The word “perineum” conjures up a feeling of uneasiness in me. What exactly is a “perineum? It sounds icky. Will it hurt before, during, and after childbirth? As a pregnancy and postpartum physical therapist and a mom of three, I’d like to share my professional knowledge and personal experience with childbirth preparation and healing.
The perineum is the tissue (meaning skin, fascia, and muscle) between the vulva and the anus. During childbirth the perineum (as well as all the other surrounding tissue of the vagina) is meant to stretch to allow for the child to exit the female body. This perineal area seems to be the point of least resistance as it will often “tear” as the baby’s head squeezes through during childbirth.
The perineum is also the area where a doctor or midwife may perform an episiotomy, and then suture after the baby is born. One study shows that as much as 85% mothers who birth vaginally are left with some kind of perineal trauma (Kettle C, Tohill S: Perineal care. Clin Evid (Online). 2008, [http://www.ncbi.nlm.nih.gov/pubmed/19445799] (accessed 24th July 2018)). With this being said, there are varying degrees of perineal tears. Grades I-IV of laceration or “tearing” are ranked on severity based on length of the laceration and by the involvement of the muscles which are torn. Grade I tears are often called a “paper cut” or a “skid mark” (meaning as the baby’s head emerged, it left a little “skid mark” on the way out). In general, grade I tears do not need stitches, whereas grade II, III, and IV need stitches to assist healing.
Obstetric perineal injury and anal incontinence
Clin Risk, 5 (1999), pp. 193-196
Below are three techniques practiced by women and health care practitioners thought to minimize or prevent perineal tearing. The “take home message” should be that with much preparation and differing methods of preparation, no pregnancy or labor and delivery is a textbook case and thus these techniques serve as a way to prepare the body for birth, but do not guarantee a tear-free birth.
1.) Perineal massage: Perineal “massage” is controversial in its effectiveness to prevent perineal trauma, but anecdotally this technique seems to help the mama-to-be. Perineal massage involves the mom or her partner or a healthcare practitioner placing a finger just inside the vagina and gently placing pressure toward the anus to stretch the tissue that is vulnerable to being torn. I did practice this technique with my first pregnancy. My husband would assist and I would provide feedback as to whether the pressure was too light or too firm. We performed this a few times a week, 3-4 weeks before the baby’s due date until he was born. I remember feeling the burning more intensely the first few times we practiced perineal massage. But after these first few times there was hardly any burning or stretching sensation at all! During childbirth, this baby was vacuum-extracted in a hospital setting with a resulting grade II tear which needing stitching to heal. I did experience pain in the perineum with sitting (which made breastfeeding very difficult!) for at least 6 weeks after birth, which I attribute to the tearing. As a side note, first time moms are more likely to tear than moms who have birthed a baby before (Kettle C, Tohill S: Perineal care. Clin Evid (Online). 2008, [http://www.ncbi.nlm.nih.gov/pubmed/19445799] (accessed 31st July 2018)).
2.) Birthing position: From my research, the optimal birthing position of the mother for decreasing the likelihood of tearing is any upright position ((Kettle C, Tohill S: Perineal care. Clin Evid (Online). 2008, [http://www.ncbi.nlm.nih.gov/pubmed/19445799] (accessed 31st July 2018)). Personally I feel the hands and knees position is optimal. My second baby was born in a birth center. I had spent an hour or so in the tub full of warm water after, and then felt the need to push. I requested to birth the baby in the tub, but the midwife wanted me to exit the tub so that she could check my cervical dilation. I got out of the tub (very hard to do in active labor; I wish I would have just pushed the baby out when I felt the urge in the tub!) and laid down in the bed. Yep, I was at 10cm dilation and ready to push! I sat up as much as my husband and doula could get me upright sitting on the edge of the bed, and with a couple contractions my second little boy entered peacefully into the world. Unfortunately, I had another grade II tear and needed stitches. The good thing is the healing with this tear less painful and healed quicker than the first.
3.) Nutrition and Exercise During Pregnancy: By the time I was pregnant with my third (and most recent baby in December 2017), I had a goal of doing everything I could to prepare to not tear during the labor and delivery. My interest in pregnancy health and exercise had piqued and I was well into my practice as a pregnancy and postpartum physical therapist. During this pregnancy I was sure to perform lots of deep squats and pelvic floor exercises (too much to write about in this article!). I also had excellent eating habits. I was eating white sugar/pasta/bread only once a week. I was eating 100g of protein per day. I was drinking up to 200 ounces of water a day. When she came time to be born, this baby made her entry to the world fast! I was in labor for 1 hour at home, and then birthed that baby within 1 hour of arriving at the birth center. With one big contraction of a push she almost fell out of me for I was in a kneeling position on top of the bed with my upper body arched over a birth ball. To my, my midwife, and my doula’s surprise - there was only a “skid mark” (grade I) tear, which meant no stitches! I attribute the birthing position and my pelvic floor exercise preparation to the minimal tearing. My midwife attributed my healthy nutrition (and a small miracle!) to the minimal tearing. I remember this midwife telling me is is thought that a slower second stage of labor would decrease the likelihood of tearing but, of course this is something the mother can not control. A slower second stage of labor didn’t seem to matter in my case of minimal tearing.
Other techniques that may promote an intact perineum include: continuous labor support, midwife assistance with stretching the perineum during second stage of labor (hands directly on the perineum as the baby crowns and use of heat and oil to the perineum during stage II of labor), water birth, and use of spontaneous pushing (versus breathing holding or valsalva) ((Kettle C, Tohill S: Perineal care. Clin Evid (Online). 2008, [http://www.ncbi.nlm.nih.gov/pubmed/19445799] (accessed 31st July 2018)). Please refer to my website (www.humanaept.com) under the resources section for several of the pregnancy and birth prep books that I love, to learn more about the above topics.
If a mother experiences any tearing during birth, it’s important to be evaluated and treated by a postpartum physical therapist to prevent pelvic pain, pain with sex, incontinence, and be educated about safely returning to exercise.
Becky Wooster PT, DPT
Dr. Becky Wooster was Texas born and raised and then moved to the great state of Iowa for her schooling. She earned her Bachelor of Science Degree in Exercise Science in 2004 and her Doctorate Degree in Physical Therapy in 2007 from the University of Iowa. Excited for warmer weather and the culture of Austin, she moved to this vibrant city where she and her husband now call home. After graduation from physical therapy school, she began her professional career as a PT at a hospital-based outpatient clinic. She earned much experience with orthopedics, rehabilitating patients post-op, getting her feet wet in aquatics PT, and treating all varieties of neural dysfunctions from carpal tunnel syndrome to stroke. She also has much experience in the small private practice setting where she broadened her skills to include vestibular conditions and continued to hone her orthopedic skills. Since being pregnant and bringing two happy, energetic boys (now ages 5.5 years and 3 years) and recently a baby girl into the world, she wholeheartedly appreciates the awesomeness of the woman's body, and therefore has focused her skills to pregnancy and postpartum PT. With there being a lack of maternal and postpartum care in the United States versus other developed countries, her passion is to educate women about their bodies to allow for the best possible pregnancy, labor, delivery, and postpartum experience, physically. Also, Becky has taught yoga for 14 years. This experience, combined with her knowledge in orthopedic physical therapy, makes her an expert in human body posture and movement. She treats the body as a whole with minimally invasive and natural techniques and never examines a woman for only her pelvic floor.