Perineal tearing is very common during vaginal births. Learn more about episiotomies and reducing your risk of a third or fourth degree tear, and get advice on what to expect from the recovery after tearing.
What is tearing?
Perineal tearing happens when the skin or muscles between your perineum and vagina breaks as they stretch to allow your baby to be born. Tearing can also happen inside your vagina as your baby moves down the birth canal.
Most tears are small and heal well, although you may need some stitches and you’re likely to be sore for a few days or weeks after the birth. In rare cases, tearing is more extensive and requires stitching in theatre.
There are four degrees of tearing:
- First-degree tear: small, skin-deep tears in the perineum or vagina that usually heal best naturally without stitches.
- Second-degree tear: As above, but the muscles of the perineum are also torn. You’ll need stitches.
- Third-degree tear: As above, but the tearing also extends to the anal sphincter (the muscle that controls the anus). This is a more serious form of tearing and you’ll need stitching in theatre.
- Fourth-degree tear: As above, but the tear extends into the rectum. This is the most serious kind of tearing and you’ll need stitching in theatre.
Will I tear during birth?
It is very likely you will tear during birth, especially if you’re expecting your first baby: 85% of first-time mothers experience tearing and 60-70% have stitches.
However, most women experience the lower degrees of tearing, requiring only the type of stitching that can be done by a midwife.
Third- and fourth-degree tearing affects 6% of first-time mothers and 2% of women who’ve given birth vaginally before, and is more common during assisted births.
Are there any ways to prevent tearing?
In most cases, tearing can’t be prevented because it can’t be predicted before birth. However, although there are no guarantees, there are some ways you can prepare during pregnancy to make it a bit less likely that you’ll experience severe tearing.
Massaging your perineum regularly from around 35 weeks of pregnancy reduces the likelihood of tears and episiotomies in women who have not given birth before, a 2013 Cochrane Review found.
To find out how to do perineal massage, have a look at instructional videos online or ask your midwife at one of your antenatal appointments.
It’s also important to talk to your midwife if you find the massage painful, so they can make sure that your technique is correct.
Your midwife can press a warm compress against your perineum as your baby’s head is crowning during the second stage of labour. The Cochrane Collaboration has found that this may reduce the risk of severe tearing.
As you may not be in a state of mind to discuss compresses when you’re about to start pushing, it can be good to note this down in your birth plan so those looking after you are aware of your preferences.
Following your midwife’s instructions when your baby’s head is ‘crowning’ can also help reduce tearing.
For example, your midwife may suggest that you stop pushing and pant or blow out through your mouth when your baby’s head is visible to allow the skin of the perineum to stretch gradually.
What is an episiotomy?
An episiotomy is a small cut at the vaginal opening, made with a scalpel or scissors. It’s a birth intervention which may be done by a midwife or doctor while you push to allow your baby to be born more quickly. It’s also often used during assisted births to reduce the risk of severe tearing.
Episiotomies used to be done often during straightforward births, but that’s no longer recommended. A 2017 Cochrane Review of the evidence showed that routine use of episiotomy resulted in more women tearing, rather than the other way around.
Just like after tearing, an episiotomy requires stitching and some women have problems with incontinence or find that sex is painful afterwards.
Stitching after tearing or an episiotomy
After you’ve delivered the placenta, your midwife or doctor will check if you’ve had a tear, and if so to what degree.
If you’re found to have a small (second-degree) tear, your midwife will be able to stitch it up themselves and you’ll get local anaesthetic to make sure you’re as comfortable as possible.
If you have a home birth or give birth in a birth centre, your midwife can do minor stitching there and then without you having to go to hospital.
“I think people tend to be fearful of the birth process, but the most difficult part for me was after the birth – the stitching actually hurt more than the birth of the baby.” Read Fiona’s birth story
Stitching in theatre
You’ll likely need to have suturing in theatre by a surgeon if you’re found to have a third- or fourth-degree tear.
You’ll get a more effective anaesthetic such as a spinal, epidural or general anaesthetic for this type of stitching, and the theatre staff will make sure you’re comfortable and kept up to date with what’s happening.
If you give birth on a labour ward, you’ll be taken to the theatre straight on a bed. However, if you have your baby at home or in a freestanding birth centre, you’ll have to be transferred to the nearest labour ward in an ambulance for the surgery.
“I was taken to theatre and had a spinal block which left me numb from the waist down. The surgery to repair my fourth-degree tear took around 50 minutes and the staff were really good at keeping me informed and calm throughout.” Read Claire’s birth story
Recovering from a first- or second-degree tear
Most women having first- or second-degree tears recover well, although you’re likely to feel sore for a few days or weeks as you heal.
You can take over-the-counter anti-inflammatory pain killers like ibuprofen and use a cold compress on your perineum for the pain. Many women also find sitting on a postpartum ring cushion (also know as a ‘donut cushion’) really helpful in the early days.
However, if the stitches are bothering you or you’re in pain for more than a couple of weeks, it’s always worth contacting your midwife or GP for help and advice.
- Read more about your recovery after a vaginal birth.
Recovering from a third- or fourth-degree tear
If you have a more severe tear, it’s likely you’ll need to stay on the postnatal ward for at least one night after the birth.
While in hospital, you’ll be offered pain killers and possibly antibiotics (since the stitches are close to the anus) and you’ll probably also be advised to take laxatives to make it easier for you to go to the toilet.
You should also be given advice on how you can be more comfortable once you go home – for example by eating a fibre-rich diet, drinking plenty of water and doing pelvic floor exercises to help your recovery.
After a severe tear, recovery often takes longer than average with many women experiencing incontinence and finding intercourse painful in the early months.
However, you may find it comforting to know that most women do make a good recovery, with 6-8 in every 10 women having no symptoms a year after the birth.
Seeking further help
You may be offered a follow-up appointment at your hospital a couple of months after the birth, to check that your stitches after a third- or fourth-degree tear have healed well.
This is also a chance for you to raise any questions you have about your recovery, and be referred to a specialist if you have problems controlling your bowels.
It’s important to note that you can also turn to your midwife, GP or health visitor at any point if you’re ever worried about your recovery or any pain your experiencing, you shouldn’t have to suffer in silence.
“I started seeing a physiotherapist eight or nine months after the birth. These appointments were really helpful. Eventually, I started to feel a lot better and experience less incontinence – however, it was a long journey to get there.” Read Claire’s birth story
Severe tearing is an issue that’s still not widely talked about, and it may feel like an isolating experience if the people close to you don’t seem to understand what you’re going through.
If you feel that you’d like to have the support of other women who have been in a similar situation to you, you may find it helpful to join a social media group for mothers who have experienced severe tearing. You can find out more at Birth Tear Support.
More from Which?
- Assisted birth: Forceps and ventouse are two instruments that can be used to help deliver your baby vaginally.
- Your postnatal appointments: Find out what help you can expect in the early weeks after birth, from midwives and your GP.
- Birth trauma and PTSD: Many women who experience difficult births develop mental health problems – but there is help and support available.
These are the sources of information used in this article.
Aasheim V, Nilsen A, Reinar L, Lukasse M. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database of Systematic Reviews (2017)
Beckmann MM, Stock OM. Antenatal perineal massage for reducing perineal trauma. Cochrane Database of Systematic Reviews (2013)
Jiang H, Qian X, Carroli G, Garner P. Selective versus routine use of episiotomy for vaginal birth. Cochrane Database of Systematic Reviews (2017)
RCOG Patient Information Committee, A third- or fourth-degree tear during birth, Royal College of Obstetricians & Gynaecologists (2015)