Perineal massage, tearing, and episiotomy

Most first vaginal births include some tearing, usually small. Perineal massage, warm compresses, and slow crowning lower the odds. Episiotomy is rare now.

What it is

Tearing means the skin and muscle between the vagina and anus, the perineum, splits as the baby's head is born. It sounds worse than it usually is. About 7 in 10 vaginal births involve some tear, most of them small. A first degree tear is skin only and may need no stitches. A second degree tear reaches muscle and gets stitches; this is the most common. Third and fourth degree tears reach the anal muscle and happen in about 3 in 100 births, more often with a first baby, a large baby, forceps or vacuum, or long pushing.

An episiotomy is a cut made by the provider to widen the opening. It was routine for decades. ACOG now says it should be rare, and rates have dropped from over half of births to under 1 in 10. Perineal massage is stretching that tissue in the last weeks of pregnancy. Warm compress is a warm cloth held against the perineum as the head crowns.

What's typical

Massage guides start at 34 or 35 weeks: a few minutes, once or twice a week, with clean hands and a little oil, pressing down and to the sides until it stretches. Many mothers find it awkward and do it anyway. At the birth, a midwife or nurse often holds a warm cloth on the perineum between pushes. After the birth, stitches dissolve over 2 to 6 weeks. Soreness peaks on days 1 to 3 and is much better by 2 weeks. A peri bottle, ice for the first day, and a pillow to sit on are the everyday tools. Third and fourth degree tears get a longer repair and a planned follow-up.

What's known

Cochrane found that in first-time mothers, perineal massage from 35 weeks lowers the chance of a tear needing stitches by about 10 percent and of an episiotomy by about 16 percent. For mothers who have given birth before, it lowers pain at 3 months. A second Cochrane review found warm compresses during pushing cut third and fourth degree tears roughly in half. Side-lying and slow, breathed crowning are linked with fewer tears. ACOG endorses warm compresses and restricted use of episiotomy.

What helps

Start massage at 34 or 35 weeks if you want to. Skipping it is fine too; the effect is modest.
Put warm compress and no routine episiotomy on your birth plan in one line.
Ask to push on your side or on hands and knees as the head comes.
After the birth: peri bottle every time you pee, ice the first 24 hours, warm water after that.
Keep stools soft with water, fruit, and fiber. The first poop is the fear most mothers have.

When to call someone

Nowbleeding that soaks a pad in an hour, or stitches that open and bleed heavily.
Todayfever, foul-smelling discharge, pain that gets worse after day 3 instead of better, stitches that have come apart, you cannot pee, or you cannot control gas or stool.
At your next visitpain with sitting at 6 weeks, pain with sex, leaking, or a feeling of heaviness. Ask for pelvic floor physical therapy.

Who helps

MidwifeOB-GYNPelvic floor PT Doula

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Sources

Cochrane — Antenatal perineal massage for reducing perineal trauma
Cochrane — Perineal techniques during the second stage of labour for reducing perineal trauma
American College of Obstetricians and Gynecologists — Practice bulletin on prevention and management of obstetric lacerations at vaginal delivery
NHS — Perineal tears during childbirth

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