How can I avoid tearing at birth?

Perineal tearing is common. Sometimes it is minor and sometimes severe and sometimes very severe. Some doctors (not me) frequently do episiotomies to facilitate delivery. Sometimes an episiotomy is done to try to avoid a nasty perineal tear. Sometimes the episiotomy extends there is both an episiotomy and tear.

Sometimes the rectal muscle is traumatised and sometimes the tear goes completely from the vagina through the rectum.

What are the implications of significant perineal trauma?

Significant perineal trauma has short term implications of

• A more uncomfortable perineum postnatally.
• Difficulty and pain passing urine and even urinary retention.
• Risk of perineal infection, bruising, breaking down, etc.

Significant perineal trauma has the long term implications of

• A more uncomfortable postnatal recovery.
• A gaping introitus.
• Vaginal flatus ("air trapping")
• Prolapse.
• Dyspareunia (painful sex)
• Bleeding with sex.
• Put off another pregnancy and especially another vaginal birth because of the unpleasant memory and fear (psychological as well as physical scarring).

What factors are important in determining your likelihood having significant perineal trauma:

• The elasticity of your perineal tissues.
• The size of baby especially of your baby and especially your baby’s head.
• Position of your babies head (Viz occipito–anterior or occipito--posterior as it comes out through the entrance of your birth canal.
• Whether your baby’s head is well flexed or deflexed at delivery (A deflexed head means a bigger diameter and is common with and occipita –posterior presentations)
• Whether you have scar tissue from a previous vaginal delivery ( Scar tissue doesn’t stretch as well)
• The speed and control of delivery of your babies head.
• Whether you have a epidural. An epidural is associated with a less perineal trauma as it a more controlled slower delivery of the baby’s head. On the other hand some women find it much harder to push their baby out with an epidural and end up with an operative vaginal delivery as a consequence.
• Whether you push your baby out.
• If an operative vaginal delivery, whether you have a vacuum delivery or a forceps delivery. There is less trauma and often no perineal trauma with a vacuum delivery. Forceps deliveries usual mean perineal trauma and episiotomy
• The competence, experience and attitudes of your accoucheur. (The accoucheur is the person delivering your baby)
•  Your position at delivery. Delivering on "all fours" or on your side will mean there is less pressure on your perineum.

What can I do antenatally to avoid perineal trauma?

• Perineal massage is probably no use. There is no evidence I can find to prove it helps
• EPI-NO can help avoid perineal tears and the likelihood of an operative vaginal delivery.

What else can to avoid perineal trauma?

• Induction of labour to avoid baby getting too big, if there is evidence clinically and on ultrasound scan that you have a big baby.
• Slow controlled delivery of head with guarding of perineum and keeping baby's head well flexed with delivery.
• An epidural.
• Vacuum rather than forceps, if operative vaginal delivery is needed
• Avoid pushing to soon in second stage.
• Delivering on "all fours" or on your side.
• Episiotomy if looks like very nasty tear will happen
• Having the right accoucheur.
• A Caesarean section delivery. Obviously there is no perineal trauma with a Caesarean section. Some women will request this and sometimes it will be recommended if there has been very significant perineal trauma with the previous vaginal delivery