What Is a Perineal Tear?

A perineal tear is a bit of an all encompassing term referring to tears that can occur during a vaginal birth. These tears can involve, as the name suggests, the perineum (the bit between your vagina and your anus), the vagina, the vulva and rarely in more severe cases, the anus. Whilst in theory there are four neat categories of perineal tear (discussed in more depth further below), in practice there is more variety and perineal trauma after birth might not fit neatly into one of these categories.

According to the Royal College of Obstetricians and Gynaecologists (RCOG) up to 9 in 10 women and birthing people will sustain some form of perineal trauma following a vaginal birth. The majority of these will be considered minor (first and second degree tears). Overall between 3-4% of women will sustain a more severe perineal tear (third and fourth degree tears, also called obstetric anal sphincter injuries or OASI). However the chance of a severe tear differs depending on if it’s your first baby (6%) or a subsequent baby and you haven’t had a severe tear before (2%). In the UK, just under 25% of women will have an episiotomy, which is surgical cut to the perineum during birth.

There can be a lot of focus on how to avoid perineal tears and there are several devices out there making bold claims about being able to prevent them - but given that the overwhelming majority of women and birthing people will experience perineal trauma of varying degrees, it makes sense to understand a bit more about them and how to care for them if you do experience one.

The Four Degrees of Perineal Tears (and Episiotomies!)

For a diagram of perineal tears see the RCOG website.

First-Degree Tears

First degree tears are superficial and only involve the skin of the perineum - they don't extend into any muscle. These are the ‘mildest’ type of tear and often heal within a week or two, usually without any stitches. Some first degree tears are so minor they're barely noticeable and might be described to you as a graze. You might not have any discomfort, or you might notice that it stings quite a bit in the first few days, particularly when weeing - and that can depend on where the tear is. NICE guidelines recommend suturing first degree tears to ‘improve healing’ - however this doesn’t appear to be backed by strong evidence.

Second-Degree Tears

Second degree tears involve the muscle of the perineum and may also involve the skin. These are the most common type of perineal trauma, and cover quite a wide range in terms of severity - some are quite small and shallow, others are deeper and more extensive. Healing time can vary, but most second degree tears heal within 4-6 weeks. The level of discomfort or pain with a second degree tear varies from person to person. We’ll talk more about whether these need stitches later on, as it's a bit more nuanced than the other categories.

Third-Degree Tears

Third degree tears extend to the muscles that surround the anal sphincter, known as the external anal sphincter (EAS). These are further subcategorised into 3a, 3b and 3c depending on how much of the sphincter thickness is torn - 3a being less than 50%, 3b being more than 50%, and 3c involving the internal anal sphincter (IAS) too. Third degree tears need repairing in theatre by a doctor, under regional anaesthesia (e.g. an epidural), and healing takes longer - usually several weeks to a few months. You should be offered follow-up care from a specialist team and often physiotherapy is recommended too, to support the pelvic floor and sphincter function as it heals.

Fourth-Degree Tears

Fourth degree tears extend into the anal sphincter complex (both the external and internal anal sphincter) and also into the lining of the rectum (the rectal mucosa). These are the most severe form of perineal trauma and, like third degree tears, are repaired in theatre by a doctor under regional anaesthesia. Recovery is typically longer and follow-up with a specialist perineal clinic alongside pelvic health physiotherapy is standard care.

More on Third and Fourth Degree Tears

Most women will heal well after a third or fourth degree tear and not experience any lasting issues, however some may experience longer-term symptoms such as pain, incontinence, or pain during sex. This is why specialist follow-up and pelvic health physiotherapy are so important, and why it's worth flagging any ongoing symptoms rather than assuming you should just push through them. Having a third or fourth degree tear (and the potential effects of these injuries) can be very distressing and some women can find their mental health is affected or in more serious cases, even develop PTSD following their birth. If you’ve been affected by a severe perineal tear, MASIC is a charity offering support and a wealth of information and resources to support you.

If you’ve had a third or fourth degree tear before, your chance of having one again is similar to someone who hasn’t given birth before - that’s to say your risk doesn’t increase but it also doesn’t reduce in the same way that someone who hasn’t had a previous 3rd degree tear does. In a subsequent pregnancy, you will however be offered the choice of planning a caesarean birth to eliminate the risk entirely, especially if you have experienced any complications as a result of your tear. That may feel right to you - but caesarean births carry several other risks so you have to weigh up the pros and cons.

Planning to birth at home has been found to reduce the risk of sustaining a third or fourth degree tear by more than 40%. This figure applies even where women did not actually give birth at home, but planned to. One of our clients had a home birth after a previous 3rd degree tear - click the button below to read her story!

Episiotomy

Just under 25% of women have an episiotomy in the UK, although the figure varies between NHS Trusts. You can find out what your local NHS Trust’s episiotomy rate is by submitting a Freedom of Information (FOI) request. An episiotomy is a surgical cut through the skin and the muscle, usually to the right side of the perineum during childbirth (right mediolateral in medical speak). An episiotomy widens the birth canal and is generally used when an instrumental assisted vaginal birth is occurring (forceps or ventouse) or when there are concerns with the fetal heart rate and it’s thought that the baby needs to be born quickly. They should always be done with your consent and only be done when birth is imminent - so for example, you shouldn’t have an episiotomy cut when the baby’s head isn't visible.

Sometimes it’s recommended that you should have an episiotomy to reduce your risk of having a third or fourth degree tear - however there isn’t evidence for this when looking at unassisted vaginal births and episiotomies can even extend to third or fourth degree tear in some scenarios. If you have an episiotomy then you are guaranteed to sustain perineal trauma where you otherwise might not have, or where you might have sustained a significantly milder form of trauma. So, that rationale doesn’t wash with us. As Rachel Reed puts it, “having an episiotomy during a non-instrumental vaginal birth would be trading a 2%* chance of significant tearing with 100% chance of perineal damage via a cut.”

*The figure is overall 3-4% in the UK - but you get the point!

For instrumental assisted births on the other hand - episiotomies have been found to reduce the chance of severe perineal trauma. Midwives or doctors can perform episiotomies, but as we said…this should always be with your explicit consent and always with good reason.

Now, not going to lie to you…episiotomies can feel quite gnarly as they’re healing. You might feel swollen and raw and it will take a few weeks to heal. Episiotomies can cause sex to be painful, some women develop scar tissue and experience long term discomfort or pain as a result of their episiotomy. It’s vital to seek support from a pelvic health specialist who will be able to offer you advice and techniques to hopefully improve any pain or discomfort.

Do All Tears Need Stitches?

In the UK dissolvable stitches are used for the repair of perineal tears and these will dissolve on their own within a few weeks - so there’s no need to have them removed by a healthcare professional. Stitches can cause some localised feelings of irritation, tightness and itching as they’re healing.

NICE recommends suturing first degree tears if the edges don’t align - however in our own clinical practice, we very rarely if ever needed to suture a first degree tear. They’re usually so superficial and it’s likely that adding stitches will cause more trauma, pain and bleeding. The exception to the rule would be if you had a first degree tear that was bleeding that wasn’t being solved with pressure or perhaps the edges were very misaligned. Third and fourth degree tears need suturing to bring all the layers back together so it can heal properly. Where a severe tear is identified correctly, they are repaired in theatre under regional anesthesia (e.g. an epidural or spinal) and by doctors. Episiotomies also are always sutured, because they’re a deep cut with straight edges that need to be brought together. They always go into the muscles of the perineum and they can bleed. Episiotomies are sometimes compared to second-degree tears because they both go into the muscle, but we would argue that an episiotomy is very different to a second degree tear - as they are always deep and always cut through the perineal body, whereas there is significantly more variety with a natural second degree tear. If you have any tears on your vulva, for example a labial tear - this may need stitches to bring it back together primarily for aesthetics or if it’s bleeding.

The debate with suturing lies with second degree tears - do they all need suturing? There was a Cochrane review in 2011 asking this question that ultimately concluded there was no difference in pain or healing time in the immediate postnatal period and up to 8 weeks following birth between those who had sutures and those who did not. This review ultimately only looked at 154 women, so much more research is needed to gain a better understanding and to look at other outcomes related to having stitches or not having stitches.

When Suturing Is Recommended

We would recommend suturing a second degree tear in the following circumstances:

• The tear is actively bleeding - stitches will help to stop this.
• The edges of the tear do not come together by themselves or there is gaping when the legs are parted.

NICE recommends that the muscle should always be sutured, but that if the edges of the skin align, the skin doesn’t necessarily need stitches.

When a Tear Can Heal Without Stitches

Stitches may not have much benefit in the following situations:

• The tear isn’t actively bleeding.
• The edges line up neatly and it looks ‘closed’ when the legs are together.

Even if the above criteria are met - in our practice we'll still discuss the option of having stitches or not, going through the potential pros and cons of both so that you can make the choice that feels right for you.

What Affects Healing Time?

There's no single timeline that applies to everyone, but a few things tend to influence how quickly a tear heals and how it feels along the way:

• Degree of the tear - as a general rule, the more extensive the tear, the longer the healing process, though this isn't always a straight line.
• Whether it was sutured - stitches can help bring tissue together to support healing, but the presence or absence of stitches alone doesn't determine how long recovery takes.
• Infection - this can significantly slow healing and needs prompt treatment, which is why watching for the signs (see below) matters.
• Nutrition and hydration - your body needs the building blocks to repair tissue, so eating well and staying hydrated genuinely helps.
• Mobility and rest - a balance of gentle movement (to support circulation) and rest (to avoid overdoing it) tends to help most people.
• Individual factors - things like smoking, certain health conditions (e.g. diabetes), and general health can all play a role in how well and how quickly tissue repairs itself.

Caring for a Perineal Tear at Home

Whether you’ve had stitches or not for your tear or episiotomy, it’s important to think about the following:

• Keep it clean - shower every day, use a peribottle or a squirty bottle to wash it when you use the toilet, consider sitz baths and change your maternity pads every few hours.
• Keep it dry - after showering, using the toilet or having a sitz bath, pat the tear dry gently with a clean towel or paper towels.
• Get some air to it - spend at least 10-15 minutes a day with your undies off, lying on a towel allowing air to get to your perineum
• Ice it - applying an ice compress to your perineum can help reduce any swelling. This could look like a soaked and frozen maternity pad or Dr Melanie Jackson of the Great Birth Rebellion suggests filling condoms with water and freezing a few so you have some handy ice packs at the ready. Never apply the ice directly to your skin (wrap it in a clean tea towel, for example) and use for 10-15 minutes.
• Avoid sitting directly on it - depending on your tear, you might find sitting very uncomfortable in the first week or so. Using a doughnut pillow can be helpful to take any pressure off your perineum if you are sitting. And if you’re breastfeeding, seeking support to find a position that’s comfortable for you can be a good shout too - laid back or side-lying position are great options.
• Avoid constipation - mostly because it’s uncomfortable, you want to aim for soft poos that you can pass easily, so you’re not straining. You’re unlikely to open your stitches but the fear of doing that can make people avoid the toilet. It might be helpful to press a wad of toilet paper or a clean pad on your perineum when you do poo to add a bit of counter pressure and support. Keep well hydrated, eat the high fibre foods you know normally help you go, put your feet up on a little step or stool when you’re sitting on the toilet and breathe deep into your belly - avoiding straining if possible. If you’ve had a third or fourth degree tear you should be prescribed laxatives as standard to soften your poos, but even if you haven’t had a severe tear but are someone who does historically suffer with constipation it might be sensible to have laxatives on hand as a back up. Your GP can prescribe them or you can buy them from a pharmacy.
• Observe for signs of infection: increasing pain, smelly discharge or bleeding, feeling generally unwell. These would be indications to call your local maternity triage and have your tear looked at. If infection is suspected the recommendation is antibiotics. Infection can delay healing and make you feel really unwell - so if you have any concerns, flag them early.
• If you have pain it’s safe to take paracetamol and ibuprofen (as per packet instructions) even if you’re breastfeeding. However, if pain medication isn’t helping or the pain is getting worse you should contact your midwife or local maternity triage.
• Consider using a mirror to observe the healing of your perineal tear - whether you’ve had stitches or not a handheld mirror can help you understand the type of trauma you’ve had and you’ll be able to see how it’s healing. Alternatively you could take (or ask your partner to take) a photo of it to observe its healing. Your midwife should offer to check your tear at any postnatal appointment you have too.

When to Contact Your Midwife

If you have any signs of infection or any concerns about how your tear is healing or your pelvic wellbeing after your birth, you should contact your midwife. If you’ve got a private independent midwife (like us!), we’re practically on speed dial for you. If you’re under the NHS how you contact your midwife team will vary from trust to trust, but if you’re unable to get hold of them or you’re very concerned about your tear you can phone your local hospital’s maternity triage for advice.

Perineal Tear Support from Juno Midwives

There are a number of ways we can support you following a perineal tear. If you've had a homebirth with us, we offer to check your perineum after birth to assess for any tears. We’ll discuss what we can see with you and then explain your options. If we suspect you’ve had a third or fourth degree tear, or if your tear is otherwise complex, we would recommend transfer to hospital for a doctor's review and repair of your tear. If you’ve had a second degree tear and you do opt for stitches, we can suture at home with local anaesthetic. Or if you choose to not have stitches we’ll respect your choice. At your subsequent postnatal appointments, we’ll offer to check your tear to monitor its healing. We can also signpost you to NHS and private services that offer specific support for your pelvic floor after giving birth.

Hopefully this post has demystified perineal tears for you and given you some guidance on what to do if you do experience one. Knowledge is power!