Pushing and Tearing: What Helps, What's Myth

The fear nobody says out loud

Let me guess: you are not actually afraid of the pain of pushing. You are afraid of the tearing. Almost every client tells me this in a lowered voice, like it is a weird thing to ask. It is not weird. It is the most normal question in the world.

So let's take the mystery out of it. Tears are graded by depth, like a sunburn scale, except the opposite of fun:

• First degree: skin and the surface lining of the vagina only. Often needs no stitches or just a couple.
• Second degree: skin plus the perineal muscle underneath. This is the most common tear that needs stitches, and it heals well.
• Third degree: extends into the anal sphincter muscle. This is the serious kind doctors watch for, and it gets repaired in the operating room.
• Fourth degree: goes through the sphincter and the rectal lining. Rare, and repaired carefully.

The reassuring part: in a study of over 113,000 spontaneous births, severe (third- or fourth-degree) tears happened in about 5.7% of first-time moms, 1.3% of moms who had given birth before, and 10.6% of VBAC moms. The vast majority of tears are first or second degree — the heal-up-fine kind.

Upright vs. on your back: what the evidence says

Here is where it gets interesting, because the answer is not the simple "upright good, back bad" story you hear on the internet.

A Cochrane review of 20 trials in women without epidurals found that upright or lateral positions (sitting, squatting, kneeling, hands and knees, side-lying) compared with lying on the back or in stirrups gave a few possible benefits: a very small reduction in the length of pushing, fewer episiotomies, and fewer assisted (forceps/vacuum) deliveries. The trade-offs: more blood loss over 500 mL, and possibly more second-degree tears, though the authors could not be certain about that last one.

Then a huge Swedish study of 113,000 spontaneous births added a nuance I think matters. Standing had the lowest rates of severe tears and lithotomy (stirrups) had the highest — but birthing seats and squatting were actually associated with increased severe-tear risk among moms who had given birth before. The authors themselves note that women in lithotomy also tended to have more inductions, epidurals, and big babies, so this is association, not proof.

My honest take as a doula, not a doctor: there is no magic position that prevents tearing. The best position is the one your body wants to be in, and the freedom to change it. I believe the body is beautifully designed — and part of that design is that pushing feels different in different positions, so your body can tell you what it needs if someone gives you the chance to listen.

"Push to ten!" — coached vs. spontaneous pushing

You know the movie scene: hold your breath, chin to chest, push to ten while everyone counts. That is directed (coached) pushing with a closed glottis. Spontaneous pushing means following your own urge — shorter pushes, breathing out, often three to five bursts per contraction, and sometimes just... waiting out a contraction without pushing at all.

A Cochrane review combining 8 trials of spontaneous vs. directed pushing found no clear difference in any of the big outcomes: not the length of pushing, not severe tears, not episiotomy rates, not whether the birth was spontaneous. The evidence quality was mostly low to very low, and the authors concluded that in the absence of strong evidence, the woman's preference and comfort should guide the decision.

Translation: nobody has proven the counting is helping. If your body is roaring at you to push, push. If it is telling you to breathe and wait, that is allowed too. My job at a birth is often just to make sure nobody rushes a woman who is clearly listening to her body — which, frankly, is one of the more awkward parts of doula work, standing between a laboring mom and a well-meaning nurse with a stopwatch.

What about "laboring down" — waiting to push?

With an epidural, many providers suggest waiting after full dilation until the baby descends on its own before pushing — called delayed pushing or laboring down. The Cochrane review of 13 trials (all with epidurals) found delayed pushing shaved about 19 minutes off active pushing and slightly increased spontaneous vaginal births — but added about 56 minutes to the total second stage, and was linked to more low cord-blood pH in babies.

Then a large observational study of 21,034 first-time moms found a less rosy picture: waiting 60+ minutes was associated with longer second stages and higher odds of cesarean (adjusted odds ratio 1.86), operative vaginal delivery, and postpartum hemorrhage — with no improvement in any neonatal outcome. Because it was observational, we cannot say the waiting caused those outcomes; the women who waited may have differed in other ways. Still, it is a good reminder that "do nothing and wait" has its own trade-offs, and these are conversations to have with your provider, not decisions to make from a blog post.

What actually protects the perineum

Okay, the part you came for. Here is what has real evidence behind it — and it is refreshingly simple:

• Warm compresses during pushing. A Cochrane review found warm compresses (a warm cloth held to the perineum during and between pushes) roughly halved third- and fourth-degree tears (average risk ratio 0.46, moderate-quality evidence). A separate 2019 meta-analysis of 7 trials found warm compresses also increased intact perineums and lowered episiotomy rates. Cheap, simple, no known harm. This is absolutely something you can put on your birth plan and ask your nurse or midwife for.
• Perineal massage during the pushing stage. In the same Cochrane review, gentle perineal massage during the second stage was associated with more intact perineums and fewer severe tears (average risk ratio 0.49). This is the provider or midwife doing it, not you — one more reason to choose a birth team you trust with your body.
• Antenatal perineal massage from about 34 weeks. A Cochrane review of 4 trials found that massaging the perineum a few minutes a few times a week in late pregnancy reduced tears needing stitches (risk ratio 0.91) and episiotomies (risk ratio 0.84) — with the clearest benefit for first-time moms. It did not reduce severe tears specifically, but fewer episiotomies and fewer stitches is a genuine win.
• Hands-off vs. hands-on perineal support. A 2019 meta-analysis of 5 trials (7,287 women) found that the "hands-on" technique — one hand controlling the baby's head, one hand pressing on the perineum — was associated with more third-degree tears (2.6% vs. 0.7%) and more episiotomies (13.6% vs. 9.8%) than a hands-off approach. Counterintuitive, but that is what the data showed. Talk with your provider about their approach.

Notice what is not on this list: any special breathing technique, any magic oil, any position you must hold. The effective stuff is unglamorous. Warm washcloth. A few minutes of massage in the third trimester. A provider whose hands stay mostly out of the way.

A few myths, busted gently

Myth: "A big baby means you will definitely tear badly." Big babies and big head circumferences are risk factors, yes — but most big babies are born without severe tears. Your provider can talk through your specific situation; a growth estimate alone is not a verdict.

Myth: "An episiotomy prevents worse tearing." Routine episiotomy is not supported by the evidence — the studies above show fewer episiotomies alongside fewer severe tears when warm compresses, upright positioning, and antenatal massage were used. Episiotomy has its place in specific situations, which is a decision for you and your provider in the moment.

Myth: "If you tear, your body failed." Absolutely not. Tearing is tissue doing exactly what tissue does under pressure. It heals. And nothing on this page should make you feel you must refuse any intervention or ignore your provider's guidance — being an informed, questioning patient is part of wise decision-making, and so is trusting your medical team when it counts.

I have said this before and I will keep saying it: I am against anything rooted in fear that takes advantage of women in the vulnerable season of bringing a baby into the world. That includes fear-based birth content — and it includes the version of "natural birth" culture that turns every choice into a pass/fail test. You cannot fail at giving birth.

Two real stories (not data)

Studies give us averages. Stories give us courage. These are personal experiences from real moms — not evidence, just two women who pushed in positions that worked for them:

• Kristen's home birth — she delivered on her hands and knees after prenatal yoga taught her labor poses and breathing techniques.
• Deborah's birth — she pushed on her knees over the side of the tub and describes holding her baby for the first time as "euphoric."

Both of my own births were unmedicated, and I want to be blunt about this: that does not make me better than anyone, tougher than anyone, or more of a mother than anyone. Birth is not a sport with a podium. Whatever your birth looks like — epidural, induction, cesarean, unmedicated in a tub — you showed up and did the hardest thing.

References

1. Position in the second stage of labour for women without epidural anaesthesia — Gupta JK et al., Cochrane Database Syst Rev, 2017
2. Pushing/bearing down methods for the second stage of labour — Lemos A et al., Cochrane Database Syst Rev, 2017
3. Perineal techniques during the second stage of labour for reducing perineal trauma — Aasheim V et al., Cochrane Database Syst Rev, 2017
4. Antenatal perineal massage for reducing perineal trauma — Beckmann MM, Stock OM, Cochrane Database Syst Rev, 2013
5. Hands-on versus hands-off techniques for the prevention of perineal trauma during vaginal delivery: a systematic review and meta-analysis of randomized controlled trials — Pierce-Williams RAM et al., J Matern Fetal Neonatal Med, 2021
6. Warm perineal compresses during the second stage of labor for reducing perineal trauma: a meta-analysis — Magoga G et al., Eur J Obstet Gynecol Reprod Biol, 2019
7. Birth position and obstetric anal sphincter injury: a population-based study of 113 000 spontaneous births — Elvander C et al., BMC Pregnancy Childbirth, 2015
8. Maternal and Neonatal Outcomes With Early Compared With Delayed Pushing Among Nulliparous Women — Yee LM et al., Obstet Gynecol, 2016

Rachel Gould is a birth doula and maternal wellness coach serving Scottsdale and the Phoenix Valley through Holista Health Collective — 1-on-1 support for preconception, pregnancy, birth, and postpartum.