How Midwives Reduce the Risk of Perineal Tearing

Written by Igel Cudiera

A perineal tear is a tear in the perineum, the area between the vagina and the anus, that can happen as a baby is born. Tears are common, especially with a first vaginal birth, and most do not cause lasting problems. Some tearing can happen even with excellent care, so the realistic goal is to lower the risk of the more serious tears, not to promise that no tear will happen.

This guide explains what the research shows about each approach, where the evidence is stronger and where it is uncertain, and what to ask your midwife before labor. If you are still choosing a midwife, the perineal support question on our list of questions to ask is a good place to start.

What Is a Perineal Tear?

Tears are graded by how deep they go. The Royal College of Obstetricians and Gynaecologists (RCOG) uses this classification:

• First-degree tear: injury to the perineal skin and/or the lining of the vagina.
• Second-degree tear: also involves the perineal muscles, but not the anal sphincter, the ring of muscle around the anus.
• Third-degree tear: extends into the anal sphincter.
• Fourth-degree tear: extends through the anal sphincter and into the lining of the anal canal.

Third- and fourth-degree tears are often called severe tears, or obstetric anal sphincter injuries (OASIS).

Some degree of tearing is common. The NHS notes that up to 9 in 10 first-time mothers who have a vaginal birth will have some sort of tear, graze or episiotomy. Severe tears are much less common. In a study of more than 7 million vaginal births in US hospitals, 3.3% involved a third-degree tear and 1.1% a fourth-degree tear. In the UK, RCOG reports an overall rate of severe tears of 2.9%, higher in first births (6.1%) than in later births (1.7%).

The American College of Obstetricians and Gynecologists (ACOG) notes that most tears do not result in long-term problems, but severe tears are more often linked with pelvic floor injury, bowel and bladder incontinence, pain, and sexual difficulties. That is why much of the research focuses on reducing severe tears.

Who Is More Likely to Tear?

RCOG lists several factors linked with a higher risk of severe tears:

• A first vaginal birth
• A baby weighing more than 4 kg (about 8.8 lb)
• A baby in the occiput posterior position, facing up toward the parent's belly
• A long second (pushing) stage of labor
• Shoulder dystocia, when a baby's shoulder gets stuck after the head is born
• An assisted birth with forceps or vacuum, with forceps carrying the higher risk
• Asian ethnicity

In the large US study, severe tears were most strongly related to assisted (operative) delivery and shoulder dystocia. RCOG cautions that these risk factors "do not allow the accurate prediction" of severe tears, and many of them, such as a first birth or a baby's size and position, are outside anyone's control.

How Midwives May Help Lower the Risk During Birth

The National Institute for Health and Care Excellence (NICE) recommends that care providers discuss your preferences for techniques to reduce perineal trauma and support your choices. The World Health Organization (WHO) also recommends these techniques "based on a woman's preferences and available options." A 2024 Cochrane review of perineal techniques concluded that, overall, the evidence for their effectiveness "is very uncertain," so it helps to know where the evidence is stronger and where it is weaker.

A warm compress while you push

Among the techniques in this guide, a warm compress has the strongest evidence. Your midwife holds a warm, wet cloth against the perineum as your baby's head begins to stretch it. The 2024 Cochrane review found that a warm compress likely reduces third- and fourth-degree tears (moderate-certainty evidence) but may make little to no difference to second-degree tears. It also likely reduces perineal pain.

ACOG says care providers can apply warm compresses during pushing to reduce the risk of perineal trauma, and NICE recommends offering a warm compress once the baby's head begins to stretch the perineum. In other words, a warm compress may lower the chance of a severe tear. It does not mean you will not tear at all.

Perineal massage during pushing: what the evidence shows

Some midwives gently massage the perineum with a lubricant during the pushing stage. The evidence here is uncertain. The 2024 Cochrane review found that massage during pushing may make little to no difference to second-degree tears, and its effect on third- and fourth-degree tears is uncertain. ACOG says it "may help" reduce third- and fourth-degree tears, and NICE suggests considering it if perineal massage is acceptable to you and you prefer it to a warm compress. It is a choice to talk through with your midwife, not a technique that has been shown to reliably reduce tearing.

How your midwife may guide the birth of your baby's head

When your baby's head becomes visible, your midwife may ask you to stop pushing and to pant or puff in short breaths. The NHS explains that this lets the head emerge slowly and gently, giving the skin and muscles of the perineum time to stretch. RCOG guidance describes "hands on" techniques at this stage, such as slowing the birth of the head and protecting the perineum, while noting that the best method of perineal support is unclear.

Research has not settled which approach is best. In the 2024 Cochrane review, a "hands off" (hands poised) approach compared with "hands on" may make little to no difference to second-, third- or fourth-degree tears, based on low-certainty evidence. Ask your midwife how they approach this stage of birth.

Pushing in a way that works for you

There is no single right way to push. WHO recommends encouraging and supporting people to follow their own urge to push, and ACOG says each person should be encouraged to use their preferred and most effective technique. A Cochrane review of pushing methods found no conclusive evidence to support or refute any specific style, and concluded that the birthing person's preference, comfort and clinical context should guide decisions. Research has not shown that any particular pushing method changes the risk of tearing.

Birth positions

You can usually give birth in whatever position feels comfortable. ACOG notes that for most women, no one position needs to be required or ruled out, and NICE advises moving into whatever positions feel most comfortable during labor, except lying flat on your back.

For people without an epidural, a Cochrane review found that upright positions were linked with fewer episiotomies and fewer assisted births, but possibly more second-degree tears and more blood loss, with no clear difference in severe tears. The certainty of this evidence varies and is weakest for tearing outcomes, so your choice of position can be guided by what feels right to you, along with your midwife's guidance.

No routine episiotomy

An episiotomy is a cut in the perineum that makes the vaginal opening a little wider. ACOG recommends restrictive rather than routine use, WHO does not recommend routine or liberal use for spontaneous vaginal births, and NICE advises against routine episiotomy during spontaneous vaginal birth. A Cochrane review found that a selective policy may result in fewer people having severe perineal or vaginal trauma, and that believing routine episiotomy reduces trauma "is not justified by current evidence." An episiotomy may still be needed in some situations, for example if the baby needs to be born quickly.

Perineal Massage in Pregnancy: What the Evidence Shows

Perineal massage can also be done in the last weeks of pregnancy. This is different from massage during labor, and the evidence is different too. A Cochrane review found that massage in late pregnancy reduces the likelihood of perineal trauma, mainly episiotomies, and that this benefit was seen in people who had not given birth vaginally before. It did not find a difference in first-, second-, third- or fourth-degree tears. People who had given birth vaginally before reported less perineal pain three months after birth. The NHS notes that the most benefit was seen in people who did it every day.

Whether it makes sense for you is worth discussing with your midwife during your prenatal care with our midwives.

Does Midwifery Care Itself Make a Difference?

A 2024 Cochrane review compared midwife continuity of care models with other models of care. People in midwife continuity models were less likely to have an instrumental birth and may be less likely to have an episiotomy. The review found little to no difference in the chance of an intact perineum (no tear), and its effect on third- and fourth-degree tears is very uncertain. So midwife continuity of care is linked with fewer interventions, but it has not been shown to change the chance of tearing itself.

To learn more, read about what midwives do and how midwives and OB-GYNs differ.

What No One Can Fully Control

Even with excellent care, some tearing can happen. Many risk factors, such as a first birth or a baby's size and position, cannot be changed, and RCOG notes that risk factors do not accurately predict who will have a severe tear. A tear does not mean that you or your midwife did something wrong. What matters is that it is checked carefully and treated appropriately.

If labor needs care that is better provided in a hospital, our guide explains how a hospital transfer works.

If You Had a Tear in a Previous Birth

If you had a severe tear before, it is natural to worry about your next birth. ACOG says people with a history of a severe tear should be counseled that the absolute risk of another one is low with a later vaginal birth. NICE advises that the risk of another severe tear is not increased compared with someone having their first baby, while RCOG reports that a previous severe tear is linked with a higher chance of another one in the next pregnancy than for those without one. NICE also advises against routine episiotomy after a previous third- or fourth-degree tear. ACOG notes that a cesarean birth on request is reasonable after talking through the risks, so this is an important conversation to have with your midwife before labor.

After Birth: Healing and When to Call

RCOG recommends that everyone who has a vaginal birth be examined systematically to assess any perineal injury, particularly before stitches. ACOG notes that if you had a tear or episiotomy, pain may be more severe and the area may take longer to heal. ACOG suggests applying an ice pack or cold gel pack for 10 to 20 minutes at a time, which is most effective in the first 24 to 72 hours after birth.

ACOG advises calling your provider right away if you have:

• A fever of more than 100.4°F
• Pain from a tear that does not go away or gets worse
• Redness or discharge from a tear
• Vaginal discharge that smells bad

In an emergency, call 911. Our postpartum care page explains how follow-up works after your baby is born.

Questions to Ask Your Midwife Before Labor

• How do you approach perineal care during the pushing stage?
• Do you offer warm compresses, and can I choose whether to have one?
• What do you think about perineal massage, in pregnancy or during labor?
• How will you guide me as my baby's head is born?
• Can I choose my position and push in the way that feels right to me?
• When would you consider an episiotomy?
• I had a tear in a previous birth. What does that mean for this birth?
• If I tear, who will check and repair it, and what will recovery look like?

If you are planning to give birth at home, see what a planned home birth involves.

This article is general educational information about perineal tearing during birth. It is not medical advice and does not replace individualized care from your midwife or physician. No technique can guarantee that you will not tear, and every pregnancy and birth is different. If you think you need urgent care, call 911.

Sources

• American College of Obstetricians and Gynecologists. Prevention and Management of Obstetric Lacerations at Vaginal Delivery, Practice Bulletin No. 198 (2018, reaffirmed 2025).
• American College of Obstetricians and Gynecologists. Approaches to Limit Intervention During Labor and Birth, Committee Opinion No. 766 (2019, reaffirmed 2025).
• American College of Obstetricians and Gynecologists. Postpartum Pain Management (last reviewed August 2022).
• Dwan K, Fox T, Lutje V, Lavender T, Mills TA. Perineal techniques during the second stage of labour for reducing perineal trauma and postpartum complications. Cochrane Database of Systematic Reviews 2024, CD016148.
• Beckmann MM, Stock OM. Antenatal perineal massage for reducing perineal trauma. Cochrane Database of Systematic Reviews 2013, CD005123.
• Gupta JK, Sood A, Hofmeyr GJ, Vogel JP. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database of Systematic Reviews 2017, CD002006.
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• Jiang H, Qian X, Carroli G, Garner P. Selective versus routine use of episiotomy for vaginal birth. Cochrane Database of Systematic Reviews 2017, CD000081.
• Sandall J, Fernandez Turienzo C, Devane D, et al. Midwife continuity of care models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2024, CD004667.
• World Health Organization. WHO recommendations: Intrapartum care for a positive childbirth experience (2018).
• National Institute for Health and Care Excellence. Intrapartum care, NICE guideline NG235 (2023, last updated June 2026).
• Royal College of Obstetricians and Gynaecologists. The Management of Third- and Fourth-Degree Perineal Tears, Green-top Guideline No. 29 (2015).
• Friedman AM, Ananth CV, Prendergast E, D'Alton ME, Wright JD. Evaluation of third-degree and fourth-degree laceration rates as quality indicators. Obstetrics & Gynecology 2015;125(4):927-937.
• NHS. Episiotomy and perineal tears (last reviewed June 2023).