Perineal Tear After Birth: Degrees, Repair and Recovery

✓ This content has been medically reviewed by an obstetrician and gynaecologist
Written & medically reviewed by: Op. Dr. Ayşet Jane Özcan, Obstetrics & Gynaecology Specialist
Istanbul Faculty of Medicine · Medical Park Bahçelievler · TJOD and TSRM member
Last updated: 15 October 2026 · Last medical review: 15 October 2026

Almost no one is told much about the perineum before labour, and then it becomes the part of the body you think about most in the weeks after birth. A perineal tear is one of the most common things that happens during a vaginal birth, and yet it is often discussed quickly, in the middle of the first hour with your baby, when very little of what is said is retained. Many women go home knowing that they "had a few stitches" without knowing what degree of tear they had, what was repaired, how long it should take to settle, or what would count as a problem.

This page is written to fill that gap. It explains what the perineum is and what tears into it, what first, second, third and fourth degree tears actually mean, how an episiotomy differs from a spontaneous tear, how repairs are done and under what anaesthesia, what a normal healing curve looks like, how to care for the wound and open your bowels without dread, which symptoms need to be seen the same day, how the pelvic floor recovers, when sex becomes comfortable again, and what the evidence genuinely supports for reducing the risk of tearing in the first place.

What is a perineal tear, and how common is it?

A perineal tear is a tear in the tissue between the vaginal opening and the anus, caused by the stretching that occurs as your baby's head and shoulders are born. Some degree of perineal trauma — a graze, a small split in the skin, or a deeper tear into the muscle — happens in the majority of first vaginal births. It is not evidence that something went wrong, and it is not a failure of your body or of the people caring for you.

The perineum is not simply skin. Beneath the surface sits the perineal body, a small wedge of fibrous tissue where several muscles meet: the bulbospongiosus and the superficial transverse perineal muscles in front, and the anal sphincter complex behind. That complex has two rings — an external sphincter, which is the muscle you squeeze voluntarily, and an internal sphincter, which works without your control and does much of the quiet work of keeping you continent. How deep a tear runs through these layers is exactly what the grading system describes.

Tears confined to the skin and the perineal muscles are by far the most common. Tears that involve the anal sphincter — known as obstetric anal sphincter injuries, or OASI — are much less common, affecting roughly three in a hundred women who have a vaginal birth, and they are more frequent in a first vaginal birth than in later ones. Those figures describe how common the injury is; they say nothing about how any individual birth will go.

Several things make a deeper tear more likely: a first vaginal birth, a bigger baby, an assisted birth (particularly with forceps), a baby who is born facing upwards, a long active pushing stage, shoulder dystocia, and a midline episiotomy. Women of South Asian background appear to be at somewhat higher risk, which is why many units pay particular attention to perineal protection in that group. Most of these factors are not things you can change, which is why the sections below focus on what can realistically be influenced.

There is a reason first births account for more perineal trauma. Tissue that has never been stretched to that extent is less elastic and gives way less gradually, and first labours tend to have a longer active pushing stage during which the head sits on the perineum. Once that tissue has stretched and healed, it behaves differently: women who tear in a first birth commonly have less perineal trauma, or none, in a later one. If a difficult first experience has left you anxious about having another baby, that is worth knowing early rather than in the next labour.

Perineal healing happens alongside everything else in the early postnatal weeks, including bleeding and the changing pattern of postpartum lochia, so it helps to know which symptom belongs to which process.

First, second, third and fourth degree tears explained

Tears are graded by how deep they go: first degree involves skin only, second degree reaches the perineal muscles, third degree involves the anal sphincter, and fourth degree extends through the sphincter into the lining of the back passage. The grade is decided by an examination immediately after birth, which normally includes a gentle rectal examination — not because anything has gone wrong, but because a sphincter injury cannot be reliably excluded from the outside.

• Graze or first degree tear — the skin of the perineum and the lining of the vagina only, with no muscle involved. Often no stitches are needed if the edges sit together and there is no bleeding.
• Second degree tear — extends into the perineal muscles but not the anal sphincter. This is the most common tear that requires suturing. An episiotomy creates an injury of the same depth.
• Third degree tear — involves the anal sphincter complex, and is subdivided: 3a, less than half the thickness of the external sphincter torn; 3b, more than half torn; 3c, the internal sphincter torn as well.
• Fourth degree tear — extends through both sphincters and into the lining of the anal canal or rectum.

Two other injuries sit outside this system. Labial and periurethral tears — small splits around the inner lips or near the urethra — can sting a great deal when you pass urine but are usually superficial, and are sometimes repaired with a single stitch to stop the labia healing stuck together. A rarer "buttonhole" tear runs into the rectum while leaving the sphincter intact; it does not fit the degree scale but is repaired with the same care as a fourth degree injury.

The examination that establishes the grade should be explained to you before it happens, and it should not be rushed. If you still have an epidural running, this is a good moment to use it; if you do not, you can ask for inhaled analgesia or local anaesthetic first. It is a brief examination, but it is the step that determines everything that follows, so it is done properly rather than quickly.

Why the grade matters

The grade determines three practical things: who repairs it and where, whether antibiotics and laxatives are prescribed afterwards, and what follow-up you are offered. First and second degree tears are repaired in the birth room and generally need no special follow-up beyond your routine postnatal check. Third and fourth degree tears are repaired in an operating theatre, and you should be offered a dedicated review — often in a specialist perineal clinic — and an onward discussion about future births. If no one told you your grade, ask. It is written in your notes, and you are entitled to know.

Episiotomy versus a spontaneous tear

An episiotomy is a deliberate surgical cut into the perineum made at the moment of crowning; a spontaneous tear is what the tissue does on its own. In depth they are comparable — a standard episiotomy is equivalent to a second degree injury — but an episiotomy produces a clean, controlled, predictable wound, whereas a spontaneous tear follows the path of least resistance and can be irregular.

Episiotomies are no longer performed routinely. Current practice is restrictive: the cut is made only when there is a clinical reason. The usual reasons are an assisted birth with forceps or ventouse, concern about the baby's heart rate that means the birth needs to be completed quickly, or a perineum that is clearly about to tear badly in a direction that would involve the sphincter. You should be told what is being proposed and why, and your consent should be sought, even in a hurried moment.

Technique matters more than most people realise. A mediolateral episiotomy — angled away from the midline, aiming at roughly sixty degrees from the vertical at the moment the perineum is stretched — moves the line of the cut away from the anal sphincter. A midline cut, still used in some countries, is more likely to extend into the sphincter if the tissue gives way. Where an episiotomy is used during a forceps birth, the mediolateral angle is a deliberate protective measure.

In recovery, the two feel broadly similar, although an episiotomy sometimes feels tighter and more bruised in the first week because it cuts through muscle in a straight line. Both are repaired with the same dissolvable sutures, both are sore when you sit, and both heal on a similar timetable. A cut is not automatically worse than a tear, and a tear is not automatically more "natural" in a way that protects you — what matters is depth, whether the sphincter is involved, and whether the repair is done well.

How a perineal tear is repaired, and what anaesthesia is used

Most tears are stitched within the first hour after birth, using absorbable sutures and local anaesthetic, in the room where you gave birth; tears involving the anal sphincter are repaired in an operating theatre under a spinal or epidural anaesthetic. The aim is the same in both settings: to bring the torn layers back into their correct position so they heal as one, and to control bleeding.

When stitches are needed

A graze or a first degree tear that is not bleeding and whose edges lie together may be left to heal on its own — stitching it would add pain without adding benefit. A first degree tear that is bleeding or gaping, and essentially all second degree tears, are sutured. The modern technique uses a continuous, non-locking stitch through the vaginal tissue, muscle and skin, with a rapidly absorbing synthetic thread, because this is associated with less short-term pain than older interrupted techniques and older suture materials.

What anaesthesia is used

If you have an epidural in place, it is topped up. If you do not, local anaesthetic is injected into the perineum before any stitching begins, and more can be added at any point — tell the person repairing you if you can feel anything sharp, because the answer is simply more anaesthetic, not endurance. Inhaled analgesia can be used alongside. You should not be expected to feel the repair.

Your baby during the repair

A repair in the birth room does not have to separate you from your baby. Skin-to-skin contact can usually continue throughout, and many women feed during the stitching; if you would rather not, your partner can hold the baby next to you. Say what you would prefer, because it is easy to assume a decision has been made for you when in fact no one has asked. At the end of the procedure the team counts swabs and needles and documents what was repaired — the record of that count and of the layers repaired is what any later clinician will read, which is another reason to ask for your notes if you are unclear about what was done.

Repair of a third or fourth degree tear

A sphincter injury is repaired in theatre for good reasons: regional anaesthesia relaxes the muscle so the torn ends can be drawn together without tension, the lighting and instruments are better, and the repair is carried out by a clinician specifically trained in it. The internal and external sphincters are identified and repaired as separate structures, the torn ends of the external sphincter joined either end-to-end or with an overlapping technique. Afterwards you would normally be given a course of antibiotics, laxatives to keep stool soft while the repair knits, pain relief, and a follow-up appointment.

Do the stitches need removing?

No. The thread used is designed to dissolve, usually over about two to six weeks. It is normal to find small fragments of suture on a pad or on the toilet tissue as they loosen — that is the material breaking down, not your repair falling apart. The knots are the last part to go and can feel like tiny sharp points for a while.

Healing timeline: what to expect week by week

The sorest period is the first one to two weeks, most of the surface healing is complete by two to three weeks, dissolvable stitches have usually gone by six weeks, and the deeper tissue continues to remodel for several months. Healing is rarely a straight line, but the overall direction should be one of improvement.

Days one to three. Swelling and bruising are at their peak, and the perineum often feels hot, heavy and tight. Sitting directly is uncomfortable. Passing urine stings, particularly if there is a graze near the urethra. This is the window in which cold packs are most useful and in which regular, scheduled pain relief makes the biggest difference.

Week one. Swelling starts to settle and the pulling sensation becomes more noticeable than the burning. Walking short distances is usually comfortable; standing or sitting for long periods is not. Many women feel a dragging sensation when they stand for too long, which is the pelvic floor telling you it needs a rest rather than a sign of damage.

Weeks two to three. The skin edges have generally sealed. Itching is common now and is usually a healing sign. Stitches begin to dissolve and may feel scratchy. You should be noticeably more comfortable than in week one — if you are not, or if pain is increasing, that needs assessment rather than patience.

Weeks four to six. Most women can sit normally, walk for longer and manage daily life without regular painkillers. At your postnatal check the perineum can be examined if you have any concerns; you do not have to wait to be asked. Bleeding has usually finished or nearly so by this point.

Three months and beyond. Scar tissue continues to soften and reorganise for months. A tight band, a slightly altered sensation, or tenderness at one specific point in the scar is common at three months and often improves further. Recovery after a third or fourth degree tear follows the same surface timetable but the functional recovery of the sphincter takes longer, which is exactly why dedicated follow-up is offered.

What can make healing slower. A deeper tear takes longer than a graze, but several other things lengthen the curve: an infection in the wound, anaemia after a heavy blood loss, diabetes that is not well controlled, a very low body weight or a diet short on protein, constipation that repeatedly strains the repair, and smoking, which reduces the blood supply that healing tissue depends on. None of these mean the wound will not heal; they mean it needs more time and more attention, and they are worth raising at your postnatal visits rather than assumed to be unavoidable.

What pain is normal, and what is not

Normal perineal pain is worst in the first few days and improves steadily after that; pain that increases after day three or four, or that becomes throbbing and severe, is not normal and needs to be examined. The trend over days matters more than the level on any single day.

Expected sensations include stinging when urine passes over the wound, a bruised ache when you sit or stand up from sitting, a pulling or tight feeling when you walk or lift your legs, and itching as the skin heals and the sutures dissolve. A sense of swollen heaviness in the first week is also expected. None of these should stop you from walking to the bathroom, feeding your baby or sleeping between feeds.

For pain relief, paracetamol and an anti-inflammatory such as ibuprofen are the usual first choices and are generally compatible with breastfeeding; aspirin is avoided while breastfeeding. Take them regularly for the first few days rather than waiting until the pain is severe, and tell your midwife or doctor if they are not enough, since stronger options exist and the need for them is itself useful information. Do not use pain relief to push through a pain that is getting worse — find out why it is getting worse first.

Pain out of proportion to the injury, pain with fever or an offensive smell, and pain that worsens suddenly after the first week each have a specific cause — a haematoma under the repair, infection, or separation of the wound edges — and the warning signs that point to each are set out in the red-flag list below. What they have in common is that none of them follow the expected pattern of steady improvement.

Perineal pain is also routinely under-reported, partly because it feels like something to be endured and partly because the conversation at a postnatal visit tends to be about the baby. If you are asked how you are and the honest answer is that sitting still hurts at three weeks, say so. It is a clinical question with clinical answers, not a complaint.

Pain that is still significant at three months, or deeper pelvic pain that is not clearly coming from the scar, deserves proper assessment rather than reassurance alone — the causes and investigation of ongoing pelvic pain in women extend well beyond the perineum.

Wound care at home: hygiene, ice and positioning

Perineal wound care is deliberately simple: keep the area clean and dry, change pads often, use cold in the first days, avoid sitting directly on the wound for long stretches, and leave the stitches alone. There is no antiseptic, cream or bath additive that has been shown to make a perineal wound heal faster, and some of them irritate the skin.

• Wash simply. A daily shower, or warm water poured over the perineum, is enough. Avoid scented soaps, bath additives, antiseptic solutions and douching. Pat dry with a clean towel from front to back rather than rubbing.
• Change maternity pads every few hours, and wash your hands before and after. A damp pad kept on for hours is the main avoidable cause of skin irritation and odour in the first week.
• Use cold in the first two to three days. A cold pack or crushed ice wrapped in a clean cloth, applied for about ten to twenty minutes at a time with breaks in between, reduces swelling and numbs the area. Never place ice directly on the skin.
• Rinse while you pass urine. Pouring warm water over the perineum as you urinate, or urinating in the shower, dilutes the urine and stops the stinging; drinking well has the same effect.
• Take the pressure off. Lie on your side to feed and to rest. When sitting, use a soft cushion and shift position often. Avoid sitting on a ring-shaped cushion for long periods, as it can pull the wound edges apart.
• Let air reach the wound. Ten minutes lying with a towel underneath and no pad, once or twice a day, helps. Wear cotton underwear and loose clothing.
• Start gentle pelvic floor squeezes early, as soon as they are comfortable. Beyond strengthening, they improve circulation to the area and help swelling settle.

Things to avoid in the early weeks: tampons or menstrual cups, swimming pools until bleeding has stopped and the wound is healed, heavy lifting beyond your baby, and strenuous abdominal or high-impact exercise. Smoking impairs wound healing anywhere in the body, and the perineum is no exception.

Opening your bowels without fear

Opening your bowels will not pull your stitches apart, and the greater risk is the opposite — delaying it until the stool is hard. The fear is almost universal and entirely understandable, and the first bowel movement is often more anxiety than pain. The plan is to make the stool soft and the process unhurried.

Drink plenty of fluid, particularly if you are breastfeeding, and keep fibre in your diet — fruit, vegetables, pulses and wholegrains. Iron tablets, often started after a blood loss at birth, are constipating, so mention this if you have been prescribed them. A stool softener or gentle laxative is commonly used in the first weeks, and after a third or fourth degree tear it is standard rather than optional: the repair needs to knit without being stretched by hard stool.

When you go, give yourself time and privacy. Rest your feet on a small footstool so your knees sit above your hips, lean forward with your elbows on your knees, and let your abdomen relax outward rather than bracing it. Breathe out steadily rather than holding your breath and bearing down. If it helps, hold a clean pad gently against the perineum for counter-pressure — this supports the wound and makes most women feel safer. Do not strain, and do not sit for twenty minutes willing it to happen; stand up and try again later.

Haemorrhoids are common after birth and can hurt more than the tear itself. Soft stool, cold compresses and topical preparations from a pharmacist usually settle them within a few weeks.

Tell your midwife or doctor if you have not opened your bowels by about three to four days, if the attempt is very painful, or if you are leaking stool or unable to control wind. Leaking wind or stool after a vaginal birth is never something to live with quietly — it is treatable, and it is far easier to treat early.

Signs of infection or wound breakdown that need same-day review

Contact your midwife, doctor or maternity unit the same day if the pain is increasing rather than easing, the discharge smells offensive, you have a fever, or the wound looks as though it is opening. A perineal wound infection is straightforward to treat when it is caught early and far harder once the tissue has broken down.

• Pain that is getting worse after the first three or four days, rather than better
• Vaginal or wound discharge with an offensive smell, or discharge that becomes thick, green or yellow
• A temperature, shivering, chills, or feeling generally unwell and flu-like
• Increasing redness, hot skin spreading around the wound, or new swelling
• A sensation that the stitches have given way, a visible gap in the wound, or tissue that looks as though it is separating
• Severe one-sided throbbing pain with a tense swelling, which may indicate a collection of blood
• New leaking of wind or stool, or being unable to control a bowel movement
• Passing wind, stool or offensive brown fluid from the vagina rather than from the back passage — this needs urgent review, as it can mean an abnormal connection has formed between the back passage and the vagina
• Difficulty passing urine, a burning that is worsening rather than settling, or needing to strain to start

Seek emergency care — do not wait for a phone call back — if you cannot pass urine at all, if you are bleeding heavily and soaking a pad within an hour or passing large clots, if you have a high fever with shivering and feel very unwell, if you have severe pain that pain relief does not touch, or if you have chest pain, breathlessness, or pain and swelling in one calf.

Two points are worth stating plainly. First, a wound that opens is not a disaster and does not always need re-stitching — many are allowed to heal from the base upwards with careful hygiene, and the final result is usually good. Second, you do not need to apologise for asking someone to look. Perineal wounds are examined routinely by midwives and doctors, and an examination is the only way to answer the question.

Pelvic floor recovery and physiotherapy

The pelvic floor needs rehabilitation after any vaginal birth, and more so after a tear — start gentle pelvic floor exercises as soon as they are comfortable, usually within the first few days, and continue them for months rather than weeks. The muscle has been stretched, sometimes torn, and like any muscle it recovers with graded, consistent use.

To do the exercise correctly, imagine stopping yourself from passing wind and drawing the vaginal opening gently upwards and inwards, without squeezing your buttocks, tightening your thighs or holding your breath. Begin with short squeezes of a second or two, several in a row, a few times a day, and build gradually towards holds of several seconds with full relaxation in between. Relaxation matters as much as contraction: a pelvic floor that is held permanently tight is weak in a different way, and that pattern is a common source of later discomfort.

In the first day or two, the bladder deserves specific attention. Swelling, an epidural that has not fully worn off and the fear of stinging all make it easy to pass only small amounts while the bladder stays partly full, and a bladder that is repeatedly overstretched recovers slowly. Pass urine regularly rather than waiting for the urge, and tell your midwife if you are passing only small volumes, if you cannot tell when your bladder is full, or if you are dribbling constantly — being unable to empty properly is a problem that is simple to manage early and much less simple later.

Ask to be referred to a pelvic health physiotherapist if you had a third or fourth degree tear, an assisted birth, or if you have any of these symptoms beyond the first few weeks: leaking urine when you cough, laugh, lift or run; a sudden urgency you cannot defer; leaking wind or stool; a feeling of heaviness, dragging or a bulge in the vagina; or pain with penetration. Many units refer automatically after a sphincter injury, and in some countries you can refer yourself.

A physiotherapist does more than teach squeezes. They assess whether you are actually recruiting the right muscle, check for muscle overactivity and scar restriction, work on coordination with breathing and lifting, and guide the return to running and heavier exercise — which for most women is a matter of months, not weeks.

Pelvic floor weakness is also the pathway to later problems, which is why early rehabilitation matters even if you feel fine; the symptoms and stages of pelvic organ prolapse are much easier to address when they are recognised early rather than years later.

Sex after a perineal tear: when does it stop hurting?

There is no fixed date — most couples resume sex somewhere between six weeks and several months after birth, and the sensible markers are that bleeding has stopped, the wound is no longer tender to touch, and you actually want to. Going back to penetrative sex because a six-week appointment has happened is the commonest reason for the first attempt to hurt.

Expect the first time to feel different. Scar tissue is less elastic than the tissue it replaced, and a tight band at the vaginal opening is common for the first months. If you are breastfeeding, oestrogen levels are low and vaginal dryness is nearly universal, which makes friction and soreness much more likely. A generous amount of a water-based lubricant is not a sign of failure; it is the single most useful thing most couples change. Take your time, choose a position that lets you control depth, and stop if it is sharply painful rather than pushing through — pain teaches the pelvic floor to guard, and guarding then causes more pain.

The non-physical side matters as much. Exhaustion, broken sleep, a body that feels unfamiliar, and the memory of a birth that may have been frightening all affect desire, and none of them are solved by a date on a calendar. It helps to agree with your partner that intimacy does not have to mean penetration for a while, and that stopping is allowed without it being a failure or a rejection. Most couples find this settles over months; if it does not, or if the birth itself keeps intruding on your thoughts, that is worth raising at a postnatal appointment, because support exists for it.

If penetration is still painful after three months, it should be assessed rather than endured. Examination can distinguish between a tender scar band, pelvic floor muscle overactivity, dryness from low oestrogen, and deeper pain that has nothing to do with the perineum. Treatment is usually some combination of pelvic floor physiotherapy, scar massage and desensitisation, and sometimes topical vaginal oestrogen while breastfeeding. Where fear and reflex muscle tightening have become the main barrier, the approach overlaps closely with treatment for vaginismus, which usually responds well to a structured programme rather than being something you have to wait out.

One practical point that is easy to forget: fertility can return before your first period, including while breastfeeding, so contraception should be discussed before you resume sex. All the main methods, including the full range of intrauterine devices, can be used after a perineal tear once healing is complete, and insertion timing can be planned around your recovery.

Can perineal tears be prevented? What the evidence supports

No approach removes the possibility of tearing, but several measures are supported by evidence and are worth discussing with your team before labour. The honest summary is that these shift the odds rather than deliver a guarantee, and that much of what determines tearing — your baby's size, position and the speed of the final moments — is outside anyone's control.

Antenatal perineal massage. Massaging the perineum from around thirty-four to thirty-five weeks, a few times a week, is associated with a lower chance of perineal trauma requiring suturing and of episiotomy, particularly in a first pregnancy. It is done by you or your partner, with a plain oil, using gentle sustained stretching rather than vigorous rubbing. It is not advised if you have an active genital infection or have been told not to.

Warm compresses and perineal support during the birth. A warm compress held against the perineum as the head is crowning, and a hands-on technique in which the midwife or doctor supports the perineum while gently controlling the speed at which the head is born, are both supported by the evidence and are standard practice in many units.

A slow, controlled birth of the head. This is where communication matters most. Being able to hear and follow the instruction to stop pushing and to breathe or pant through the final contractions allows the tissue time to stretch. Discuss beforehand that you want to be guided at that moment.

Restrictive, correctly angled episiotomy. Routine episiotomy is not recommended. When one is clinically needed, particularly during a forceps birth, a mediolateral cut made at the correct angle is a protective measure against sphincter injury.

Position. Evidence on birth position is mixed, and no single position reliably prevents tearing. What is reasonable is to avoid being fixed flat on your back with your legs in stirrups unless there is a clinical need, and to keep the option of changing position. These are useful things to raise during routine pregnancy follow-up appointments rather than for the first time in labour.

If you have had a third or fourth degree tear before

Most women who have had a sphincter injury can have a vaginal birth next time, and the decision is made individually. The discussion should cover whether you have any symptoms now — leaking wind or stool, urgency, or pain — and in some units an assessment of the sphincter with ultrasound and pressure measurement. If you have symptoms or evidence of a significant residual defect, a planned caesarean may be recommended. If you are well and the sphincter has healed, a vaginal birth with careful perineal protection is a reasonable choice. What matters is that this is a planned conversation during pregnancy, not a decision made in labour.