Protecting the Perineum: Understanding Tears, Episiotomy, and the Pathways to Birth

Midwives often speak with pride about supporting a woman to birth with an intact perineum. It’s a phrase that carries deep meaning — representing gentleness, awareness, and respect for the body’s innate design.

But what really causes tearing, and is it truly possible to avoid it? To answer that, we need to look at perineal anatomy, birthing positions, episiotomy, and most importantly, the physiology of birth itself.

The “Ring of Fire” and the Wisdom of Slowing Down

Many women describe a Ring of Fire in those final moments of birth — a burning, stretching sensation as the baby’s head begins to crown.

This moment is the body’s natural signal to pause. To slow down.

Panting or breathing through the intensity instead of pushing allows the perineum to stretch gradually, reducing the chance of tearing.

Rushing through this stage — especially with coached pushing — can increase the risk of trauma. Remaining aware and supported is vital. This awareness is helped by:

• Avoiding lying flat or deep squatting positions

• Avoiding an epidural (as it limits body feedback)

• Allowing instinctive, rather than directed, pushing

When women birth instinctively, they often move into hands-and-knees or kneeling, leaning forward positions. These postures naturally slow the birth, giving the tissues time to stretch. Those who have birthed before often do this more intuitively.

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Evidence and Insight: Perineal Protectors

Rachel Reed’s Perineal Protectors offers a thorough look at the research behind perineal care — from antenatal techniques like massage or the epi-no, to birth practices of varying invasiveness.

For those who experience augmented labour, have an epidural, or are birthing on their backs, some interventions can help protect the perineum:

• Warm compresses applied during birth have been shown to reduce major tears, especially for first-time birthers.

• Encouragement to slow down during crowning, avoiding pushing through the burning phase, can also be protective.

Gloria Lemay’s Midwife’s Guide to an Intact Perineum beautifully describes the emotional and physical sensations of the pushing stage — and how birth attendants can help mothers stay connected and calm through it.

What the Research Tells Us

Perineal trauma is more likely when:

• It’s your first baby

• Forceps or vacuum are used

• You are from certain ethnic backgrounds (e.g. Indian, Chinese)

• Labour is long, particularly the pushing stage

• You have an epidural

• An episiotomy is performed

• You’re birthing lying on your back (especially in lithotomy)

• The baby’s head is in an abnormal position

• The baby is large (over 4kg)

• A private obstetrician is providing care (specific to episiotomy rates)

Perineal trauma is less likely when:

• It’s your second or subsequent baby

• You stay active and mobile during labour, avoiding an epidural

• You birth in a side-lying or upright position

• You’ve practiced perineal massage in late pregnancy

• Warm compresses are used

• The baby’s head is birthed slowly or between contractions

• You birth in a birth centre or at home

• You’re cared for by midwives

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Perineal Massage: Know Your Body, Not a Prescription

Carolyn Hastie’s Perineal Stretching Massage outlines the technique, but with an important reminder: you don’t need to do anything.

If it feels good, helps you connect with your body, or increases your confidence — wonderful. But this is about knowledge and respect, not obligation.

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Understanding the Clitoris and Perineal Anatomy

Vicki Hobbs’ work provides a comprehensive overview of perineal and clitoral anatomy, and Margaret Jowitt’s research adds a fascinating perspective:

Could the clitoris play a cushioning role in labour?

Images of women birthing on their backs often misrepresent physiological birth. In reality, upright or forward-leaning positions align with how the body is designed — perhaps offering protection through both movement and anatomy.

Episiotomy: What the Evidence Shows

Understanding perineal anatomy is essential when considering episiotomy, as the angle of incision significantly affects outcomes.

In Australia, episiotomies are generally performed at around a 30° angle, aiming to reduce the risk of severe (third or fourth-degree) tears. However, research has found that this angle can still impact the bulb of the vestibule — part of the clitoral anatomy essential for sexual function and arousal.

• High (≥45°) mediolateral incisions impact the clitoral bulb in 100% of cases

• Medium (16–44°) in 80%

• Low (10–15°) in 75%

• Midline (0°) doesn’t impact the bulb but increases the risk of major tears and fecal incontinence

These findings remind us that episiotomy isn’t a simple or benign intervention — and its implications extend beyond birth.

In Conclusion: Knowledge, Awareness, and Choice

The same principles that help avoid a tear also help avoid an episiotomy.

The cornerstone of prevention is physiological birth — staying active, upright, aware, and supported.

Avoiding unnecessary interventions like epidurals, when possible, can make a significant difference. This is where childbirth education and creating a birth plan/map with your partner and care provider become invaluable.

Understanding your options and the pathways that birth may take allows you to navigate confidently — making informed, empowered decisions that protect both your body and your birth experience.

To explore this further, read The Flows of Modern Birthing for a deeper look at how these pathways unfold.