What it is
Tears are graded by how deep they go. Grade 1: skin only. Grade 2: skin and perineal muscle (most common; usually a few stitches). Grade 3: extends into the anal sphincter. Grade 4: extends through the sphincter into the rectal lining. Grades 3–4 are called OASIS (obstetric anal sphincter injuries). Several practices during pushing lower the risk: warm compresses on the perineum, slower pushing at crowning, upright or side-lying positions, and — importantly — restrictive rather than routine episiotomy.
Evidence review links
Each link opens the full review on the publisher's site in a new tab.
- ACOG Practice Bulletin 165: Prevention and Management of Obstetric Lacerations at Vaginal DeliveryACOG
- Perineal techniques during the second stage of labour (Cochrane Review)Cochrane
- Antenatal perineal massage for reducing perineal trauma (Cochrane Review)Cochrane
- ACOG Committee Opinion 736: Optimizing Postpartum CareACOG
- ACOG Committee Opinion 766: Approaches to Limit Intervention During Labor and BirthACOG
Possible benefits
- Warm compresses during pushing reduce severe (3rd/4th-degree) tears[Cochrane↗][ACOG↗]
- Position changes (side-lying, hands-and-knees) and unhurried pushing help the tissue stretch[Cochrane↗][ACOG↗]
- Prompt repair of higher-grade tears reduces long-term problems[ACOG↗]
- Perineal massage in the last few weeks of pregnancy modestly reduces tearing for first births[Cochrane↗]
Possible risks
- 3rd/4th-degree tears can affect continence, healing, and sexual function; specialized follow-up matters[ACOG↗]
- Even small tears can be uncomfortable during recovery, urination, and first bowel movements[ACOG↗]
- Risk factors include first vaginal birth, larger baby, assisted (vacuum/forceps) birth, midline episiotomy, and prolonged pushing[ACOG↗]
Alternatives
- Hands-on ("guarding") vs. hands-poised approaches are both reasonable — ask what your provider does[Cochrane↗]
- Warm water immersion, upright pushing, and self-directed pushing over coached pushing[ACOG↗]
- For anyone with prior 3rd/4th-degree tear: discuss route of birth for future pregnancies[ACOG↗]
Current evidence
ACOG Practice Bulletin 165 covers prevention, grading, and repair of tears. Cochrane reviews support warm compresses and antenatal perineal massage; the ACOG Committee Opinion 736 (Optimizing Postpartum Care) frames postpartum pelvic-floor recovery as ongoing rather than a single 6-week visit.
Where the evidence is clear · where people may choose differently
For most topics, guidelines from ACOG, WHO, and other major bodies broadly agree on the core safety points (when to act in an emergency, informed-consent standards, monitoring baselines). Where reasonable people — and even guidelines — differ tends to be around thresholds (when to start or stop something), preferences (comfort, environment, support), and values (how you weigh small risks against benefits). Use the questions below to explore those pieces with your care team.
Educational only. Your care team can help you weigh what applies to your specific situation.
Related evidence topics
- EpisiotomyA cut made in the perineum during birth to enlarge the vaginal opening. Once routine, now only recommended for specific situations.
- Vacuum vs. Forceps (Operative Vaginal Birth)Instruments used to help the baby out during pushing, usually when the baby is close but not quite born and there's a reason to speed things up.
Questions to ask your care team
- ?What do you do during pushing to lower the chance of tearing (warm compresses, positions, timing)?
- ?If I tear, what grade would prompt what type of repair, and by whom?
- ?How will you manage my pain and care for the area in the first days?
- ?What warning signs should send me back in?
- ?If I have a 3rd or 4th-degree tear, what specialist follow-up do you recommend?
Universal questions (works for any decision)
A short BRAIN-style set you can bring to any conversation about interventions, monitoring, or care decisions.
- ?Why are you recommending this now — is it urgent, routine, or optional?
- ?What happens if we wait an hour (or longer) before deciding?
- ?What signs would tell us this is working — or that we need to change course?
- ?What are the alternatives, including doing nothing?
- ?What would you recommend if this were your family?
- ?What would change your recommendation?
Sources & provenance
Tap a source to open the original guideline or review in a new tab.
- ACOG Practice Bulletin 165: Prevention and Management of Obstetric Lacerations at Vaginal Delivery — ACOG
- Perineal techniques during the second stage of labour (Cochrane Review) — Cochrane
- Antenatal perineal massage for reducing perineal trauma (Cochrane Review) — Cochrane
- ACOG Committee Opinion 736: Optimizing Postpartum Care — ACOG
- ACOG Committee Opinion 766: Approaches to Limit Intervention During Labor and Birth — ACOG
Plain-language paraphrase. Re-verify before publish.
Last reviewed: 2026-07-03
Further reading — canonical references
Read the source material directly. Each link opens the publisher's own current guidance in a new tab — cross-check what we summarize against what they say.
Tier 1 · Clinical guidelines
Tier 2 · Systematic reviews
Educational only. Guidelines evolve — the linked publisher pages will reflect newer guidance than any static snapshot.
Version history — v1.0.0
v1.0.0 · 2026-07-03 · LlaMamma editors
Initial perineal-tears topic.
New guidance from ACOG, WHO, Evidence Based Birth, or other listed sources is recorded here and can be updated remotely without a new app release.