Understanding the Perineum: A Comprehensive Guide
The perineum is a crucial but often overlooked part of the body, nestled between the vagina and anus (you could understand why it get’s overlooked). This area is composed of a complex network of muscles, connective tissues, nerves, and blood vessels that play a vital role in various bodily functions, particularly during childbirth.
Though it might be overlooked by many, the perineum tends to be the "butt of the joke" (pun intended) in movies and TV shows, where it's either used to scare or intimidate some ‘naive’ pregnant mother or person about childbirth, you know…for “comedic effect”.
We discussed earlier the many benefits of pelvic floor exercises - let’s now look at what else is included in this muscular bundle and what we can do to support their function (with less fear and more empowerment).
The Perineum at its Finest
During childbirth, the perineum undergoes intricate biomechanical processes to accommodate the passage of your baby through the birth canal.
Meaning, though it is under a decent amount of pressure, it is very well equipped to for this role.
Let’s Talk About the Perineum: Muscles, Tissues, and Nerves—Oh My!
When it comes to the perineum, there’s more going on than you might think. It’s not just a patch of skin—it’s a powerhouse of muscles, tissues, and nerves working together to keep things running smoothly. Let’s break it down:
Muscular Marvels
The perineum is home to two superstar muscle groups: superficial muscles and deep muscles.
Superficial muscles are the unsung heroes providing structural support to the area. Think of them as the foundation of a well-built house.
Deep muscles are part of the pelvic floor dream team, keeping everything stable and supporting your pelvic organs. These guys are all about strength and balance.
Connective Tissues and Ligaments
Inside the perineum, you’ll also find a network of connective tissues and ligaments. These add flexibility and structural integrity, ensuring the region can adapt and stay strong when life gets tough (we’re looking at you, childbirth!).
And speaking of childbirth, ligaments are VIPs here—they truly help support the pelvis during this amazing process.
Nerve Central
Here’s where things get really interesting: the perineum is buzzing with activity thanks to branches of the pudendal nerve. These nerves are the messengers, delivering all kinds of sensory updates to your brain.
They let you feel pressure, stretch, or even pain (yes, during childbirth too—shout out to biology).
But they’re also key players in movement and sensation, making this area as functional as it is fascinating.
So next time you think about the perineum (or maybe it’s the first time—no judgment!), remember all the incredible work it’s doing behind the scenes. It’s a small region with a big job!
The Perineum Under Pressure
Let’s talk about the perineum during childbirth—it’s a tough little area, but it definitely has its work cut out for it (sometimes literally). As baby makes their grand entrance, the perineum faces incredible pressure. And in some cases, this results in tearing or the need for an episiotomy (that’s a fancy way of saying a small surgical cut made by your healthcare professional to make more room). Statistics reveal that up to 9 in 10 first-time mothers who opt for vaginal birth experience some form of tear, graze, or episiotomy. It might sound intense, but don’t panic—your body is impressive, and there’s plenty of support to help you through this process (plus some great recovery tips for after). But first….Let’s break down the types of tears that can happen during a vaginal birth—because knowledge is power (and I guess a little humour never hurts).
First-Degree Tears: The Perineum’s Paper Cut
These are the minor league players of childbirth tears, affecting only the skin. They heal quickly on their own, but don’t be fooled—they can still feel stingy and achy, like your perineum just got a papercut.
Second-Degree Tears: The “Let’s Call in the Stitches” Kind
These tears dive a little deeper, involving both the skin and the underlying perineal muscle. Stitches are often recommended for these, and while they usually heal without long-term drama, they might leave you wincing a bit when you sit down for a while.
Third- and Fourth-Degree Tears: The Big Leagues
Third-degree tears extend into the muscle that controls the anal sphincter (the muscle MVP of your backside).
Fourth-degree tears take things even further, reaching into the lining of the anus or rectum.
The good news? These deeper tears are relatively rare. About 6 in 100 first-time vaginal births result in a third- or fourth-degree tear. For those who’ve been down this road before, the odds drop to less than 2 in 100.
The Rare But Bizarre: Rectal Buttonhole
Now here’s a curveball you probably weren’t expecting. A rectal buttonhole (yes, it’s a real thing!) is a rare injury where the anal sphincter stays intact, but a tiny tunnel forms between the rectum and vagina. This quirky phenomenon can lead to gas or stool taking an unexpected detour through the vaginal canal. It’s rare, but if it happens, it’s certainly a story to tell (after it’s been surgically repaired, of course).
While tears can sound intimidating, remember: your body is resilient, and there’s plenty of practical support to help you heal. Your perineum might be in for a wild ride during childbirth, but it’s tougher than it looks!
Can I Avoid Perineal Tears?
Welcome Perineal Massage
Facing the challenges of childbirth head-on can feel like a bit overwhelming, but fear not, because perineal massage might just be your secret weapon! Backed by research, studies show that a little TLC for your perineum can reduce the chances of tearing or needing an episiotomy. Yep, that’s right—perineal massage might be the smooth operator you didn’t know you needed!
Why Perineal Massage Works
Perineal massage is especially helpful for first-time mothers/parents. How? It helps improve the flexibility of the perineal tissues, making them more adaptable during labour (which hopefully means less chance of those tears). The Royal College of Obstetricians and Gynaecologists even has a handy online guide on how to do it, which I’ve adapted into my own discussions on this oh-so-important technique.
You’ll want to start this gentle practice in the final weeks of pregnancy. Not only does it help prepare for childbirth, but it can also ease discomfort after birth. Whether you go solo or have a partner lend a hand, it’s a great way to take charge of your birth experience and hopefully make things go a little smoother.
Other Pro Tips for Reducing Tearing
Optimal Birth Positions
Did you know that the position you choose during labour can play a role in reducing tearing? Exploring alternative positions like kneeling, being on all fours, or even lying on your side might help minimise your risk or lessen the severity of any tears. More flexibility in your positioning can make all the difference, so feel free to book a chat with me or your preferred birth team about the best options for you.
Support from Your Doula or Midwife
Your doula or midwife is your behind-the-scenes hero when it comes to preventing tears. They can offer guidance and encouragement during labour, especially when it comes to pushing and breathing. Instead of prolonged pushes, they might guide you to take short, quick breaths, allowing the skin and muscles to stretch more naturally. This gentle approach gives your perineum a little extra time to adjust, reducing the chance of tearing.
Additionally, they may use a warm compress as the baby’s head crowns—while it’s not a guarantee to prevent tears, it could help soften the skin and ease the process. Definitely chat with your birth team about adding this to your birth proposal.
Creating the Perfect Birthing Environment
Where you give birth can also play a role in how your perineum handles the pressure. Whether you choose a cosy home birth or a midwife-led unit, the relaxed environment might help reduce tension, which could lower the risk of tearing. Your doula will be a great resource, walking you through the options and helping you choose what feels right for you.
Water Birth: A Relaxing Option
Have you heard about water births? There’s some evidence to suggest that being in warm water during labour could lower the chances of tearing (though the research is still ongoing). If you’re intrigued, talk it through with your midwife or doula to weigh the pros and cons and see if it’s right for you.
In Conclusion
Understanding the intricate anatomy and biomechanics of the perineum in childbirth underscores the importance of perineal care and preparation during pregnancy. By promoting perineal flexibility and resilience through techniques such as perineal massage and pelvic floor exercises, expectant mothers/parents can optimise their birthing experience and enhance postpartum recovery. Perineal massage, smart birth positions, supportive guidance from your birth team, and choosing the right birthing environment all come together to help you have a smoother, more comfortable experience. So, whether you're massaging away or leaning into those cosy birth options, you’ve got a number of ways to give your perineum the best prep possible for the big day and beyond.
Some Resources
Royal College of Obstetricians & Gynaecologists (nd.) Perineal tears and episiotomies in childbirth. Available at: https://www.rcog.org.uk/en/patients/tears
NHS Choices (2023) Episiotomy and perineal tears. Available at: https://www.nhs.uk/conditions/pregnancy-and-baby/episiotomy/ (Accessed December 2024) (Page last reviewed 09/06/2023 Next review due 09/06/2026)
NICE (2023) Intrapartum care: NICE clinical guideline 235. Available at: https://www.nice.org.uk/guidance/ng235 (Accessed January 2025) (Page last reviewed 29/09/2023)
Lindgren, H. E., Brink, Å., & Klinberg-Allvin, M. (2011). ‘Fear causes tears - perineal injuries in home birth settings. A Swedish interview study’. BMC pregnancy and childbirth, 11, 6.
Royal College of Obstetricians & Gynaecologists (nd.) Your pelvic floor. Available at: https://www.rcog.org.uk/en/patients/tears/pelvic-floor/ (Accessed December 2024)
