The perineum is the area between the vaginal opening and the anus, and perineal tears during birth are among the most common birth-related injuries — and among the least openly discussed. Women often emerge from childbirth with significant perineal trauma and minimal information about what to expect from recovery, whether their recovery is normal, or where to get help if it is not.
Third and fourth degree tears in particular — injuries that extend into or through the anal sphincter — can have long-term effects on continence, sexual function, and quality of life. Most women recover well with appropriate surgical repair and physiotherapy, but they need that support to be offered proactively rather than having to seek it out themselves.
Healthbooq (healthbooq.com) covers postnatal recovery and maternal health.
Classification of Tears
First degree: superficial tear of the vaginal mucosa or perineal skin only; often does not require suturing; heals readily.
Second degree: extends into the perineal muscle but not the anal sphincter. Most common grade requiring suturing. Repaired by midwife or obstetrician in the birth room under local anaesthetic.
Third degree (OASIS — obstetric anal sphincter injury): involves the anal sphincter complex. Subdivided:
- 3a: less than 50 per cent of the external anal sphincter (EAS) thickness
- 3b: more than 50 per cent of the EAS
- 3c: internal anal sphincter (IAS) also involved
Fourth degree: sphincter complex plus rectal mucosa.
Third and fourth degree tears require surgical repair under regional or general anaesthesia in an operating theatre by a trained surgeon.
Risk factors for OASIS include: first vaginal birth, a large baby, prolonged second stage, instrumental delivery (forceps more than ventouse), midline episiotomy, and certain ethnic backgrounds (South Asian women have approximately twice the risk of white British women at equivalent birth weights, for reasons that are not fully understood).
Episiotomy
An episiotomy is a surgical cut to the perineum to enlarge the vaginal opening. NICE guidance (NG235) recommends that episiotomy is not performed routinely — it should be used only when clinically indicated. Indications include: fetal distress requiring rapid delivery, instrumental delivery (most forceps deliveries require episiotomy), and situations where a spontaneous tear extending to the anal sphincter seems likely.
Mediolateral episiotomy (angled to the side rather than straight down) has been shown to reduce the risk of progression to third and fourth degree tear compared to midline episiotomy. Midline episiotomy is rarely performed in UK practice.
Recovery
For first and second degree tears and episiotomy:
Ice packs to the perineum in the first 24 to 48 hours reduce swelling and pain. Foam cushions or rubber rings for sitting are comfortable aids in the first week. Regular paracetamol and ibuprofen (unless contraindicated) manage pain far more effectively than as-needed use.
Keeping the area clean with water during and after urination, and gentle patting dry, reduces infection risk. Salt baths have not been shown to reduce healing time or pain in RCTs but are soothing for some women. The stitches are dissolvable and do not need removal.
Bowel movements: many women are frightened of opening their bowels after perineal trauma. Adequate hydration and a gentle stool softener (lactulose is commonly prescribed) prevent constipation. The stitches will not "burst" from passing stool.
Warning signs requiring assessment: increasing pain rather than gradual improvement, foul-smelling discharge, fever, spreading redness, or breakdown of the wound (dehiscence).
For third and fourth degree tears:
All women with OASIS should receive specialist follow-up at a dedicated OASIS clinic at approximately six weeks and then again at a few months postnatally. This includes assessment of healing, perineal physiotherapy, and a discussion about future deliveries. Pelvic floor physiotherapy beginning in the early postnatal period is important for sphincter recovery.
Women with OASIS should be advised that a planned caesarean section for future pregnancies is a reasonable option; the decision depends on sphincter function, symptoms, and the individual woman's preferences and is best made with a specialist.
Pelvic Floor After Birth
All women who have given birth vaginally benefit from pelvic floor exercises. The pelvic floor has sustained significant load during pregnancy and birth even without a significant tear, and pelvic floor exercises (Kegel exercises) are the first-line approach to preventing and treating urinary incontinence and supporting recovery.
Squeezing and lifting the pelvic floor muscles ten times, three times per day, and building to longer holds, is the standard recommendation. A women's health physiotherapist can provide individualised assessment and a more targeted programme, and referral should be offered to all women who report any symptoms of pelvic floor dysfunction.
Key Takeaways
Perineal tears are common in vaginal birth, affecting approximately 85 per cent of women who give birth vaginally. Most are first or second degree and heal well with or without suturing. Third and fourth degree tears (obstetric anal sphincter injuries, or OASIS) affect approximately 3 to 5 per cent of vaginal births and require surgical repair under anaesthetic, followed by specialist follow-up including physiotherapy and debriefing. Episiotomy (surgical incision of the perineum) is not routinely performed; it is reserved for specific clinical indications. Recovery from perineal trauma typically takes several weeks; pelvic floor physiotherapy is beneficial for most women after vaginal birth, particularly those with third or fourth degree tears.
