Articles

Key takeaways

• Perineal tears and episiotomies are common during vaginal birth.
• Tears vary in depth, from minor skin breaks to deeper muscle involvement.
• An episiotomy is a cut made to widen the vagina for birth.
• Strategies can help prevent tears, and care helps healing.

What are perineal tears and episiotomies?

Your perineum – the area between your vaginal opening and anus – may stretch during your baby's birth. Sometimes, it cannot stretch enough. This can lead to a tear. Tears can also happen inside the vagina or on other parts of the vulva, like the labia.

Perineal tears

Up to 9 in 10 people having a vaginal birth for the first time will have some type of tear, graze, or episiotomy. Most tears are minor and heal quickly.

There are different types, or degrees, of perineal tears:

• First-degree tears – These are small and only affect the skin. They usually heal quickly without treatment.
• Second-degree tears – These are deeper and affect the skin and muscle of the perineum. They often need stitches.
• Third-degree tears – These extend into the muscle that controls your back passage (the anal sphincter).
• Fourth-degree tears – These go further into the lining of the anus or bowel.
• Rectal buttonhole – This is a rare injury where the anal sphincter does not tear, but there is a hole between the back passage and the vagina.

About 3 in 10 people will have a first or second-degree tear. Around 5 in 100 people having a vaginal delivery will have a third or fourth-degree tear. This is slightly more likely for first-time pregnancies, at 6 in 100. Deeper tears are usually repaired by a specialist doctor in an operating theatre to help you heal well.

Episiotomies

An episiotomy is a cut made by a healthcare professional. It goes through the vaginal wall and perineum. This cut makes the opening of your vagina wider. About 1 in every 6 people giving birth will have an episiotomy.

Episiotomies are not done routinely in the UK. They might be recommended if your baby needs to be born quickly. This can happen if your baby is in distress, meaning their heart rate changes. An episiotomy can also be done if instruments like forceps or a vacuum device (ventouse) are needed to help with the birth. It may also be done to try and prevent a severe tear, such as a third or fourth-degree tear. While an episiotomy aims to prevent a severe tear, it is possible for the cut to extend further as your baby is born.

Prevention strategies and options during labour

Your midwife can help you try to avoid a tear during labour. When your baby's head becomes visible, your midwife may ask you to stop pushing. They might ask you to pant or puff a couple of quick, short breaths, blowing out through your mouth. This helps your baby's head emerge slowly. It gives the skin and muscles of the perineum time to stretch.

Perineal massage and warm compresses

Massaging the perineum in the last few weeks of pregnancy can reduce the chances of needing an episiotomy. This often involves inserting 1 or 2 fingers into the vagina. You then apply downward or sweeping pressure towards the perineum. Doing this every day can be most beneficial.

Your midwife or doctor may also gently place a warm compress on your perineum. This happens as your baby's head comes out. This may not stop tearing completely, but it might reduce how much you tear. You can ask your midwife about this option.

Birth environment and communication

Some research suggests that giving birth at home or in a midwife-led unit may reduce the risk of tearing. This might be because some people feel more relaxed in these places. There is not enough evidence to prove that water births help avoid tearing.

If your doctor or midwife feels you need an episiotomy, they will discuss it with you. An episiotomy is usually only done when there is no other option. An episiotomy might be suggested if it seems very likely you will have a serious tear without one. You can talk to your midwife about the chances of having a tear.

Healing and recovery after a tear or episiotomy

Most tears and episiotomies are repaired with stitches after the birth. These are dissolvable stitches – they soften and fall out on their own. You will not need to return to the hospital to have them removed.

Managing pain and discomfort

It is common to feel some pain after an episiotomy or tear. Painkillers like paracetamol can help relieve pain. It is safe to use paracetamol if you are breastfeeding. Ibuprofen can also help with swelling and is thought to be safe while breastfeeding, but check with your doctor first. Aspirin is not recommended as it can pass to your baby through breast milk.

To help ease pain and discomfort:

• Place an ice or cool pack on the area for about 10 minutes at a time. Wrap it in a clean flannel or towel to avoid ice-burn.
• Take a warm bath.
• Sit on a rubber ring for no more than half an hour at a time. This can affect the blood flow to the area.
• Change your position often. Try standing, sitting, or lying on your side.
• Pour warm water over your perineum with a small jug during and after weeing. This can help with stinging.
• Eat a healthy, balanced diet and stay hydrated. This helps avoid painful constipation.

Promoting healing and hygiene

It is important to keep the area clean to prevent infection. Bathe your stitches every day. Have a shower or bath using only plain warm water on the area. You can use the shower head to gently wash the wound. Do not rub soap into it.

Wash your perineum and the surrounding area after every trip to the toilet. Pat the wound dry carefully with a clean towel. Change your maternity pads often to reduce the risk of infection.

To help with healing:

• Avoid using a hairdryer on the area, even on a cool setting. This can damage the tissue.
• Wear breathable fabrics, such as cotton. Disposable briefs with loose clothing can also help.
• Expose the wound to fresh air. Take off your underwear and lie on a towel on your bed for about 10 minutes, once or twice a day.
• Do your pelvic floor exercises. This helps increase blood flow to the area and speeds up healing.

Recovery timeline and signs of complications

It is normal to feel pain or soreness for 2 to 3 weeks after a tear. Your stitches may also irritate you, and it might sting when you wee. They may feel a little itchy, which often means they are healing. The skin part of the wound is likely to heal within a few weeks. If you had a third or fourth-degree tear, it may take longer to heal. Stitches should heal within 1 month of the birth. If pain lasts longer than 2 to 3 weeks, speak to a doctor, health visitor, or other health professional.

Look out for any signs that the cut or surrounding tissue has become infected. These signs include:

• Red, swollen skin around the cut or tear.
• Unusual discharge or fluid from the cut.
• Persistent pain.
• An unusual smell.

It is rare for stitches to come undone. However, an infection or pressure from bleeding underneath can cause stitches to break. When a wound opens up after being stitched, it’s called a wound breakdown (perineal wound dehiscence). Wound breakdown can cause pain, new bleeding, or an unusual discharge. You may also feel unwell, especially if you have an infection.

Call your midwife, health visitor, or GP if you have any concerns about your stitches. Tell them as soon as you can about any possible signs of infection.