Tearing during childbirth is one of the most common concerns of pregnant people. While 85% to 90% of first-time vaginal birthers do develop some tearing, most tears are not serious and heal on their own without stitches or with only a few stitches.

But what about those more significant tears? It is true that large tears do happen. Fortunately, research has shown us that there are ways to reduce the risk of tearing during a vaginal birth. Some of these ways of preventing tears can be done before childbirth, while others are done during birth.

Before childbirth

1. Perform perineal massage.

Perineal massage is a type of stretching for the vagina to prepare for childbirth. Typically, a pregnant person does the stretching on themselves by using one or two thumbs to widen the opening of the vagina, although sometimes a partner helps. Here’s a link to directions on how to perform perineal massage. 

Research done between 2022 and 2024 on perineal massage done prior to birth compared with birthers that did not do any prenatal perineal massage found that it:

• Reduced the risk of any tearing, but specifically reduced tearing that needed stitches by 9%
• Reduced the risk of needing an episiotomy (an incision to widen the vaginal opening) by 17%
• Reduced the risk of perineal tears that reached the anus (grade 3 and 4) by 64%.
• Reduced pain in and around the vagina after birth for 3 months after birth
• Reduced swelling in the perineal area in the first 10 days after birth
• Reduced the involuntary loss of gas in the 45 days after birth.

How much perineal stretching should you do? Perineal massage is often started eight to four weeks prior to the expected due date. It can be done daily for 5-10 minutes per day. It can be done sitting or lying down.

Pregnant people should check with their medical provider before starting perineal massage. Frequently, people on pelvic rest or at risk of early delivery may be instructed not to perform perineal stretching. 

2. Consider Kegels

Kegel exercises are also known as Pelvic Floor Muscle Training (PFMT). Some studies show decreased frequency of episiotomy, and less tears that reach the anus (grade 3 and 4) when Kegels are performed. However, a systematic review shows that after urinary incontinence develops in pregnancy Kegel exercises don’t improve incontinence before birth or in the year after birth. The same systematic review also looked at preventing urinary incontinence in pregnancy and results were a decrease in developing urinary incontinence of 62% with performing Kegels. Therefore, the recommendation is that Kegels be considered by women as a potential aid to prevent urinary incontinence.

How many Kegels should I do? One study prescribed 5 to 8 second Kegels, then 8 seconds of rest, repeated for 10 minutes, three times per day. However, the Mayo Clinic recommends sets of 10-15 Kegels three times per day. A systematic review found wide variation in dosing and determined that there were no recommendations for maximum benefit. When to start is also widely variable. Some recommend starting as early as 12 weeks gestation, while other studies looked at starting near term. 

3. Practice birthing positions ahead of time.

Certain positions are more likely to lead to larger perineal tears. These positions are ones where the sacrum (part of the low back) is pressed against another surface, such as a bed or chair. Research has shown that perineal trauma is reduced when giving birth on one’s side or kneeling out of a bed. Pushing in a squatting position has been shown to decrease overall time of pushing but has a slightly higher risk of tearing than the other two. Squatting with a grab bar or something for the birther to hold on to is more comfortable. Often, it is easier to remember what TO DO when it comes to birthing, versus what not to do. For this reason, I encourage birthing people to practice positions that will be less likely to cause tears (sacrum is freer to move). Here are some things to practice before going into labor:

• Side-lying
• Kneeling
• Squatting

Recent research suggests that upright positions in general are less likely to lead to tears while horizontal positions are more likely to lead to a birthing person having an episiotomy performed. Use of an epidural has not been found to increase the risk of severe perineal tearing.

4. Make a perineal tear prevention plan.

A study in 2026 compared individualized prevention plans with standard care. The results of the study showed that those with individualized plans had significantly lower rates of episiotomy, 15% shorter second stage labor, and significantly less pain in the postpartum period. So, make a visit to the midwife or obstetrician to talk about ways they can reduce the risk of perineal tearing during birth. It is much easier to include perineal tear prevention strategies in the birth process if they have been agreed upon before labor starts.

Here are some of the common ways a midwife or obstetrician might try to reduce the risk of perineal tearing:

• Controlled birth of the baby’s head
• Individualized positioning to optimize the pelvic outlet
• No routine episiotomy
• Warm compress on the perineum with pushing
• Continuous communication between the birther and the medical and nursing staff.

Warm compresses with pushing can be created from clean washcloths that are soaked in warm water, changing as they become cool. A systematic review showed that there were more of intact perineum, tears that didn’t need to be stitched, less overall tears, less rate of episiotomy, and less pain in the birthers who had warm compresses than in those that didn’t.

During childbirth

5. Consider fewer vaginal examinations during labor.

Having five or more vaginal examinations is associated with a higher risk of a severe perineal tear, even when other factors are controlled for. A birthing person might consider requesting the medical team to only perform medically necessary examinations, so that the exams are limited to as few as possible.

6. Get in the water for pushing.

Waterbirth has been associated with having no perineal tears at birth, at a rate which is significate when compared to those not in water. First time birthers were also significantly less likely to have an episiotomy. Being in water also decreases pain in labor and at the time of birth. If a birthing person is interested in a water birth, they should be sure to check (a) that they have a provider who will honor their wish to birth in the water and (b) that a tub will be available. A tub may need to be rented or purchased depending on the birthing location.

7. Push with an urge and breathe through pushes.

Some birthing people are instructed to push right when they reach 10 centimeters of dilation, while others wait until they feel the urge to push. Delaying pushing does lead to a slightly longer second stage of labor; however, the time of active pushing by the birther is shorter. To spontaneously push the birther should push without holding one’s breath. One technique is to inhale over a second or two, then exhale over 4-5 seconds. Benefits of delayed pushing are slightly more spontaneous vaginal births, and perhaps less fatigue as active pushing is less. Studies show mixed results as to whether delayed pushing prevents lacerations. If someone plans on doing delayed pushing without breath holding, it can be helpful to discuss this decision with the midwife or obstetrician ahead of time, so that the birthing person does not receive unwanted coaching.

Conclusion

Keep in mind that regardless of the amount or type of tearing, the human body has a tremendous capacity for healing. This includes the ability to heal from tears and episiotomies. If a perineal tear does occur, with or without preventative measures being taken, it is not the birthing person’s fault. There are many forms of support for recovering from a perineal tear, from medical treatments to support groups. Regardless of the outcome, birthing people have options for feeling restored. These days, there are many specialists from pelvic floor physical therapists to medical doctors who are board-certified in female pelvic medicine and reconstructive surgery (FPMRS), also known as a urogynecologist, as well as colorectal surgery. No one should suffer alone. If you have a student, client or patient with a significant tear who needs support, please share the resource Life after Fourth Degree Tears.

References

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Published: June 19, 2026

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Childbirth educationPelvisPhysical TherapyKatie McGeeTearingPerineumKen McGeeSeries: The Body in Birth