A GF of mine had good results with the epi-no - only a superficial tear from her 10lbers shoulders both coming out at once. I didn't do anything prior to birth, however I followed my midwives instructions meticulously and I tore badly anyway (terrible skin elasticity and really strong uterus expulsion reflex even without pushing) - so I will be trying perineal massage this time around and am hoping that helps and have heard good things about it- I think there's a section here somewhere on it but can't find it right now or would make a link for you.