My first had a nuchal hand. The tearing went every which way, perineum, urethra, labia on both sides. Fortunately, the most severe was labial--just cosmetic. The urethral tear hurt like a <expletive,> but it healed ok. Unfortunately, my perineal tear developed a cyst when it healed. I had discomfort with sex and even just sitting until after my second birth when I finally had it repaired.
Going into my second birth, I was scared. Really, truly afraid. I felt like homebirth was my best option (the tear wasn't all that I disliked about my first birth.) Waterbirth is supposedly great for preventing tears, but it didn't appeal to me.
I decided on 2 things--1, not to push unless I absolutely couldn't help it, and 2, to stay off my back and off my feet at all costs. I wanted plenty of time to stretch. I worked hard on preparing not to push. When the time came, I breathed through the pushing contractions until I couldn't any longer, and then I restrained myself as much as I could and only pushed a tiny bit. Her head was born after two tiny pushes, her shoulders and body after the third. She was a big baby, so I had to go big with the third push. At the time, I was focused on getting her out, so my fear of tearing didn't even cross my mind.
I only tore a tiny bit--enough to expose the cyst, which my midwife then removed before she gave me only a couple of stitches. It healed beautifully. I have been pain-free ever since. (My labia still "have character"
I clearly remember sitting on cold concrete steps 10 days after my second birth and thinking to myself "I've been sitting here for a while and it doesn't hurt a bit!"
My third child just kind of fell out (on land--actually, the bathroom floor.) No tearing, no discomfort, nothing. He was 10lb, 2oz.