You Can Avoid an Episiotomy and Reduce Tearing!
When I attended my first births in the mid-1990s, episiotomies were common. Many hospitals believed it was better to make a surgical cut than to allow the tissues to tear naturally.
Then the research started telling a different story.
Over the past 30 years and more than 700 births, I’ve watched obstetrics change. Today, I’ve attended fewer than 20 births where an episiotomy was even considered, and fewer than 5% of my clients have actually had one.
That’s very good news.
Research has shown that routine episiotomies often cause more harm than good. Today, organizations like the World Health Organization recommend against routinely performing episiotomies during normal vaginal births. Instead, they recommend reserving them for situations where they are truly necessary.
That doesn’t mean an episiotomy is never appropriate.
Twice in my career, I’ve been at births where the baby’s head remained crowning for so long that even I found myself waiting for the doctor to suggest an episiotomy. Both times the doctors waited as long as they safely could, made the tiniest incision imaginable, and the baby was born with the very next push.
Those experiences reinforced something I already believed.
An episiotomy should be the exception, not the expectation.
What Is an Episiotomy?
An episiotomy is a surgical incision made in the perineum, the tissue between the vaginal opening and the anus, to enlarge the opening for birth.
Years ago, many doctors believed a clean surgical cut would heal better than a natural tear.
We now know that is usually not the case.
For most healthy pregnancies, allowing the tissues to stretch naturally results in less trauma, less pain, and often a faster recovery.
Why Were Episiotomies Once Routine?
When I started attending births, episiotomies were simply part of the way many hospitals practiced obstetrics.
The thinking was that they would:
- Prevent severe tears
- Protect the pelvic floor
- Speed the birth
- Heal better than natural tears
As more research became available, those assumptions were challenged and found to be wrong.
Today, most care providers perform episiotomies only when there is a clear medical reason.
When Is an Episiotomy Necessary?
- A true fetal emergency where every second counts.
- Some cases of shoulder dystocia, depending on the situation and the provider’s skill and judgment.
- Occasionally when the baby’s head has remained crowning for an extended period and the tissues are preventing birth despite excellent pushing efforts.
The important point is that these situations are uncommon. An episiotomy should not be done simply because it has always been done that way.
How to Avoid an Episiotomy
While there are never guarantees in birth, there are several things that may reduce your chances of needing an episiotomy or experiencing significant tearing.
Talk With Your Doctor or Midwife During Pregnancy
One of the best times to discuss episiotomies is long before labor begins. When preparing your birth plan, you’ll need to create a list of questions to discuss with your doctor or midwife. See the sample birth plans in the Birth Plans and Preferences section here: https://bestdoulas.com/pregnancy/
Ask questions like:
- How often do you perform episiotomies?
- Under what circumstances would you recommend one?
- What techniques do you use to help reduce tearing?
Include your wishes in your birth plan and discuss them during a prenatal appointment instead of waiting until you’re in labor. If your care provider says they always cut an episiotomy, that should be a deal breaker!
Practice Perineal Massage During Pregnancy
Beginning around 34 to 35 weeks of pregnancy, gentle perineal massage at home may help improve the flexibility of the tissues.
Your partner can help, or you can do it yourself if you’re limber enough. I recommend asking your partner to help. If they’re not willing to help, remind them that if you have a serious tear, sex will not be an option for a much longer amount of time after the birth. And if they’re not willing to help with this simple task, you will definitely need the help of a doula during your labor and birth.
You can download my short instructional guide to perineal massage here:
https://bestdoulas.com/wp-content/uploads/2020/06/perineal.pdf
Understand the Difference Between Perineal Massage and Perineal Stretching
This is one area where I think the terminology creates unnecessary confusion.
Gentle perineal massage performed during pregnancy is completely different from the aggressive stretching I’ve seen performed during birth.
Early in my career, I watched physicians perform what they called “perineal massage” during pushing. In reality, it was forceful rubbing and stretching of tissues that were already under tremendous pressure.
I remember being surprised when the physician seemed equally surprised that the patient immediately began bleeding from a tear that the stretching had created.
Massage should never create injury.
If your doctor or midwife says they will do perineal massage during labor, it’s reasonable to ask exactly what they mean. Ask them to describe the process.
Ask for Warm Compresses During Pushing
One of my favorite techniques is wonderfully simple.
You, your partner, or your doula can ask your nurse to bring a bowl of warm water and several clean washcloths.
Between pushes, the warm compresses can be placed gently against the perineum to help the tissues relax.
An added benefit is that the warm cloth naturally covers the tissues, making it less likely that anyone will feel tempted to repeatedly stretch the area with their fingers.
Push in Positions That Reduce Pressure
The position you push in matters.
Many people experience less pressure on the perineum when pushing in positions such as:
- Side-lying
- Hands and knees
- Upright positions
- Squatting, when appropriate
Your labor nurse or doula can help you find positions that work well with your labor and your baby’s position.
Avoid Forceful Coached Pushing When Possible
Holding your breath and pushing as hard as possible for a count of ten is rarely the best approach.
Whenever it’s safe to do so, following your body’s natural urge to push often allows the tissues more time to stretch gradually.
If You Have an Epidural
Many parents wonder how to prevent tearing during birth with an epidural.
An epidural doesn’t automatically mean you’ll tear more or need an episiotomy.
In many situations, allowing the baby to descend before beginning active pushing and avoiding rushed pushing can give the tissues more time to stretch.
Discuss your provider’s approach before labor begins.
Turning down the epidural until you have an uncontrollable urge to push is much better and safer than pushing because you’re 10 cm dilated without the urge to push. Don’t turn the epidural off, just down.
Can You Prevent Tearing During Birth?
Many people search for home remedies to prevent tearing during birth or exercises to prevent tearing during birth.
The truth is that there isn’t one magic solution.
The best results usually come from combining several approaches:
- Good nutrition throughout pregnancy to support healthy tissues.
- Gentle perineal massage during the last few weeks of pregnancy.
- Staying active with exercises approved by your healthcare provider.
- Labor positions that reduce pressure on the perineum.
- Warm compresses during pushing.
- Patience while the baby’s head crowns.
- Avoiding unnecessary interventions whenever possible.
If you’ve been searching Reddit or parenting forums for how to prevent tearing during birth with an epidural, you’ve probably found dozens of different opinions.
My advice comes from supporting more than 700 births.
No technique can guarantee you won’t tear.
But giving your body time, avoiding unnecessary interventions, and working with a supportive birth team can significantly improve your chances of avoiding both severe tears and an unnecessary episiotomy.
What About Food?
People often ask what to eat to prevent tearing during birth.
There isn’t a specific food that prevents tearing.
A healthy diet that includes adequate protein, vitamins, hydration, and healthy fats helps support healthy tissue throughout pregnancy, but your nutrition is only one piece of the puzzle.
Your baby’s position, your pushing technique, your care provider’s patience, and your labor support all play important roles.
Can You Refuse an Episiotomy?
If your care provider recommends an episiotomy, ask why.
Understanding the reason allows you to make an informed decision.
In most situations, you have the right to discuss your options and ask questions before giving consent.
The best time for that conversation is during pregnancy, not while you’re pushing.
My Thoughts After More Than 700 Births
I’ve watched hospital birth change dramatically over the past three decades.
I’m grateful that routine episiotomies have largely become a thing of the past.
I’ve also learned that preventing unnecessary episiotomies doesn’t depend on one magic trick.
It starts with choosing a care provider whose philosophy matches yours.
It continues with learning about your options before labor begins.
It includes preparing your body, understanding your choices, and surrounding yourself with people who are willing to be patient while your body does what it was designed to do.
That’s exactly what I hope to help every expectant family accomplish.
Learn More
If you’d like more practical information about preparing for a hospital birth, you may also enjoy these resources:
- Perineal Massage Guide
- Childbirth Classes/The 700 Babies Solution
- Contact a Doula/Meet tracy
- Buy 700 Babies: Expectant Parent’s Survival Guide to Hospital Births (2nd Edition)
- Buy 700 Prepared Partners: The Non-Gestational Parent’s Survival Guide to Hospital Births
Reference
World Health Organization (WHO) and National Institute of Health (NIH) recommend NOT performing routine episiotomies.
