across the term 'UFO' for birth, then rest assured, it has absolutely nothing to do with flying objects or outer space. It stands for upright, forward and open and refers to birthing positions that can help you during labour. These positions involve standing, all fours, or kneeling, which can help open up your pelvis, and there is a wealth of evidence associating such positions with reduced rates of perineal trauma (Haith-Cooper, 2016; Huang et al, 2019; Familiari et al 2023) . They're called "UFO" positions because they encourage you to stay upright, lean forward slightly, and keep your pelvis open. Creating space in your pelvis means your baby is more likely to adopt an optimal position for birth and pass through the birth canal more easily. As well as this, adopting "UFO" positions promotes freedom of movement so you can instinctively move your body in ways which help the descent of your baby and reduce the strain on your muscles.


Avoid "Purple Pushing''

"Purple pushing" refers to the intense and forceful pushing technique often observed during the pushing stage of labour, particularly in hospital settings. It's called "purple pushing" because it often involves holding your breath and pushing forcefully for prolonged periods, which can lead to your face turning purple due to increased pressure and strain. It is commonplace to be told to take a deep breath, hold it and push hard into your bottom. This is the sort of image often portrayed in media so many people believe this is how birth is supposed to be. However while this may work for some (particularly with an epidural), this kind of pushing is not instinctive and takes the control away from the birthing person and gives it to the healthcare provider. As we have discussed, lack of control and going against instincts can increase your chance of sustaining tears. On top of this, 'purple pushing' may also cause your baby to become distressed. For most people, they will feel the fetal ejection reflex kick in at some point, where your muscles start to push your baby down and out physiologically. This sort of 'involuntary pushing' is much more conducive to a smoother birth and is more likely to result in an intact perineum than purple pushing.


Breathing Techniques

There are various breathing techniques that can be used during birth to reduce unnecessary strain on the pelvic floor and perineal muscles. The best techniques will depend on many different factors, so it is important to listen to your body and your care provider to find what works for you. However, a good technique for when you are spontaneously pushing in a vaginal birth is to fill your lungs, then slowly exhale whilst bearing down with the urges to push. It often feels similar to opening your bowels, and some people will make noises on exhaling. This is perfectly normal and nothing to worry about! As your baby's head is crowning you may be advised to pant, blow or take more 'in' breaths to allow your baby's head to birth slowly.


Warm Water/Compress

It is well known that warmth has a multitude of benefits for muscles including releasing tension, increasing circulation and soothing discomfort. It may therefore seem logical that applying warmth to the perineum during birth can help the muscles to stretch, and reduce the risk of perineal trauma. Lots of research has ben undertaken into this subject, and it is well documented that giving birth in water, or applying a warm compress to the perineum during birth can reduce the likelihood of tearing (Bovbjerg, Cheyney and Caughey, 2021; Burns et al, 2022; Mahsa Maghalian et al, 2023; Magoga et al, 2019) If you are giving birth at home, it is easy to hire a birthing pool, and most midwife-led care settings have access to pools. Access to a birthing pool can be more difficult in obstetric led settings, but if you are unable to birth in water or are choosing to birth on land, consider a warm compress.


Summary

There are many factors which may influence your chance of sustaining an injury or tear during childbirth. Some variables such as your genetics are uncontrollable, however there are practical steps throughout both pregnancy and during birth that you can take to reduce your risk. It's important to feel informed and empowered going into your birth, and remember - your most valuable resource is your own intuition. Trust your body, know your physiology and birth instinctively.


For more information or to read the full research articles, click the links throughout this post, and see the reference list below.



References

Bovbjerg, M.L., Cheyney, M. and Caughey, A.B. (2021). Maternal and neonatal outcomes following waterbirth: a cohort study of 17,530 waterbirths and 17,530 propensity score‐matched land births. BJOG: An International Journal of Obstetrics & Gynaecology, 129(6). doi:https://doi.org/10.1111/1471-0528.17009.


Burns, E., Feeley, C., Hall, P.J. and Vanderlaan, J. (2022). Systematic review and meta-analysis to examine intrapartum interventions, and maternal and neonatal outcomes following immersion in water during labour and waterbirth. BMJ Open, 12(7), p.e056517. doi:https://doi.org/10.1136/bmjopen-2021-056517.

Familiari, A., Neri, C., Passananti, E., Marco, G.D., Felici, F., Ranieri, E., Flacco, M.E. and Lanzone, A. (2023). Maternal position during the second stage of labor and maternal-neonatal outcomes in nulliparous women: a retrospective cohort study. AJOG Global Reports, 3(1), p.100160. doi:https://doi.org/10.1016/j.xagr.2023.100160.


Haith-Cooper, F.L. (2016). The effect of maternal position at birth on perineal trauma: A systematic review. [online] British Journal Of Midwifery. Available at: https://www.britishjournalofmidwifery.com/content/researchliterature-review/the-effect-of-maternal-position-at-birth-on-perineal-trauma-a-systematic-review/#:~:text=Kneeling%20and%20all%2Dfours%20positions [Accessed 11 Apr. 2024].


Huang, J., Zang, Y., Ren, L.-H., Li, F.-J. and Lu, H. (2019). A review and comparison of common maternal positions during the second-stage of labor. International Journal of Nursing Sciences, [online] 6(4), pp.460–467. doi:https://doi.org/10.1016/j.ijnss.2019.06.007.

Leon-Larios, F., Corrales-Gutierrez, I., Casado-Mejía, R. and Suarez-Serrano, C. (2017). Influence of a pelvic floor training programme to prevent perineal trauma: A quasi-randomised controlled trial. Midwifery, 50, pp.72–77. doi:https://doi.org/10.1016/j.midw.2017.03.015.


Magoga, G., Saccone, G., Al-Kouatly, H.B., Dahlen G, H., Thornton, C., Akbarzadeh, M., Ozcan, T. and Berghella, V. (2019). Warm perineal compresses during the second stage of labor for reducing perineal trauma: A meta-analysis. European Journal of Obstetrics & Gynecology and Reproductive Biology, [online] 240(240), pp.93–98. doi:https://doi.org/10.1016/j.ejogrb.2019.06.011.

Mahsa Maghalian, Alikamali, M., Mahsan Nabighadim and Mojgan Mirghafourvand (2023). The effects of warm perineal compress on perineal trauma and postpartum pain: a systematic review with meta-analysis and trial sequential analysis. Archives of Gynecology and Obstetrics. doi:https://doi.org/10.1007/s00404-023-07195-2.

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Reitsma, A., Simioni, J., Brunton, G., Kaufman, K. and Hutton, E.K. (2020). Maternal Outcomes and Birth Interventions among Women Who Begin Labour Intending to Give Birth at Home Compared to Women of Low Obstetrical Risk Who Intend to Give Birth in hospital: a Systematic Review and meta-analyses. EClinicalMedicine, [online] 21(100319), p.100319. doi:https://doi.org/10.1016/j.eclinm.2020.100319.

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