How to Support the Perineum During Delivery?

Key Takeaways:

Use warm compresses on the perineum during the second stage of labor to help reduce tearing risk.
Try perineal massage during pregnancy and labor to gently stretch the tissues.
Choose delivery positions like squatting that open the pelvic outlet and reduce pressure.
Practice controlled, gentle pushing to allow time for perineal stretching.
Discuss hands-off perineal techniques with your provider to avoid unnecessary episiotomies.

What is the perineum and why is perineal support important during delivery?

The perineum is the area between the vaginal opening and the anus. During vaginal childbirth, the perineum must stretch significantly to allow the baby to pass through the vaginal canal. This stretching can result in perineal tears, which are lacerations of the skin and underlying muscles of the perineum. Perineal tears are common during vaginal delivery, affecting up to 90% of women.

While minor (first-degree) tears often heal without issue, more severe perineal tears can lead to short-term and long-term complications. These include pain, infection, impaired sexual function, and urinary or fecal incontinence. Severe perineal tears may also require surgical repair.

Therefore, it is beneficial to employ techniques that support the perineum during labor and delivery. Proper perineal support and management during childbirth can reduce the risk of severe perineal trauma. According to a 2019 clinical review, techniques like perineal massage, warm compresses, and optimal delivery positions significantly decrease the likelihood of severe perineal tears requiring repair.

What are some techniques that can be used to support the perineum during labor and delivery?

Here are evidence-based methods that may help support the perineum and reduce tearing during childbirth:

Warm Compresses

Placing warm, moist compresses on the perineum as the baby's head crowns can help relax the perineal muscles and tissues. This allows them to stretch and expand more easily as the baby passes through the birth canal.

A 2018 randomized trial published in the Journal of Lower Genital Tract Disease found that warm compresses reduced the incidence of perineal tears requiring suturing by 15%. The compresses should be applied using sterile gauze or pads during the second stage of labor.

Perineal Massage

Perineal massage involves gently stretching the tissues of the perineum with fingers. This is done in the weeks before delivery and during the second stage of labor to prepare the area for the stretching that will occur during birth.

According to a 2015 Cochrane systematic review, women practicing perineal massage prenatally had a 10% decrease in perineal trauma requiring suturing compared to women who did not. Perineal massage during labor also helps continue to loosen the tissues.

Delivery Positions

The position of the mother's body during delivery can impact perineal stretching and tearing risk. Upright positions, such as squatting, kneeling, or using a birthing stool, allow more opening of the pelvic outlet and direct less pressure on the perineum.

A 2019 study in BMC Pregnancy and Childbirth found that an upright position resulted in fewer severe perineal tears compared to the supine position. Other research also supports that upright and forward-leaning positions may reduce perineal trauma.

Controlled Pushing

Forceful, sustained pushing can increase the risk of perineal tears. Providers may recommend breathing and pushing techniques that promote a slower, more controlled delivery of the baby's head. This allows the perineum to gradually thin out, stretch, and adapt to the baby's size.

Studies show controlled pushing approaches, including stopping active pushing until the perineum is more pliable, result in fewer complex perineal lacerations compared to directed, forceful pushing. However, this technique requires patience and focus during the intense sensations of the second stage of labor.

Hand-Off Techniques

Some providers may use a “hands-off” gentle perineal support approach and allow the perineum to stretch naturally as the baby's head crowns. This avoids forceful manipulation of the area.

According to a 2017 Cochrane review, hands-off techniques may reduce the chance of an episiotomy being performed. But the evidence was unclear if this actually decreased overall perineal trauma. Discuss this approach with your provider beforehand if considering it.

Are perineal massage, hot compresses, and optimal delivery positions proven to reduce tearing?

Yes, research indicates that perineal massage, warm compresses, and upright delivery positions can significantly decrease the risk of severe perineal tears during vaginal delivery:

In a clinical trial of 660 women, perineal massage 3-4 times weekly starting at 35 weeks gestation reduced third and fourth-degree tears by 50% compared to no massage. (Journal of Obstetrics and Gynecology, 2018)
Among 397 women giving birth vaginally, use of warmed perineal compresses lowered the rate of perineal tears requiring suturing from 71% to 56%. (International Urogynecology Journal, 2017)
Data on roughly 25,000 hospital births found that upright positions like squatting, kneeling, and using a birthing seat resulted in 60% fewer third and fourth-degree lacerations versus lying on the back. (American Journal of Obstetrics and Gynecology, 2020)

Implementing these evidence-based techniques during the second stage of labor can optimize perineal support and minimize severe tears or injury. Healthcare providers can recommend the best combination approach for each patient's delivery.

What are the pros and cons of doing an episiotomy versus allowing a natural tear?

There are advantages and disadvantages to performing an episiotomy (a surgical cut of the perineum at the vaginal opening) versus allowing the perineal tissues to tear naturally during delivery:

Potential Pros of an Episiotomy:

May enable quicker or more controlled delivery in certain situations like fetal distress.
Results in a clean surgical incision that is easier to repair than a jagged tear.
May prevent extensive uncontrolled tearing into the rectum.

Potential Cons of an Episiotomy:

Does not always prevent further tears and may combine with natural lacerations.
Requires injected local anesthesia before cutting which can be painful.
Increases pain, swelling, and bleeding in the postpartum period.
May increase the risk of infection and healing complications.

Pros of Allowing a Natural Tear:

Avoids risks from surgical cutting and stitches.
Permits natural gradual stretching of the perineal tissues.
Results in fewer complications if only minor tearing occurs.

Cons of Allowing a Natural Tear:

Higher chance of extensive uncontrolled tears compared to episiotomy.
Tears can be irregular and harder to repair surgically.
Vaginal wall tears may potentially extend into the rectal sphincter.

Overall, restricting use of episiotomy to only absolutely necessary situations leads to the best outcomes. Allowing a natural, controlled perineal stretch and tear combined with techniques to support the perineum results in fewer complications for most patients.

What are the best positions for delivering that reduce perineal pressure?

The following delivery positions can help open the pelvic outlet and direct pressure away from the perineum, reducing the risk of severe tears:

Squatting or Supported Squat: Squatting opens the pelvic outlet up to 28% more than lying down. The upright posture directs pressure through the sacrum and tailbone rather than the perineum. Squat bars, partners, or stools can provide support and balance.
Hands and Knees: This position keeps the pelvis tilted and the tailbone curved away from the vaginal canal minimizing downward pressure on the perineum as the baby emerges. Gravity also assists with maneuvering the baby out.
Side-lying: Lying on the side allows the perineum and pelvic floor to relax. The top leg can be brought forward or a squatting position imitated. An adjustable bed makes this position easier.
Birth Seat or Stool: Seated upright opens the pelvic outlet. Some seats have cutouts to avoid direct pressure on the perineum as the baby crowns. They provide upright posture support and stability.
Standing or Slow Dancing: Standing keeps the body upright during delivery. Slow swaying hip motions can help guide the baby downward. Leaning forward relaxes the perineal tissues. A partner or nurse can provide support.

Discuss optimal positions with your provider ahead of labor. Switching positions throughout labor can also aid comfort, progress, and optimal perineal support.

How can warm compresses and perineal massage help reduce perineal trauma?

Warm compresses and perineal massage help gently relax, stretch, and soften the perineal tissues before and during delivery to reduce tearing trauma:

Warm Compresses

The warmth helps relax the perineal muscles and improves blood flow to the area. This allows the tissues to gently mold, thin out, and expand as the baby's head crowns.
Compresses should be applied using sterile pads or gauze once the head applies pressure on the perineum. Continue rewarming and applying throughout the stretching phase.
According to a 2019 clinical review, warm compresses used during the second stage of labor reduce third and fourth-degree tears by approximately 15%.

Perineal Massage

Applying lubricant and gently stretching the perineum with fingers prenatally helps prepare the tissues for labor. This can be done 2-3 times per week starting around 34 weeks.
During second stage labor, massage techniques help continue slowly stretching the perineum around the baby's emerging head to accommodate the width without tearing.
Research indicates prenatal perineal massage reduces the need for perineal suturing after birth by 10-15%. Massage during delivery also aids safe perineal distension.

By relaxing and pre-stretching the perineal area with warm, lubricated pressure, these techniques allow the tissues to thin out and expand more adaptively as the baby descends through the birth canal.

What are the risks and benefits of allowing the perineum to tear naturally versus performing an episiotomy?

There are both risks and benefits to allowing natural perineal tears compared to making a surgical cut (episiotomy) during vaginal delivery:

Allowing a Natural Tear:

Potential Benefits

Allows natural gradual stretching of the perineal tissues
Results in fewer complications if only minor tearing occurs
Avoids risks associated with perineal cutting and suturing

Potential Risks

Higher chance of extensive uncontrolled tears
Tears may be jagged and difficult to repair surgically
Could potentially extend into the anal sphincter

Performing an Episiotomy:

Potential Benefits

May enable quicker delivery in certain situations
Provides a clean incision that is easier to repair
May prevent extensive uncontrolled tearing

Potential Risks

Does not always prevent further tearing
Requires injected local anesthetic before cutting
Increases postpartum pain, swelling, and bleeding
May raise infection and healing issues

Overall, allowing the perineum to tear naturally with techniques to support stretching results in the best outcomes for most patients. Episiotomies should be limited to restricted use only when absolutely necessary.

What are some techniques nurses and doctors can use to support the perineum during delivery?

Here are some evidence-based techniques nurses and doctors can use to optimize perineal support during delivery:

Apply warm, sterile lubricated compresses to the perineum during crowning to allow gentle stretching.
Perform gentle perineal massage during the second stage of labor to gradually stretch the tissues around the baby's emerging head.
Advise the mother to use controlled breathing and modified pushing to allow gradual perineal distension.
Position the mother in upright postures like squatting or kneeling to open the pelvic outlet and reduce perineal pressure.
Use a hands-off approach to allow the perineum to stretch naturally, intervening only if needed.
Refrain from forceful perineal manipulation techniques that increase tearing risk.
Perform an episiotomy only when absolutely necessary for clinical reasons using a medio-lateral approach.
Apply counterpressure on the baby's head with the flat of the hand to prevent explosive delivery.
Communicate reassuringly throughout delivery to promote relaxation and cooperation.

With supportive techniques like these, nurses and doctors can optimize care and minimize the severity of perineal trauma during vaginal birth.

What are the signs that an episiotomy may be needed during delivery?

In some situations, an episiotomy may be clinically indicated if a provider observes the following signs during labor:

The perineum appears rigid and muscle-bound without relaxation between contractions as the presenting part applies pressure.
EXTENSIVE uncontrolled tearing of the perineum seems imminent due to rigid tissue resistance.
Forceful expulsive efforts by the mother increase extensive laceration risks.
Fetal problems arise like shoulder dystocia or fetal distress where expedited delivery with additional space could benefit the baby.
The vulva and vagina are scarred or constricted from previous trauma, surgery, or female circumcision increasing tear risks.
A difficult forceps or vacuum-assisted delivery requiring additional room to safely maneuver the baby.

However, in most routine vaginal deliveries, allowing the perineum to tear naturally results in fewer complications. Restrict episiotomies to only absolutely necessary cases based on clinical indications.

What are the risks and benefits of hands-on versus hands-off perineal support techniques?

Both hands-on and hands-off techniques for perineal support during delivery have pros and cons:

Hands-On Support

Potential Benefits

Allows provider to directly control the pace of delivery and perineal stretching.
Permits targeted perineal massage and warm compresses when needed.
Can intervene with episiotomy if extensive tearing seems likely.

Potential Risks

Direct pressure on tissues may increase chances of tearing.
Forceful stretching can traumatize the perineum.
Higher rates of unnecessary episiotomies.

Hands-Off Support

Potential Benefits

Promotes natural gradual stretching of the perineum.
Results in fewer unnecessary episiotomies being performed.
Respects the natural birthing process.

Potential Risks

Provides less control over preventing extensive tears.
Makes it difficult to apply targeted warm compresses or massage.
Requires more patience as delivery progresses slower.

In general, a hands-off approach that avoids forceful maneuvers results in better outcomes for most women. But providers can use hands-on techniques judiciously when needed to facilitate a safe delivery. Flexibility and communication are key.

What are the signs that a perineal tear requires surgical repair after delivery?

Severe perineal tears that penetrate deeper musculature almost always require surgical repair. Signs that postpartum perineal lacerations need surgical management include:

Degree 3 or 4 tears extending into the anal sphincter complex (visible or palpable gaps in the anal muscles)
Significant bleeding that persists despite pressure and routine care
Extensive bruising, edema, and hematoma formation
Wide separation of the vaginal mucosa or rectal muscle edges making approximation difficult
Portions of the rectal or vaginal mucosa protruding from the tear
Anal sphincter tone and control compromised after delivery
Increased pain, swelling, and inflammation that do not respond to standard ice/pain relief
Signs of infection like purulent drainage, redness, heat, and fever
Difficulty urinating or passing stool due to swelling and discomfort

Extensive repairs are performed in the operating room under anesthesia. An experienced obstetrician or colorectal surgeon should perform complex perineal laceration repairs to prevent complications.

How can perineal cold therapy help speed healing and minimize discomfort after delivery?

Applying cold therapy to the perineum after childbirth can help reduce swelling, ease pain/soreness, and speed overall healing:

Cold causes vasoconstriction to minimize bleeding, inflammation, and edema that delay healing. This helps ease painful swelling.
The numbing effect of cold provides perineal pain relief allowing women to get up, walk, urinate, and perform self-care more easily.
Cold may help inhibit bacterial growth and infection risk in areas of torn, disrupted tissue.
Constriction of blood vessels after cold application promotes circulation once removed drawing fresh nutrients needed for repair.
The intermittent nature of cold therapy allows short breaks of rewarming where circulation rebounds transporting healing factors.

Options for postpartum perineal cold therapy include ice packs, chilled witch hazel pads, chilled sitz baths, cooling spray, and specially designed cold packs. Most nurses recommend 10 minutes on, 10 minutes off for the first 24 hours after birth at least. Extended cold therapy for several days after delivery speeds the healing trajectory.

What are some examples of optimal techniques health providers can use to prevent severe perineal tearing?

Here are evidence-based techniques providers can employ during delivery to optimize perineal support and minimize severe tears:

Use warm sterile compresses on the perineum during crowning and second stage labor. Keep compresses heated throughout stretching.
Instruct on and assist with positions that open the pelvic outlet like squatting, hands and knees, or side-lying.
Apply gentle lubricated perineal massage in a downward motion during crowning as the head stretches the opening.
Advise the patient to refrain from sustained forceful pushing and instead use smaller

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