So you think you need . . . An episiotomy:What to do to avoid perineal tears

* Prenatal perineal massage. There is significant evidence to show that you can increase the flexibility of your perineum by regularly massaging the tissue before giving birth.

In a randomised controlled trial carried out across five hospitals in Canada, researchers found that women who massaged their perineum for 10 minutes every day, from the 34th or 35th week of pregnancy until delivery, were more likely to end up with an intact perineum than women who did not practice perineal massage (Am J Obstet Gynecol, 1999; 180: 593-600). The study also revealed that women who were having their first vaginal delivery benefited the most from the massage.

This is also a case of the older, the better. One UK study showed that women over the age of 30 were more likely to benefit from perineal tissue massage than younger women (Br J Obstet Gynaecol, 1997; 104: 787-91).

The best time to do perineal massage is after a warm bath, when the tissues are softer and more flexible. Choose a simple base oil such as sweet almond, vitamin E, jojoba, wheatgerm or olive oil.

Step 1: Wash your hands thoroughly and make sure your fingernails are trimmed and without jagged edges

Step 2: Place a generous amount of oil onto your fingers and thumbs as well as around your perineum

Step 3: Insert both your thumbs inside your vagina, and place your fingers on the base of the perineum

Step 4: Using gentle but firm pressure, move the thumbs from the base of the vagina up to the sides, making the shape of a ‘U’, while gently pulling the tissue forwards

Step 5: Return the thumbs to the base of the vagina, and repeat the procedure.

For best results, perform the massage daily for around 10 minutes and from four to six weeks before delivery.

* Kegel exercises. Devised by US gynaecologist Dr Arnold Kegel, these exercises strengthen the pelvic floor muscles that surround the openings of the urethra, vagina and rectum. These muscles are attached to the pelvic bone and act like a hammock to support your pelvic organs, and can be isolated by trying to stop and start the flow of urine.

A research team in Norway put a group of nearly 150 pregnant women through an intensive 12-week, pelvic floor muscle-training programme, and found that the exercises helped to prevent urinary incontinence in one in six women during pregnancy and in one in eight women after delivery (Obstet Gynecol, 2003; 101: 313-9).

* Water births. Aside from providing pain relief, warm water increases tissue elasticity and strength, thereby reducing the likelihood of perineal tears. In an Austrian study comparing the outcomes of water births with normal vaginal deliveries, the women in the water-birth group had significantly lower rates of episiotomy and vaginal trauma than those undergoing non-water births (Wien Klin Wochenschr, 2002; 114: 391-5).

Another study found that, while around 70 per cent of water births do not require the use of analgesics, only 30 per cent of bed births were able to do away with painkillers (Gynakol Geburtshilf Rundsch, 2003; 43: 12-8).

* Nutrition. Vitamins A, C and E, and the minerals zinc and silica are known to promote suppleness in skin and, hence, are often recommended for preventing stretch marks. Supplementing your diet with these nutrients as well as drinking plenty of water can help to increase the elasticity of your perineum and prepare it for the intense stretching of giving birth.