Ruptures and episiotomy during childbirth: how to reduce the risk

2026-05-27 12:00 Childbirth

In short: perineal tears occur in about half of primiparous women, but most of them are small and heal well. Episiotomy today is not done routinely, but only according to indications. Perineal massage in the third trimester reduces the risk of serious tears.

Degrees of perineal tears

Obstetricians distinguish four degrees of tears:

Stage I – perineal skin and/or vaginal mucosa. Often does not require stitches.
Stage II – skin and perineal muscles, but not the rectal sphincter. It is sutured under local anesthesia.
Stage III – damage to the external or internal sphincter of the rectum.
Stage IV – the rupture passes through the sphincter and the wall of the rectum.

III-IV degree ruptures occur in 1-3% of cases in primiparous women and require closure in the operating room. After healing, most women do not have long-term problems.

What is an episiotomy and when is it done?

Episiotomy is a surgical incision of the perineum, which is made at the time of eruption of the head. The goal is to expand the output and prevent an uncontrolled gap.

Current recommendations from the WHO, NICE and ACOG against routine episiotomy: it does not reduce the risk of severe tears in standard delivery. Indications for episiotomy:

threatening rupture during rapid eruption;
instrumental birth (forceps, vacuum);
fetal distress, requiring a rapid birth;
Childbirth in breech presentation.

Incisions vs. tears: which is worse

Contrary to popular myth, episiotomy is not "better" than spontaneous rupture. Randomized trials show that in routine episiotomy:

more blood loss;
the risk of rupture of III-IV degree is higher (if the incision "goes" deeper);
more painful healing.

Small, spontaneous tears of I-II degree tend to heal faster than an incision with a scalpel of the same length.

How to reduce the risk of tears: perineal massage

Starting from the 35-36th week of pregnancy , daily massage of the perineum for 5-10 minutes reliably reduces the risk of ruptures and episiotomy in primiparous women.

Technique:

Clean hands, short-cropped nails.
Neutral oil (olive, almond) on the thumbs.
Insert your thumbs 3-4 cm into the vagina and press down and to the sides until a slight stretching sensation appears.
Hold the pressure for 1-2 minutes, then U-shaped movements for 3-4 minutes.

Behavior in pushing

The method of pushing greatly affects the risk of tears:

Slow, controlled birth of the head ("breathing" the baby, not "pushing it out") reduces the risk of serious tears.
Warm compresses on the perineum at the time of eruption relax the tissues and reduce the frequency of III-IV degree tears.
Obstetric support of the perineum with the hand ("perineal protection") reduces the likelihood of severe tears.

Discuss these wishes with your midwife when planning your birth.

Position for childbirth

Upright pushing postures (standing, squatting, on all fours) reduce the incidence of episiotomy compared to the supine position. On all fours, the head is born slower and more controllable - there is less risk of rupture.

Care after ruptures and episiotomy

For more information about the care of sutures, see the article stitches after childbirth. Briefly:

Rinsing with clean water after each visit to the toilet.
Cold compresses in the first 24 hours reduce swelling.
Soft food and sufficient drink to avoid constipation.
Do not touch the sutures - they dissolve on their own.

When to see a doctor

Consult an obstetrician-gynecologist if:

perineal pain increases after discharge, rather than decreases;
there is an unpleasant odor or discharge from the suture area;
temperature above 38 °C;
seam divergence or visible threads "fell out" too early;
If there is gas or fecal incontinence, sphincter failure is possible.

Frequently Asked Questions

When can you have sex after breakups?

It is recommended to wait 6-8 weeks and get your doctor's permission at the postpartum checkup. There is no need to rush: if you feel discomfort, you can consult a pelvic floor physiotherapist.

Is it possible to completely avoid tears?

There is no complete guarantee - perineal tissues are very individual. But massage, the right position and an experienced midwife significantly reduce the risk of serious damage.

Grade 1 tear – do you need stitches?

Not always. Many first-degree tears heal without suturing if the edges are well aligned. The midwife assesses the situation after childbirth.

Conclusion

Ruptures are a common part of births, and most are small and heal well. Routine episiotomy is not necessary. Perineal massage from 35 weeks, upright postures and slow birth of the glans are real ways to reduce the risk. The main thing is to trust an experienced obstetric team.

Bibliography

WHO. WHO recommendations: intrapartum care for a positive childbirth experience. 2018. https://www.who.int/publications/i/item/9789241550215
ACOG Practice Bulletin No. 198. Prevention and Management of Obstetric Lacerations at Vaginal Delivery. Obstet Gynecol. 2018.
Beckmann MM, Stock OM. Antenatal perineal massage for reducing perineal trauma. Cochrane Database. 2013. https://pubmed.ncbi.nlm.nih.gov/23440794/
NICE guideline CG190. Intrapartum care. 2014 (updated 2017). https://www.who.int/publications/i/item/9789241550215
Ministry of Health of the Russian Federation. Clinical recommendations: Normal delivery. 2021. https://cr.minzdrav.gov.ru/
Aasheim V et al. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database. 2017. https://pubmed.ncbi.nlm.nih.gov/28182255/

This material is for informational purposes only and does not constitute medical advice and is not a substitute for medical advice. If a child's sleep is accompanied by alarming symptoms, a pronounced deterioration in health, problems with breathing, feeding or weight gain, it is necessary to consult a qualified medical specialist as soon as possible, and not rely only on information from the Internet.

Lunora