Perineal Support

Part of Midwifery and Childbirth

Techniques to protect the perineum during delivery, manage tears when they occur, and support healing afterward.

Why This Matters

The perineum — the tissue between the vaginal opening and the rectum — must stretch dramatically to accommodate a baby’s head during delivery. This stretching can result in tears ranging from minor skin splits to severe lacerations extending through the anal sphincter. Unrepaired severe tears cause lifelong consequences: bowel incontinence, fistula formation, sexual dysfunction, and chronic pain.

In obstetric care before antiseptic technique and skilled repair, perineal trauma was a major cause of maternal disability. The obstetric fistula — a hole connecting the vagina to the rectum or bladder — became so common in some regions that institutions were established specifically to house women disabled by it. The tragedy is that most severe tears are preventable with technique and that even significant tears can be repaired successfully by a knowledgeable attendant.

Perineal support is not a passive activity. The birth attendant’s hands, the mother’s pushing technique, and the position of delivery all directly influence the likelihood and severity of perineal injury. This article covers what can be done before, during, and after delivery to protect this critical tissue.

Anatomy and Tear Classification

Understanding the layers the perineum can tear through helps in both preventing and repairing tears.

Layers from outside in:

1. Skin and subcutaneous tissue
2. Superficial perineal muscles (bulbospongiosus, ischiocavernosus)
3. Deep perineal muscles (external anal sphincter, transverse perineal)
4. Anal sphincter (external and internal components)
5. Rectal mucosa

Tear classification:

Degree	Tissues involved	Management
First	Skin only	Usually heals without sutures; observe
Second	Skin + perineal muscles	Requires suturing for good healing
Third	Skin + muscles + anal sphincter	Requires careful anatomical repair
Fourth	Through anal sphincter into rectal mucosa	Complex repair; difficult without surgical training

Third and fourth degree tears require precise, layered repair to restore sphincter function. Poorly repaired or neglected sphincter tears lead to fecal incontinence — inability to control bowel movements — which is socially devastating and difficult to treat later.

Antenatal Perineal Preparation

Beginning in the last 4-6 weeks of pregnancy, perineal massage can stretch the tissues and reduce tear risk.

Perineal massage technique:

1. The woman (or her partner) washes hands thoroughly
2. With clean hands, apply a small amount of natural oil (olive, coconut, almond) to the thumbs
3. Insert both thumbs about 3-4 cm into the vagina
4. Apply firm downward pressure toward the rectum for 1-2 minutes
5. Sweep the thumbs in a U-shaped motion from side to side, maintaining gentle pressure
6. Total duration: 5-10 minutes, performed 1-4 times per week

Evidence base: Multiple studies show perineal massage in the final weeks of pregnancy significantly reduces the rate of severe tears and episiotomies in first-time mothers. It also reduces postpartum perineal pain.

Communication: The pressure should be noticeable but not acutely painful. Some burning or stretching sensation is expected. The goal is to stretch the tissue, not to cause injury.

Techniques During Delivery

The delivery moment itself is where perineal technique most directly prevents tears. The key principle is controlling the speed of head emergence.

Warm perineal compresses: Applying a warm, moist cloth to the perineum during crowning has been shown to reduce severe tears significantly.

1. Soak a cloth in warm water (comfortable on your inner wrist)
2. Apply over the perineum and hold gently but firmly during contractions and between them
3. Replace with fresh warm cloth as needed
4. The warmth increases tissue elasticity and blood flow

Hands-on versus hands-off: Two approaches exist for the delivery moment:

Hands-on: The attendant places one hand on the baby’s head to control speed, and the other hand supporting the perineum. Hands-off: The attendant keeps hands near but does not routinely touch head or perineum.

Both produce similar outcomes. The most important element is slow, controlled head emergence — regardless of which approach is used.

Controlling head emergence:

1. When the baby’s head begins to crown (visible between contractions), instruct the mother to stop pushing hard
2. Ask her to pant (quick, shallow breaths) — this reduces the urge to push while contractions propel the baby forward
3. Place a hand on the baby’s head if it is emerging rapidly — gentle counterpressure to slow emergence without stopping it
4. The slower the head emerges through the perineum, the more time the tissues have to stretch

Lateral flexion: The baby’s head exits in a slightly deflexed position (chin lifted from chest). If the head is hyperextended (chin up, forehead leading), the presenting diameter is larger and tears are more likely. Gentle support under the chin, encouraging the baby to keep the chin down, may reduce the presenting diameter.

Delivery position effects on perineum:

• Lithotomy (flat on back, legs in stirrups): Historically associated with highest tear rates — increases perineal tension
• Left lateral (on side): Consistently shows lowest rates of severe tears in studies; good control of delivery speed
• Upright/squatting: Opens pelvic outlet but increases tear rate due to gravitational force
• All fours: May reduce severe tears; allows attendant to support perineum from behind

Episiotomy: When It Is and Is Not Indicated

An episiotomy is a deliberate surgical cut in the perineum to enlarge the vaginal opening. It was performed routinely in 20th century obstetrics under the belief that a clean cut heals better than a tear. This has been comprehensively disproven — routine episiotomy increases maternal trauma, blood loss, and healing time compared to spontaneous tearing with support.

Episiotomy is justified in specific circumstances:

• Fetal distress requiring urgent expedited delivery — baby must come out immediately and the perineum is delaying this
• Shoulder dystocia requiring additional maneuvers
• Forceps or vacuum delivery
• An obstructed delivery where tissue is tight and endangering the baby

Episiotomy is NOT indicated:

• To “prevent” tearing in routine deliveries
• Based on rigid timelines (“you’ve been pushing for X minutes”)
• Routinely in primiparous (first-time) mothers

If episiotomy is necessary:

1. Infiltrate the perineum with local anesthetic if available (10 mL of 1% lidocaine injected into the perineal tissue)
2. Use sharp, clean scissors
3. Make a mediolateral cut (angled 45 degrees toward the left thigh) — this avoids cutting toward the anus
4. A midline cut (straight toward the anus) heals better but, if it extends, directly involves the anal sphincter
5. Repair promptly after delivery

Perineal Repair

Most second-degree tears and episiotomies require suturing. The principles of good repair:

Timing: Repair within 1-2 hours of delivery, while tissues are still edematous and pliable, and before significant blood loss occurs.

Analgesia: Local infiltration with 1% lidocaine (if available) at 10-20 mL injected into the perineal tissue provides adequate anesthesia for repair.

Layers and materials:

• Deep muscle layer: Absorbable suture (catgut or Vicryl) using continuous or interrupted sutures
• Superficial muscle: Same material, approximating but not strangulating tissue
• Skin: Can be closed with interrupted absorbable sutures or a subcuticular (below-surface) continuous suture
• Do not leave dead space (gaps between layers) — this traps blood and promotes infection

Sphincter repair (third degree): The external anal sphincter is a cylinder of circular muscle. Both ends of the torn sphincter must be identified and sutured together end-to-end (or overlapping) with 3-4 interrupted sutures. Failure to identify and reapproximate the sphincter ends causes permanent fecal incontinence.

Post-repair care:

• Keep clean and dry (see Infection Prevention)
• Ice packs or cold compresses in the first 24 hours reduce swelling
• Sitz baths (sitting in shallow warm water) from day 2 aid healing and comfort
• Avoid constipation — straining against repaired sphincter is painful and risks breakdown
• Abstain from sexual intercourse for minimum 6 weeks

Recognizing Complications

Hematoma: Blood pooling under the skin without external laceration can form a painful swelling in the perineum or labial folds. Small hematomas (smaller than an egg) can be managed with compression and ice. Large or expanding hematomas require surgical drainage and, if available, ligation of bleeding vessels.

Wound breakdown: If sutured repair dehisces (opens), do not attempt immediate re-suturing of infected tissue. Clean the wound, allow granulation healing (healing from the base up), and if re-suturing is needed, wait 3-4 weeks for infection to clear.

Fistula: A fistula is an abnormal channel connecting the vagina to the bladder or rectum, usually resulting from prolonged obstructed labor or failed repair of severe tears. Symptoms: continuous leakage of urine or stool through the vagina. Repair is surgical and beyond field midwifery capacity — referral is required. Prevention through avoiding prolonged obstructed labor is far preferable to treatment.

Pain management: Perineal discomfort after significant repairs is significant and should be addressed:

• Clean, cool compresses
• Positioning (side-lying reduces perineal pressure)
• Analgesia: paracetamol (acetaminophen) is safe for breastfeeding mothers
• NSAIDs (ibuprofen, naproxen) are effective for perineal pain and safe during breastfeeding after the first few days

The perineum’s integrity directly affects a woman’s quality of life for decades after childbirth. The investment of skill and attention in protecting and repairing this tissue pays dividends that compound across every subsequent pregnancy and the entire remainder of her life.