Perineal tears happen in the majority of vaginal births. The degrees, the stitches, the healing, the scar — and what comes after — are almost never discussed honestly beforehand. This guide covers everything: what the degrees actually mean, how to recover well, what specialist care for serious tears involves, and the longer-term picture that most postnatal guidance skips.
🌸 Open WiseMama — freePerineal tearing — where the skin and tissue between the vaginal opening and the anus stretches or splits during the baby's delivery — happens in the majority of vaginal births. Around 85% of women who give birth vaginally will experience some degree of perineal trauma. The classification system can sound alarming, so it is worth understanding what each degree actually involves.
A superficial tear affecting only the skin. It may bleed a little and be sore, but often does not require stitching — the edges may be left to heal on their own. Heals relatively quickly, typically within a few weeks, and rarely causes ongoing problems.
The most common tear requiring repair. It extends into the perineal muscle beneath the skin but does not reach the anal sphincter. It is stitched using dissolvable sutures under local anaesthetic — usually in the delivery room shortly after birth. Most women with second degree tears recover well within 3–6 weeks, though some soreness and tightness can persist longer.
A third degree tear extends into the anal sphincter — the ring of muscle controlling bowel control. It is further classified by depth:
The most extensive tear, extending through the anal sphincter and into the rectal mucosa — the lining of the rectum. Third and fourth degree tears together are called OASI — Obstetric Anal Sphincter Injuries. They affect approximately 3% of all vaginal births overall, and around 6% of first vaginal births.
Tears can also occur in the labia or around the urethra (the urinary opening). These are painful and can cause urination difficulty in the first days but typically heal well without complication. They sit outside the standard degree classification but are worth knowing about.
The degree alone doesn't determine how much pain you'll be in or how long recovery will take. A significant second degree tear can be more uncomfortable than a minor third degree in the early days. Individual experience varies considerably — don't compare your recovery to someone else's degree.
An episiotomy is a surgical cut to the perineum made during the pushing stage of labour to widen the vaginal opening. In the UK, NICE guidance states that episiotomy should be performed selectively — not routinely — and only when there is a clinical indication.
The main indications are: instrumental delivery (forceps or ventouse, which require more space); signs of fetal distress requiring rapid delivery; a perineum that appears likely to tear badly in an uncontrolled way; and sometimes in shoulder dystocia (where the baby's shoulder is stuck). For most straightforward vaginal deliveries, episiotomy is not indicated or necessary.
UK practice uses a mediolateral episiotomy — the cut is made at approximately a 60-degree angle away from the midline. This direction reduces the risk of extension toward the anal sphincter compared to the midline episiotomy used in some other countries. A correctly positioned mediolateral episiotomy should not increase the risk of OASI; a poorly positioned one may.
You should be asked for consent before an episiotomy is performed. In a non-emergency situation, there should be time to explain that an episiotomy is being recommended and why. In a genuine emergency — rapidly deteriorating fetal heart rate, for example — consent may be sought simultaneously with the procedure. If you feel an episiotomy was performed without adequate explanation or consent, this is worth raising — with your midwife, via PALS at your trust, or with a Birthrights adviser.
Episiotomies are stitched in the same way as second degree tears and recover over a similar timeline — though the cut nature of the wound rather than a natural tear can mean different healing dynamics, and some women find episiotomy scars cause more ongoing tightness than natural tears of comparable severity. Scar massage (from 6 weeks) is particularly useful for episiotomy scars.
The immediate postnatal period with a perineal tear or episiotomy involves managing pain, hygiene, and the practicalities of basic functions that are suddenly much harder than they used to be. Most of this is not discussed beforehand — and it should be.
Being in significant perineal pain makes everything harder — feeding, moving, sleeping, caring for your baby. Regular paracetamol and ibuprofen (if you are not contraindicated — check if breastfeeding), taken on a schedule rather than waiting until pain becomes severe, are the most effective first-line approach. In the first 24 hours, a diclofenac suppository is often offered by midwives — it provides excellent targeted pain relief and is worth accepting.
Cold helps enormously in the first 48 hours. Maternity ice packs, cold gel pads, or ice wrapped in a cloth applied to the perineum reduce swelling and numb the area. Do not apply ice directly to the skin.
Urination in the first days can sting significantly, particularly if there are any labial or periurethral tears. Pouring a jug of warm water over the perineum while urinating dilutes the urine and significantly reduces the sting. Take the jug to the toilet with you. This simple measure makes an enormous difference and is not always mentioned by midwives. Ensure you are urinating within 6 hours of birth — difficulty urinating may need monitoring.
The first bowel movement after a perineal repair is genuinely feared by most women who have one, and the fear is understandable. In practice it is rarely as bad as anticipated, but there are things that help: stool softeners (lactulose is standard, ask for it if not offered), drinking plenty of water, and eating fibrous foods rather than avoiding food to delay the inevitable. Do not hold on — constipation makes everything worse. Leaning forward on the toilet rather than sitting upright can help. Supporting the perineum gently with clean pad or toilet paper while bearing down can reduce anxiety and discomfort.
Stitches dissolve on their own — they do not need to be removed. They typically dissolve within 3–6 weeks. Some women feel the stitches as an intermittent prickling or tugging sensation as they dissolve, which is normal. You may see stitch material in the bath or on a pad — this is also normal. If you notice a stitch that appears to be causing a persistent point of pain or the wound appears to be opening, contact your midwife or GP.
Keep the area clean with warm water — baths and showers are both fine and encouraged. Pat dry rather than rubbing. Change maternity pads regularly. There is no need for any specific antiseptic preparation unless your midwife advises otherwise. Salt baths are soothing and traditionally recommended, though evidence for their therapeutic benefit beyond comfort is limited — if they help, use them.
Increasing rather than decreasing pain after the first few days; wound that appears to be opening, smells unpleasant, or has unusual discharge; fever above 38°C; significant swelling or bruising developing after 48 hours rather than reducing; or any new difficulty controlling your bladder or bowels (beyond normal early postpartum changes). These may indicate infection or wound breakdown — both treatable, but needing prompt attention.
Obstetric Anal Sphincter Injuries — third and fourth degree tears — are significantly more serious than first and second degree tears, and they deserve significantly more information and care than they are often given. If you have had an OASI, this section is for you.
OASI repair is performed in theatre, under regional or general anaesthetic, by an obstetrician (not a midwife) with specific training in sphincter repair. The repair is layered — sphincter muscle, then deeper tissue, then skin — using specific suture techniques. The quality of the repair matters significantly for long-term outcomes, which is why it must be done by a trained surgeon in a proper surgical environment rather than in the delivery room.
Following OASI repair, you will typically receive: stool softeners and laxatives for several weeks to keep stools soft while the repair heals; antibiotics to reduce infection risk; regular pain relief; and a catheter for 24 hours to rest the bladder and allow monitoring of urine output. Midwives and ward staff should be checking the repair regularly in the initial postnatal period.
Many women experience some urgency — a sudden strong need to open their bowels without much warning — and some experience leakage in the weeks following OASI. This is distressing but often improves significantly with time and physiotherapy. It does not mean the repair has failed, and it should be reported to your clinical team rather than borne silently.
You should be referred to a specialist clinic for follow-up at 6–12 weeks after an OASI. This appointment typically includes an internal examination to assess healing, a referral to or review by a specialist pelvic health physiotherapist, and in some centres an anorectal physiology assessment (a non-invasive test of sphincter function). If you are not contacted about a follow-up appointment within 4–6 weeks, contact your hospital directly and ask — this follow-up is part of your care, not optional.
The OASI Care Bundle — an NHS initiative — has improved care standards significantly in participating trusts. Pelvic health physiotherapy is the most important element of OASI recovery and should be accessed early.
The vast majority of women with well-managed OASI recover well. Ongoing significant symptoms — particularly faecal incontinence — occur in a minority, are more likely with severe injuries, and can often be improved further with specialist input. Recovery takes months rather than weeks and requires patience. Comparing your progress at 8 weeks to someone else's second degree tear serves nobody well.
Much postnatal information focuses on the first six weeks. The reality of perineal recovery often extends considerably beyond this — and the longer-term aspects are the ones most women feel least prepared for and least able to raise with healthcare professionals.
Healed perineal tears and episiotomies form scar tissue. Scar tissue is less elastic than the original tissue and can feel tight, tender, or different from the surrounding area — sometimes for many months after birth. This is normal, and it can be improved.
From approximately 6 weeks after birth — once the wound is healed — scar massage is recommended. This involves gently mobilising the scar tissue using clean fingers or a small amount of oil (coconut, vitamin E, or a specific perineal massage oil), initially just touching the area and gradually working up to gentle circular and stretching movements. The goal is to soften the scar and improve tissue mobility. It is not comfortable initially, but it becomes less uncomfortable as the tissue softens. A pelvic health physiotherapist can show you exactly how to do this effectively.
Painful sex after perineal repair is extremely common and almost never discussed. Studies suggest that up to 41% of women experience dyspareunia at 3 months postpartum, and a significant proportion continue to have difficulties beyond 6 months. It is not something to simply accept or push through — it is a treatable condition.
Common causes include: scar tissue tightness at the vaginal opening; reduced lubrication (particularly when breastfeeding, as oestrogen levels are suppressed); muscle tension and guarding secondary to the birth experience; and occasionally a repair that has healed in a way that requires further treatment. All of these have management options.
Adequate lubrication — a good quality lubricant, used generously — makes a significant difference to comfort. Pelvic health physiotherapy addresses both scar tissue and muscle tension. If sex remains painful beyond 3 months despite these measures, ask your GP for a referral. A small number of women need a Fenton's procedure — a minor surgical revision of the scar — to restore comfortable function. This is available on the NHS and is not a failure of healing; it is a recognised outcome that has a recognised solution.
A pelvic health physiotherapist — a physiotherapist with specific training in the pelvic floor and perineum — is the most valuable resource for perineal recovery beyond the immediate postnatal period. They can assess scar tissue, identify muscle tension or weakness, guide scar massage, advise on returning to exercise, and address painful sex. In many NHS areas, you can self-refer (ask your GP or health visitor); in others, you need a GP referral. You do not need to wait until the 6-week check to begin — if significant issues arise earlier, contact your GP.
Perineal injury after birth is rarely acknowledged as what it is: a physical injury to a part of the body that carries enormous personal, sexual, and psychological significance. The emotional response to that injury — shock, grief, anger, anxiety about future births, distress about changes to your body and your relationship — is real and valid, and it is frequently left unaddressed.
Being told "the important thing is you and the baby are healthy" is well-intentioned and also insufficient. A serious perineal tear is a significant physical trauma. The pain, the functional limitations, the changes to intimacy, the length of recovery — these are real losses alongside the arrival of a baby, and acknowledging them does not diminish the joy. Many women describe feeling guilty about their distress — as though injury to their body during one of the most significant experiences of their lives should be accepted without complaint. It should not. Your experience of this matters.
If you have had a serious tear — particularly an OASI — anxiety about future births is entirely understandable. This should be raised in advance of any subsequent pregnancy, ideally at a preconception appointment or at the earliest antenatal booking. Many women with a history of OASI are offered an elective caesarean section or a carefully managed vaginal birth with a prophylactic episiotomy — both are appropriate choices, and the decision should be made with full information about your specific injury, its healing, and your preferences.
If distress about your birth experience or recovery is significantly affecting your wellbeing — sleep, mood, relationships, sense of self — please speak to your GP or health visitor. A referral to the perinatal mental health team is appropriate and available. The MASIC Foundation also provides peer support specifically for women with bowel and bladder problems after childbirth — sometimes talking to someone who has been through the same experience is what helps most.
I had a 3b tear and nobody really told me what that meant until I was discharged. I spent the first six weeks convinced something was irreparably wrong with me. When I finally got to the OASI clinic and they explained what had happened, what the repair involved, and what my realistic outlook was — I felt things shift. Information is not alarming. The not knowing is alarming.
Having had a perineal tear or episiotomy does not automatically determine what will happen in a subsequent birth — but it is information your care team should have and factor into your care.
Second and subsequent vaginal births generally involve less perineal trauma than first births — the tissue has been stretched before and is typically more accommodating. However, scar tissue from a previous repair can behave differently from unscarred tissue, and the location and nature of any previous tear can affect where and how a subsequent one occurs.
If you have had a third or fourth degree tear, your options for a subsequent birth should be discussed with a consultant obstetrician — ideally before you conceive again. The RCOG recommends that women with a history of OASI are offered the choice between elective caesarean section and a carefully managed vaginal birth. There is no single right answer — the best choice depends on whether the sphincter has healed fully (assessed by the OASI clinic), your own preferences, and your specific obstetric circumstances. A prophylactic episiotomy during a subsequent vaginal birth is often recommended by some clinicians, though evidence for this reducing OASI recurrence is not conclusive.
Antenatal perineal massage — performed from around 34 weeks — has good evidence for reducing the risk and severity of perineal tearing in first-time mothers and in those who have had a previous tear or episiotomy. It involves gently stretching the perineum for a few minutes several times a week in the final weeks of pregnancy. It is mildly uncomfortable but not painful when done correctly. Ask your midwife for guidance, or the RCOG patient information leaflet on perineal massage covers the technique clearly.
Make sure your previous perineal history is clearly documented in your notes and discussed at your booking appointment in any subsequent pregnancy. Ask specifically what support will be in place during the second stage of labour — including the availability of a senior obstetrician if needed — and what the plan is if circumstances develop that put the perineum at risk.