I think it has a lot to do with many things. Strong kegal muscles to help the woman control her pushing efforts. Allowing the woman to push as her body says it needs to. Allow mom to move around and change positions.

I have had directed pushing with all three of my babies and have never needed a stitch. I do my kegals religiously, though and feel that this is what helped me. However, allowing a woman to push on her own could give the tissue more time to stretch as baby descends. Once they hit that ring of fire, most moms I've seen usually stop for a minute, it's such a shock! That gives the skin some more time to stretch. Of course, there are those babies that just rocket out. So I don't really have a perfect answer for you!

I've seen primips do beautiful with barely a skid and multips tear from one end to the other (okay, that's dramatic, but bad tears). Counselling moms on doing their kegals, excellent nutrition and lots of visualization I think will give them the best chances.

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Sasha, Doula, Mama, Wife, Student Midwife

Three little wild boys and one soldier husband