Protect your perineum!
A recurring fear for many first time moms is tearing during their labor and delivery. Here are some tips based on the literature on best practices to protect your perineum. These are all things we as Get Babied! Doula implement in our practice and help remind you of during your labor.
1. You are more likely to tear if you push in the traditional semi-recumbent feet in stirrup position. The most perineal friendly position is on all fours.
2. You are more likely to tear if you have an epidural. If you can manage the pain without it, do it. If you do get an epidural and don’t have enough feeling in your legs to support a hands and knees pushing position, pushing in a side-lying position is the most friendly to your perineum. Epidurals also increase the use of forceps/vaccuum – which almost 100% of the time cause perineal damage. So forgoing the epidural will bring this risk down as well. If you have to get an operative delivery, the vaccuum is kinder to the perineum than forceps.
3. You are more likely to tear if baby head has malpresentation – ie – not facing down. If baby is coming out facing up or facing sideways it takes up more room in your pelvis and takes a wider opening to get out – hence more tearing. You can correct a suspected OP or OT baby by laboring on your hands and knees, or sidelying; early prevention of OP is easy and cheap too – sleep on your front/sidelying position throughout pregnancy and do lots of walking during the day and throughout your pregnancy to the very end (exercise is good to get that baby down in the right position).
4. Big babies are more likely to cause perineal damage – nothing you can do about that one – so just do your best on the top three. 
http://onlinelibrary.wiley.com/doi/10.1111/j.0730-7659.2005.00365.x/abstract
ABSTRACT: Background: Most women will sustain some degree of trauma to the genital tract after vaginal birth. This study aimed to examine the association between maternal position at birth and perineal outcome in women who had a midwife-attended, spontaneous vaginal birth and an uncomplicated pregnancy at term. Methods: Data from 3,756 births in a major public tertiary teaching hospital were eligible for analysis. The need for sutures in perineal trauma was evaluated and compared for each major factor studied (maternal age, first vaginal delivery, induction of labor, not occipitoanterior, use of regional anesthesia, deflexed head and newborn birthweight >3,500 g). Birth positions were compared against each other. Subgroup analysis determined whether birth positions mattered more or less in each of the major factors studied. The chi-square test was used to compare categorical variables. Results: Most women (65.9%) gave birth in the semi-recumbent position. Of the 1,679 women (44.5%) who required perineal suturing, semi-recumbent position was associated with the need for perineal sutures, whereas all-fours was associated with reduced need for sutures; these associations were more marked in first vaginal births and newborn birth weight over 3,500 g. When regional anesthesia was used, semi-recumbent position was associated with a need for suturing, and lateral position associated with a reduced need for suturing. The four major factors significantly related to perineal trauma included first vaginal birth, use of regional anesthesia, deflexed head, and newborn weight more than 3,500 g. Conclusions: Women should be given the choice to give birth in whatever position they find comfortable. Maternity practitioners have a responsibility to inform women of the likelihood of perineal trauma in the preferred birth position. Ongoing audit of all clinicians attending births is encouraged to further determine effects of maternal birth position and perineal trauma, to investigate women’s perception of comfortable positioning at birth, and to measure changes to midwifery practice resulting from this study.
