An episiotomy is a cut an obstetrician makes in the area between the vaginal opening and the anus (known as the perineum) to help facilitate childbirth. The first thing to note about this topic is that your consent will always be required for an episiotomy. This intervention may be recommended by your doctor during childbirth for a number of reasons, not all of which can be avoided. One of the most common questions Unii’s obstetricians hear from first-time mums is about avoiding tears “down there” in childbirth. Some women refer to tears as birth injuries, as they feel the term “tear” does not adequately describe the maternal experience. Unii means no disrespect by adopting the more widely used term in this article; it is simply to help as many people find this information as possible.

Perineal tearing is most common in first-time mums and significant tears (third or fourth degree) can have serious health consequences. The risk of a third- or fourth-degree tear is one of the reasons a woman may be offered an episiotomy during childbirth.

Some other reasons an episiotomy may be recommended include a distressed baby that needs to be delivered quickly (an episiotomy can speed up the pushing stage), a preterm or breech baby, an assisted delivery with forceps or a ventouse, and a baby being large or struggling with shoulder dystocia. There can be other reasons.

Read Unii articles on reducing your risk of preterm and breech birth.
The size of your baby can depend on taking good care of yourself throughout your pregnancy, but it can also be hard to predict.
You can refuse an assisted delivery with forceps or ventouse or avoid the risk of having one through an elective caesarean. Hypnobirthing and choosing to have a home birth are also thought to reduce your risk of intervention.
Shoulder dystocia cannot be predicted, according to the Royal College of Obstetricians and Gynaecologists, making it hard to prevent unless you opt for an elective caesarean. You are at increased risk if you’ve experienced it in past pregnancies, have diabetes, or if your baby is big. Shoulder dystocia in childbirth is considered a medical emergency.

This article will focus on reducing your risk of episiotomy through reducing your risk of serious tears in childbirth.

What are perineal tears?

The perineum is the area between the front of the pelvis and the rectum. When we talk about protecting women from perineal tears in childbirth, we mean the tissue between the vaginal opening and the anus. Perineal tears are classified as stages one to four depending on severity, with one being the least severe and four being the most. We won’t publish visuals here, though they are easy to find online if you want to see how each stage looks.

A first-degree tear is typically the least significant and only involves the skin around the vaginal opening (the description is reductive only for comparison’s sake—pain thresholds differ widely, and we recognise a first-degree tear may be absolutely awful for some mums)

A second-degree tear involves the muscles between the vagina and the rectum and usually requires stitches.

A third-degree tear involves injury to the muscles around the anus and may require repair in the operating room after birth. You will be given an epidural or a spinal beforehand. A third-degree tear may be divided into further subgroups based on its severity.

A fourth-degree tear reaches the tissue lining the anus and the rectum and is the most severe. Repairs will also be carried out in the operating theatre after you’re given a spinal or epidural, and you may need to take a course of antibiotics while you heal.

Can my risk of perineal tearing or needing an episiotomy be predicted?

According to the Royal College of Obstetricians and Gynaecologists, nine in ten women who choose to give birth vaginally will experience some kind of graze, tear, or episiotomy. The College also says that it is hard to predict why severe tearing happens. However, there are some risk factors for spontaneous tearing generally. These include your first vaginal birth, the use of forceps in assisting your delivery, a very long or very short pushing stage of labour, a family history of severe tears, and having a large baby (relevant to their week of gestational age).

In your first pregnancy, your risk of a third or fourth-degree tear during a vaginal birth is 5-6%, and this drops to less than 1% for a second pregnancy.

What are the health consequences of tearing or an episiotomy?

Most perineal tears heal without long-term issues. However, the following can result from tearing or an episiotomy:

Urinary and faecal incontinence
Prolonged pain
Infection
Sexual discomfort
Research shows that women with third- or fourth-degree tears are at more significant risk of developing postpartum depression.
Feelings of trauma related to how any repairs were carried out
Feeling of abandonment about the lack of information and support given about tearing.

None of these results are normal, and they should not be accepted. If you’re told any of them are when you seek help, ask for a second opinion. You have the right to have anything that happened during your labour and birth explained to you, even months after the fact, and learning from the experience could help you during future deliveries. Research in this area is challenged by the fact that many women are not asked questions about how their tears affect them after birth unless they report a problem themselves, which is a difficult and potentially embarrassing thing for a tired, busy postpartum mum to attempt.

How can my risk of tearing or an episiotomy be reduced?

There are a number of evidence-based ways to reduce your risk of tearing or an episiotomy, and some methods that don’t have lots of supporting data but may still be beneficial.

Birth positions

The right birth position for you will depend on your body, baby, and how your labour is progressing. You have no doubt heard birth stories from mums who were advised not to assume a certain position and yet found it was most comfortable and effective for them on the day. However, you can work with your doctor or midwife to adopt positions more likely to protect you from tearing. It may not surprise you that these don’t include lying on your back, as giving birth is so often depicted on screen. You may hear your midwife use the term “upright, forward, and open.” Delivering while squatting and upright, on all fours, or while kneeling, all of which are thought to be safer for the perineum. When you’re upright, there’s a better oxygen supply to your baby, and the uterus contracts more strongly and efficiently, supporting a smoother labour and birth. A more upright birth position (which never means simply sitting up in bed; you need to be more upright than this) has also been found to decrease pain. Lying on your side may also help to protect your perineum.

Pelvic floor exercises

The famous “kegel” exercises, also known as pelvic floor exercises! You may have learnt about these for Samantha Jones on Sex and the City long before you were confident of where your pelvic floor lies and what it has to do with carrying and birthing a baby. A quick reminder: Your pelvic floor is a hammock of muscles at the bottom of what you call your “core” in pilates, that area that begins at your diaphragm and has your lower abdominals at the front. This hammock extends from your pubic bone at the front to your tailbone at the back and side-to-side at the sit bones. The muscles help us to walk straight with continence and when we’re growing and having babies. The muscles go around the urethra, the vagina, and the anus. Some women describe the exercise as feeling like trying to stop urinating and having a bowel movement at the same time. So you squeeze, lift, and hold gently for a count of five. Do this ten times three times a day throughout your pregnancy (though you can start beforehand) to prevent tearing. These exercises can also help with your postpartum recovery.

Men can benefit from kegels too, as they can improve male bowel, urinary, and sexual function, but where tearing is concerned, it’s really all on the pregnant mum! It’s worth remembering that high-impact forms of exercise such as HIIT classes can weaken the pelvic floor muscles, making it an even better idea to give these up before you start trying to conceive. Pilates, on the flipside, is a wonderful choice for preconception and pregnancy exercise.

Perineal massage from 35 weeks of pregnancy

You can receive detailed information on conducting your own perineal massages antenatally here. Massaging antenatally is considered a more effective way to prevent perineal injury in childbirth than massage during labour itself.

The influence of a midwife

Not every mum will have a choice about who is caring for her in labour and birth or be able to see the same professionals consistently, but the most recent research shows that simply having a midwife attend your birth makes you less likely to need an episiotomy. This isn’t necessarily about the midwife disagreeing with the doctor in every case; delivery rooms are not usually confrontational spaces, but midwives are trained to advocate for mum’s wishes as far as is safely possible. They are also very experienced in helping women with the birth positions mentioned above. In the UK, if you choose to have a home birth or give birth in either a freestanding midwife unit or one that’s attached to a hospital, your birth will be overseen by a midwife throughout unless there are complications. Studies also show that your risk of tearing is lower if you give birth at home or in a freestanding midwife-led unit than if you do so in a hospital.

Refusing Pitocin

Pitocin is a synthetic hormone you may be offered if you have to be induced. The oxytocin-like impact of this drug is typically extremely effective in getting things going and can cause long, frequent contractions that increase your risk of vaginal tearing. You can specify that you do not wish to be offered Pitocin in your birth preferences or refuse it in the birthing suite. Your doctor may still recommend it for the third stage of labour (the afterbirth) if you are at high risk of postpartum haemorrhage.

Warm compress (cloth)

This method may not sound like it would do much, but it is an evidence-based way to reduce your risk of perineal tearing. Warm compresses from the second stage of labour not only prevent perineal tearing but come with other health benefits, including increasing maternal comfort, and can make you less likely to experience urinary incontinence after birth. It’s also been associated with less perineal pain in the postpartum period.

Antenatal yoga

The regular practice of antenatal yoga has been proven to shorten labour and reduce your need for induction of labour and episiotomy. It can be undertaken daily in even high-risk pregnancies, provided you are under the guidance of a registered teacher who specialises in pregnancy yoga and is aware of your condition.

Hypnobirthing

Hypnobirthing promotes gentler births using breathing, relaxation, and other techniques. Unii’s expert Tamara Cianfini recommends you practice from 20 weeks of pregnancy. As a baby being born quickly is a key cause of tearing, and hypnobirthing takes a controlled, calm approach that avoids intervention; it is also thought to reduce your need for an episiotomy. While hypnobirthing is increasingly mainstream, it is less studied than some of the other methods we’ve mentioned above.

There are also some tools available for home use that are designed to strengthen the pelvic floor muscles. Manufacturers claim they also prevent episiotomy. It’s important to ask your midwife or doctor about these before trying them while pregnant.

What are my choices regarding episiotomy?

You are unlikely to want an episiotomy. We’ve mentioned that preferences like your place of birth, your birth positions, whether a midwife attends, and committing to practicing yoga, pelvic floor exercises, and perineal massage in pregnancy can also help you.

The most certain way to prevent an episiotomy is to plan to give birth by caesarean section. However, this is by no means an “easy option"—a c-section is a serious abdominal surgery that comes with risks and consequences for you and your baby that should be discussed fully with your doctor. Fear of tearing and episiotomy is very legitimate and should never be dismissed by anyone. We hope this article will help you feel more comfortable while writing your birth preferences. For more information on caring for yourself in every week of pregnancy, please check out Unii’s Pregnancy Journey week-by-week video course with Dr. Shree Datta. And for more information on your labour and delivery, watch Unii’s Giving Birth Journey with Dr. Keith Duncan.

For more advice on taking care of yourself in pregnancy, labour, and birth, check out Unii’s Antenatal Classes, with prenatal video episodes taught by senior NHS midwives, an award-winning obstetrician and gynaecologist, and six other leading healthcare experts. Only at unii.com.

Antenatal Class Questions: How can I avoid needing an episiotomy?

Unii looks at reducing your risk of tearing and episiotomy in childbirth.