Most people who give birth vaginally will experience some degree of tearing, but there are real, evidence-backed steps you can take before and during labor to lower your risk and reduce the severity. About two-thirds of tears are first-degree, meaning they’re shallow and heal quickly. The strategies below target both the weeks leading up to delivery and the decisions you make in the delivery room itself.
Why Tearing Happens
Perineal tears occur when the tissue between the vagina and rectum stretches beyond its limit as the baby’s head passes through. The tissue’s natural elasticity, the baby’s size and position, the speed of delivery, and how you push all influence whether and how badly you tear. First-degree tears involve only the skin and heal on their own or with a few stitches. Second-degree tears go into the muscle and need repair. Third and fourth-degree tears extend toward or into the anal sphincter and are far less common.
You can’t eliminate the risk entirely, but you can meaningfully shift the odds toward a smaller tear or none at all.
Start Perineal Massage Around Week 35
Perineal massage is the single most studied at-home technique for reducing tears. Starting around the 35th week of pregnancy, you or your partner gently stretch the tissue of the perineum using a U-shaped downward motion with lubricated thumbs. Research published in the BMJ found that women who did this were about 9% less likely to have perineal trauma requiring stitches compared to women who didn’t.
You don’t need to do it daily. Massaging once or twice a week for about four weeks before your due date appears to be enough. Each session typically lasts 5 to 10 minutes. The goal isn’t to stretch aggressively. It’s to familiarize the tissue with the sensation of pressure and gradually improve its flexibility. UT Southwestern Medical Center recommends having a provider or pelvic floor therapist teach you the technique around five weeks before your due date so you’re confident in the motion.
Choose Your Birthing Position Carefully
The position you’re in when you push has a significant effect on your perineum. Lying flat on your back (supine) or in stirrups (lithotomy) are consistently linked to worse tearing outcomes, yet they remain the default in many hospitals simply because they’re convenient for the provider.
The positions with the best evidence for protecting the perineum are hands-and-knees (all fours) and side-lying. A Norwegian study found that kneeling was associated with an 85% lower risk of severe tears compared to semi-recumbent positions. A Chinese randomized controlled trial found that women who delivered on hands and knees had lower rates of episiotomy and second-degree tears, and higher rates of keeping the perineum completely intact, compared to women on their backs.
Squatting is often assumed to be protective because it’s an upright position, but the evidence is mixed. One study found a twofold higher risk of severe tears in women who squatted compared to those in a sitting position. The extra downward pressure may work against you. If you want to be upright, kneeling or using a birth stool with support tends to be safer for the perineum than a deep squat.
Let Your Body Guide the Pushing
There are two styles of pushing during the second stage of labor. Directed pushing, sometimes called “purple pushing,” is when a nurse or provider coaches you to hold your breath and bear down for a sustained count of ten. Spontaneous pushing is when you follow your body’s natural urges, pushing in shorter bursts and breathing between them.
Spontaneous pushing is gentler on the perineum. Women in spontaneous pushing groups are less likely to experience extended episiotomies and cesarean births during labor. The slower, more controlled delivery of the baby’s head gives the tissue more time to stretch. If you don’t have an epidural, your body will naturally signal when and how hard to push. If you do have an epidural, you can still ask your team to use “laboring down,” which means waiting until you feel pressure before actively pushing rather than starting immediately at full dilation.
Ask for Warm Compresses During Delivery
Applying a warm, wet cloth to the perineum during the second stage of labor is one of the simplest interventions your birth team can use. A systematic review and meta-analysis found that warm compresses reduce perineal trauma and relieve postpartum perineal pain, particularly for first-time mothers.
The compresses are typically soaked in water between 38 and 44°C (about 100 to 111°F) and applied when the baby’s head begins to stretch the perineum. Some providers apply them continuously throughout the second stage, while others use them during contractions only. Both approaches appear beneficial. The warmth increases blood flow to the tissue, making it more pliable and better able to stretch around the baby’s head. This is something you can include in a birth plan and discuss with your provider ahead of time.
Strengthen and Relax Your Pelvic Floor
Pelvic floor preparation for birth isn’t just about Kegels. In fact, the ability to relax your pelvic floor muscles on command may matter more for preventing tears than the ability to contract them. During delivery, you need those muscles to release and lengthen so the baby can pass through.
Deep squats and child’s pose are two exercises that help lengthen the pelvic floor muscles and stretch the perineum. Practicing these regularly in the third trimester helps your body learn the sensation of a relaxed, open pelvic floor. A pelvic floor physical therapist can teach you how to consciously release tension in these muscles, which is particularly useful if you tend to hold stress in your lower body. This awareness pays off during labor when your provider asks you to relax between contractions.
Perineal Balloon Trainers
Devices like the EPI-NO are inflatable balloons you insert vaginally in the weeks before birth to gradually stretch the perineal tissue. The research is promising but not definitive. In one observational study, 46% of women who used the device had an intact perineum compared to 17% in the control group. A multicenter randomized trial found a higher rate of intact perineum in the device group (37.4% versus 25.7%). The device also appears to reduce episiotomy rates in several studies.
Side effects are generally mild: about 9% of users reported pain and 8% had minor bleeding. The device is not widely available in every country, and some providers are unfamiliar with it. If you’re interested, start the conversation with your midwife or OB early in the third trimester.
What Doesn’t Help as Much as You’d Think
Lubricant applied to the perineum during the second stage of labor, with or without massage, does not appear to reduce first or second-degree tears compared to a hands-off approach. This was the finding of multiple randomized controlled trials, though the data on severe tears is too limited to draw conclusions. So while your provider may use lubricant for comfort, it’s not a reliable tear-prevention strategy on its own.
Routine episiotomy, the surgical cut once given to nearly every first-time mother, has also fallen out of favor. The American College of Obstetricians and Gynecologists advises against routine episiotomy. A meta-analysis found that restricting episiotomies to only urgent situations reduced the procedure’s occurrence by 39% without worsening perineal outcomes or affecting newborn safety. In other words, the cut that was supposed to prevent tearing doesn’t reliably do so, and you have every right to decline one unless there’s a specific medical reason.
Putting It All Together
The most effective approach combines several of these strategies. In the weeks before birth, start perineal massage at week 35, practice deep squats and pelvic floor relaxation, and consider a perineal balloon trainer. During labor, request warm compresses, choose a hands-and-knees or side-lying position if possible, and push spontaneously rather than holding your breath on command. Talk to your provider about avoiding routine episiotomy.
No single technique guarantees you won’t tear. But stacking multiple evidence-based strategies gives your perineum the best chance of stretching rather than splitting, and if a tear does happen, it’s more likely to be shallow and quick to heal.