I have a strong dislike for the word tear as it relates to childbirth.  It brings to mind horrible wounds.  In fact, I had a doula client who insisted on an episiotomy.  In her mind, a tear was worse simply because it sounded so bad.  The good news is that a lot of women walk away from labor intact, or with just a few stitches. 

More  good news is that fewer obstetricians routinely perform  episiotomies.  However, this is not true of all OBs, so the first step is to have an open discussion with your OB or midwife about the frequency that they are done, and under what circumstances.  If you receive the reply "I only do them when necessary.", the next question should be "How often is that?".

In addition, remind your OB or midwife during your delivery that you would prefer to avoid an episiotomy unless truly needed, and yes, there are times when they are needed.  Often mom is not able to express her wishes during labor, as she is busy with other things, so it may be up to the labor partner to do this for her.

In addition to having a frank discussion with your OB or midwife, other things to try include:

1.  Good nutrition.   Huh?  What does nutrition have to do with it?  It's simple, good nutrition and hydration are necessary for tissue health and elasticity.  Making sure you eat enough protein, Vitamin E, and Omega-3 and -6 fatty acids.(1)

2,  During birth, choose a good position.  Recommended positions include side-lying and hands and knees.  Avoid any position that requires you to be on your back, including a sitting position.  The on-the-back-with-legs-spread-super-wide position is the worst position for avoiding a tear.  Again, making sure you have chosen a caregiver comfortable with delivery in any position is key.

3.  Understand pushing.  True second stage occurs when mom feels an uncontrollable urge to push when the baby's head puts pressure on the nerves of the pelvic floor.  This usually means that the baby has settled into a good position for birth and is properly rotated into position.  If a mom works with her body to work her baby down, and her baby is descending, then it is best not to mess with the process.  Holding the breath until purple during the pushing stage puts tremendous pressure on the perineum and may cause swelling, not to mention depriving the body of oxygen.  Allowing a mom to push with her urges will allow adequate time for tissues to stretch.   (There may be times when directed pushing is necessary, but as long as mom can move her baby down after she gets the hang of it, no direction is necessary.)

4.  Controlling your pushing efforts as the baby crowns.  Along with understanding pushing, controlling effort as the baby crowns is important.  If you have chosen a caregiver skilled in birth without episiotomy, he or she will help you to control your efforts.  At this point we are looking for a S-L-O-W birth.  Rushing birth will increase the chance of tearing.  Listen to your caregiver, and ask your labor partner to remind you to do so.

5.  Practice perineal massage.  There are mixed reports on the effectiveness of this procedure, but most evidence supports that it may improve elasticity of tissues.  Perineal massage is gently stretching the perineum to prepare for birth.  Make sure you get the OK to try this first, and stop if you get irritated.  For more information, click here for an article on performing perineal massage.  Written by a certified-nurse midwife, the article also provides statistics on the benefits.

6.  Kegel.  By isolating the pelvic floor muscles you can learn to better control this area.  These exercises also help to increase circulation and improve elasticity and tissue health.  To find the pelvic floor muscles, try to stop the flow of urine.  Once you get the hang of it, perform the exercise as often as you remember, several times a day.

Remember, even if you do end up with a tear it is often not as bad as expected.  You will heal.  However, with making an informed selection in a caregiver and by using the tips above you'll reduce your risks.

I hope this helps!

(1) Avoiding Tears and Episiotomies, Rachel Silber, CCE, CD, CD(DONA), CLE, CPD, CPDT.