How Common Is Perineal Tearing During Childbirth?

I know nobody wants to hear this, but perineal tearing is a normal part of childbirth, but rest assured that most tears will heal well. The Royal College of Obstetricians and Gynaecologists (RCOG) state that up to 9 out of 10 women giving birth for the first time will experience some form of perineal tearing, with most being minor. Perineal tears are classified in the following way: first, second, third and fourth. The RCOG have a guide on the different types of tear and what they anatomically involve, should you wish to learn more. 

There is understandably anxiety amongst some women and birthing people about this, because I mean, who would be thrilled at the prospect of a perineal or a vaginal tear? So, whilst yes, tearing is a very common and normal part of childbirth, I don’t intend to minimise the impact it can have – whether that’s antenatal anxiety and/or postnatal physical discomfort.

What Are Perineal Massage Devices and What Do They Claim?

If your social media algorithm is anything like mine, you may have seen adverts for devices that claim to reduce the chance of tearing and/or episiotomy (an intentional cut to the vagina during childbirth) during childbirth. Which sounds pretty good right?

These vaginal dilators and perineal massagers claim to prepare the perineum (and sometimes the pelvic floor) to stretch for childbirth, reduce the chance of tearing, increase ‘control during delivery’ and cause ‘less stress for mother and baby during the second stage’, to name a few. I, for one, would love to know what evidence there is that a vaginal dilator reduces the stress for a mother and baby…

So, are these bold claims based on any solid evidence? Despite some incredibly effective marketing, the actual evidence to back up the claims is limited. The three delightfully named devices I will be looking at in this blog are:

– The Aniball

– The EPI-NO

– The Perimom

Does the Aniball Reduce Tearing? What the Data Shows

Aniball – Cost: £59.95 – Method: Vaginal dilator

Here are some direct quotes from the Aniball website:

‘Experience natural birth without tearing or interventions’.

‘Aniball is a proven pelvic floor trainer, it greatly reduces the risk of tearing or episiotomy and speeds up your postpartum pelvic floor recovery’.

‘With Aniball, you greatly increase the chance of a positive birth experience without tearing.’

Aniball cites one 2016 study from the Czech Republic as evidence for its effectiveness. Unfortunately, the full text article is not freely available online (although I did email the journal asking for a copy…). Below is what I gained from the article abstract:

A retrospective study, looking at 315 primiparous (first time birthing) women, who were questioned following their birth about methods they used to try and prevent perineal tearing. Methods quoted were: Vaginal dilators such as the Aniball and the EPI-NO, perineal massage and so called ‘natural methods’ which included linseed and raspberry leaf tea.

Women who used methods to prevent perineal trauma during pregnancy were compared with a control group of women who did not use any methods during their pregnancy. Women who experienced spontaneous vaginal birth and instrumental assisted (forceps or ventouse) birth were included in the study.

The authors report a significantly higher rate of an intact perineum amongst women who used vaginal dilators in pregnancy: 43.1% vs. 14.1% in the control group, they also found less episiotomies at 29.3% vs. 57.7%. They also reported a lower rate of instrumental assisted birth following the use of vaginal dilators. They found no difference in perineal outcomes for women using linseed or raspberry leaf tea.

So, we have a small study population, unassisted vaginal births being grouped with instrumental assisted births and an episiotomy rate that is far higher than the average rate in the UK. Furthermore, the abstract doesn’t go into detail about when in pregnancy the women started using the vaginal dilators and how often they did the exercises. All of which doesn’t scream ‘robust data’.

The claims of the Aniball (see quotes above…or go and check out their website for fun!) cannot be said to be based on good evidence.

Does the EPI-NO Reduce Tearing? What the Data Shows

EPI-NO – Cost: £99.99 – Method: Vaginal dilator

Quotes from the EPI-NO website says:

‘The best birth preparation training device’

‘…clinically proven to significantly increase the chance of an intact perineum, control during delivery and is more effective than perineal massage’.

‘Using EPI-NO from 37 weeks has been proven to reduce tearing by up to 42%’

Does the EPI-NO Reduce Tearing? What the Data Shows

EPI-NO has a page on its website for data and cites several studies (an Australian pilot study from 2004, a 2004 Israeli study by a midwife who distributed the EPI-NO, a 2009 German prospective RCT involving 276 women, a German study of 80 women from 2000, a German study in 2001 involving 50 women) that support the use of the EPI-NO as a method for reducing episiotomies and perineal tears. They have also included the experiences of several midwives in this page called ‘Data and Clinical Trials’.

Most of the studies cited are over 20 years old and involved a small number of participants. The most recent article is a 2016 literature review of the existing research on the use of the EPI-NO, which found 5 studies and concluded that whilst the EPI-NO has the potential to be a promising device, there is no good evidence available to support the claims of reduced episiotomy and perineal tear rates.

Where EPI-NO has got the figure of a 42% reduction in tears is not clear…possibly from their survey of 1323 women between 2021-2023…? What’s interesting about that survey is that 35% of the women reported they had an episiotomy and 13.3% had a third- or fourth-degree tear – both of these figures are higher than the UK national average of approximately 25% and 3.1%, respectively.

On another page of the website EPI-NO claims that by using their device, the chance of episiotomy is reduced by 65%, with a link to survey results that doesn’t work…I don’t know about you, but I am seeing holes in these claims.

Does the Perimom Work? What the Research Says

Perimom – Cost: £32 – Method: Perineal massage tool

Quotes from the Perimom website:

‘The ultimate tool for perineal massage’

‘…a thumb shaped tip allows you to perform the massage at the right angle…like it’s been done for generations.’

‘You’re doing everything you can to prepare yourself for a positive birthing experience.’

Presumably, with the last quote, they mean, by doing perineal massage.

What’s the data?

So, there’s no specific data on the use of the Perimom, but there are several research papers on perineal massage.

The Cochrane review, which looked at 4 studies, found that doing antenatal perineal massage did not alter the likelihood of women having first, second, third or fourth degree tears; but it did appear to reduce the incidence of episiotomy by 16%. They also concluded there was no difference in the chance of assisted vaginal birth.

I’m not convinced women have been doing perineal massage ‘for generations’ – but it sounds good right? I also can’t ignore that the Perimom resembles a shoe horn.

Does Your Perineum Actually Need to Be 'Prepared' for Birth?

All these devices claim to reduce the incidence of perineal trauma. They also feed into the idea that the perineum needs to be prepared for childbirth, that women and birthing people’s bodies are so inherently flawed that they must be prepared for birth. Rachel Reed writes wonderfully (as per) about this here and notes that whether a woman ‘prepares’ her perineum during pregnancy or not – it will indeed stretch during childbirth. Perineal trauma as mentioned earlier is a very common and normal part of childbirth. It is also however influenced by childbirth practices – for example, research shows that giving birth on your back increases the chance of perineal trauma. Yet, giving birth on your back is very much the norm.

What You Need to Know About Severe Perineal Tears

Third- and fourth-degree tears are considered severe, but the incidence is low at 3.1% (or less than 4 per 100) in England and Wales, according to the 2022 National Maternity and Perinatal Audit (NMPA). Interestingly, in the aforementioned EPI-NO survey, 13.3% of women experienced a third- or fourth-degree tear – which is way higher than what the NMPA found. Women giving birth for the first time were found to have an incidence of 4.5% with an unassisted vaginal birth and 6.9% with an instrumental assisted birth. Women and birthing people having their second (or more) baby were noted to have an incidence of 1.3% with an unassisted vaginal birth and 4% with an instrumental assisted birth. Severe tears can be life-altering for women and birthing people and it is very much a postcode lottery in the UK when it comes to support and care following this type of trauma.

The data shows that regardless of if you have an unassisted or an assisted vaginal birth, if you’re giving birth for the first time you have a higher chance of sustaining a third- or fourth-degree tear compared to those giving birth to a second or more baby. And overall, instrumental assisted births increase the chance of sustaining a third- or fourth-degree tear, whether it’s your first or second or more baby. But it is important to remember, there’s still a significantly higher chance of not having a severe tear during childbirth. 

The Truth About Episiotomies: How Common Are They Really?

According to data from the NMPA in England and Wales, 24.6% of women had an episiotomy. This is separated into 9.7% of women and birthing people having an unassisted vaginal birth and 88.7% of women having an instrumental assisted birth (94.7% for forceps and 79.8% with a ventouse). There was a 35% episiotomy incidence amongst the women who responded to the EPI-NO survey…again, higher than the average in England and Wales.

Practices around episiotomy vary significantly around the world. In the study that Aniball quotes, the episiotomy rate (29.3%) in women who use a vaginal dilator is also higher than the overall episiotomy rate in England and Wales. Routine episiotomies were introduced as a means of ‘protecting’ the perineum of first-time mothers. At an exhibition we went to in Glasgow recently, it was reported that the rates of episiotomy increased from 5% in 1900 to 80% in 1950. Luckily routine episiotomies are no longer recommended as (surprise, surprise) research does not support this practice. An episiotomy is not a ‘natural’ outcome of childbirth, it is the result of a healthcare professional making the decision that more space is needed in the birth canal. In the same way that any intervention used in childbirth can be be useful and necessary, episiotomies have their place, but I would question if almost a quarter of women and birthing people giving birth vaginally in England and Wales truly need an episiotomy?

Should You Buy a Perineal Massage Device? Our Verdict

What is perhaps slightly misleading about all of the devices mentioned, is the sense of a promise that using them will make a significant difference to the chances of a perineal tearing – and the data just doesn’t support that. Furthermore, it reinforces the idea that women and birthing people need to prepare the perineum for birth because our bodies are faulty. These companies all use excellent marketing tactics, making it seem as though without them the chance of tearing or having an episiotomy during childbirth is much higher. Oh, and they all encourage the spending of more money on their specialist lubrication too. These companies ignore the different practices of both individual midwives and obstetricians, and the modern day cultural practices around childbirth that contribute to perineal trauma (cascade of interventions anyone…). Educate yourself on physiological birth, learn about the cascade of interventions and don’t waste your money on these products.

In our next blog we will be looking at the Cochrane reviews on methods for reducing perineal trauma in more depth – watch this space!