Perineal Injury

Perineal injury during childbirth is very common, affecting up to 9 in every 10 first-time mothers who have a vaginal birth. While most tears are minor and heal quickly, understanding what happens, how to care for yourself, and when to seek help can make your recovery smoother and less stressful.

Table of contents

• What is a perineal injury?
• Types of perineal tears
• How common are perineal injuries?
• Causes and risk factors
• What is an episiotomy?
• Possible complications
• Treatment and repair
• Recovery and self-care at home
• Reducing your risk
• When to call for help

What is a perineal injury?

• Perineum
• Vagina
• Anus
• Rectum
• Labia
• Vulva

A perineal injury is damage to the perineum, which is the area of tissue between your vaginal opening and your anus (back passage). This type of injury commonly occurs during vaginal childbirth when your baby’s head stretches the vagina and perineum as it passes through^[1]. Tears can also happen inside the vagina or affect other parts of the vulva (the external female genitals), including the labia (the folds of skin around the vaginal opening)^[2].

During a vaginal delivery, the skin of your vagina naturally thins out to prepare for childbirth. This part of your body is designed to stretch and allow your baby to pass through. However, it is very common for some degree of tearing to occur^[6].

Types of perineal tears

Perineal tears are classified into four degrees based on how deep the injury goes and which tissues are affected^[1].

First-degree tears are the least severe. These small tears affect only the skin of the perineum and the tissue directly beneath it. First-degree tears usually cause some pain or stinging when you urinate, but they often heal quickly without treatment. Some may need stitches, but many do not^[3].

Second-degree tears are the most common type. The tear is slightly bigger than a first-degree tear and extends deeper through your skin into the underlying muscles of your vagina and perineum. These tears almost always require stitches to help them heal properly^[1]. Healing usually takes about 3 to 4 weeks^[3].

Third-degree tears are more serious. These tears extend from your vagina to your anus and involve injury to the skin and muscles of your perineal area, as well as damage to your anal sphincter muscles. These are the muscles that control how you pass bowel movements. Third-degree tears need to be repaired with stitches, sometimes in an operating theatre rather than the delivery room^[1].

Fourth-degree tears are the most severe but least common type. These tears extend from your vagina through your perineal area and anal sphincter muscles and into your rectum (the last part of your large bowel). Like third-degree tears, these require careful repair in an operating theatre. You will be given an epidural (pain relief injected into your back) or spinal anaesthesia (numbing medicine injected into your spine) so that you have good pain relief during the repair^[1].

Third- and fourth-degree tears are also known as obstetric anal sphincter injuries (OASI)^[1].

How common are perineal injuries?

Perineal injuries during childbirth are very common. Up to 9 in every 10 first-time mothers who have a vaginal birth will experience some sort of tear, graze, or episiotomy. It is slightly less common for mothers who have had a vaginal birth before^[1]. For most women, these tears are minor and heal quickly^[1].

More severe tears are less common. About 3.5 out of 100 women (approximately 3% to 5%) will experience a third- or fourth-degree tear^[1][6]. These deeper tears need more specialized repair and careful follow-up care.

Causes and risk factors

Tears happen naturally as the baby stretches the vagina and the perineum during birth^[1]. A vaginal tear during childbirth occurs because your baby stretches your vagina and perineum during birth. This is normal and common^[6].

Several factors can increase your chances of having a perineal tear. You are more likely to tear if this is your first vaginal delivery. Other risk factors include having a large baby (more than 8 pounds or over 4 kilograms), your baby being in certain positions during delivery (such as face up instead of face down), and having a prolonged second stage of labor (the pushing stage)^[6][7].

The use of instruments during delivery, such as forceps or a vacuum (ventouse) to assist the birth, also increases the risk of tearing^[1][7]. Other factors include being of Asian ethnicity, older maternal age, and having had an epidural during labor^[6][2].

If your baby’s shoulder gets stuck behind the pubic bone during delivery (a condition called shoulder dystocia), this also raises the risk of a more severe tear^[7].

What is an episiotomy?

An episiotomy is a cut made by your healthcare professional into the perineum and vaginal wall to make more space for your baby to be born. This is different from a tear because it is a deliberate cut, not a spontaneous injury^[1].

Episiotomies are done with your consent. They are only performed if your baby needs to be born quickly (often during an instrumental delivery with forceps or vacuum), or if you are at risk of a serious perineal tear^[1][5].

A local anaesthetic is used to numb the area so you do not feel pain during the cut. If you have already had an epidural, the dose can be topped up before the cut is made. The doctor or midwife will usually make a small diagonal cut from the back of the vagina, directed down and out to one side. The cut is stitched together using dissolvable stitches after the birth^[5].

Possible complications

While most small vaginal tears heal within two weeks, some women may experience complications. It is common to feel discomfort for a month or two if your tear was larger^[6].

Common complications of perineal tears include infection, bleeding, painful intercourse (once you are permitted to have intercourse), fecal incontinence (leaking solid or liquid stool), and ongoing pain and soreness^[6]. Women with deeper perineal trauma (third- or fourth-degree tears) may experience greater perineal pain at 6 months after birth, are more likely to have weaker pelvic floor muscle strength, and are more likely to experience anal or fecal incontinence at some point in the future^[22].

Severe lacerations can result in prolonged pain, sexual dysfunction, and embarrassment. These complications need prompt identification and proper treatment^[2].

Treatment and repair

After the birth of your baby, your healthcare professional will carefully examine your vagina, perineum, and rectum to see if you have a tear, and if so, what type. They will then advise you if you need stitches^[1].

First-degree tears may not require stitches, although some of them do. If a first-degree tear needs stitches, the repair can typically be done in the delivery room^[3].

Second-degree tears typically require stitches, which can often be done in the delivery room^[3]. The doctor or midwife usually closes the perineal tear with stitches. The stitches will dissolve in 1 to 2 weeks, so they do not need to be removed^[8].

If you have sustained a third- or fourth-degree tear, you will be transferred to the operating theatre where your muscles will be repaired. You will be given an epidural or spinal anaesthesia so that you have good pain relief. These deeper tears need more specialized repair^[1].

Sometimes a small tear will not be closed with stitches and will be allowed to heal on its own^[8].

Recovery and self-care at home

Recovery can be uncomfortable or painful, depending on how deep and long the tear is. Pain is usually most intense at the beginning, but you should feel better each day. Pain typically affects sitting, walking, urinating, and bowel movements for at least a week. A tear is usually healed in about 4 to 6 weeks^[8].

Managing pain: For mild pain, try over-the-counter pain medicine such as paracetamol or ibuprofen. These are safe to use if you are breastfeeding^[5][8]. To ease pain, try placing an ice pack or ice cubes wrapped in a towel on the affected area for 10 to 20 minutes at a time. Put a thin cloth between the ice and your skin. Avoid placing ice directly on your skin as this could cause damage^[5][8].

Sitz baths: Sit in a shallow bath of warm water (sitz bath) for 15 to 20 minutes, 3 times a day and after bowel movements. Then pat the area dry. This helps with healing and pain relief^[8]. You may find that drying the area with a hair dryer instead of using a towel feels better^[8].

Keeping clean: Keep the area clean by pouring or spraying warm water over the area outside your vagina and anus after you use the toilet. After going to the toilet, pour warm water over your vaginal area to rinse it^[5][8]. Use baby wipes or medicated pads instead of toilet paper after a bowel movement^[8].

Preventing constipation: It is important to prevent constipation to avoid straining, which can affect healing. Ease constipation by drinking plenty of fluids and eating high-fiber foods. Ask your doctor or midwife about over-the-counter stool softeners^[8].

Activity and rest: Rest when you feel tired. Getting enough sleep will help you recover. Avoid lifting anything heavy or doing strenuous activities such as bicycle riding, jogging, and weightlifting until your doctor or midwife says it is okay^[8]. Exposing the stitches to fresh air can help the healing process. Taking off your underwear and lying on a towel on your bed for around 10 minutes once or twice a day may help^[5].

Reducing your risk

While it is not always possible to prevent perineal tears, there are some things you can do to reduce your risk.

Perineal massage during pregnancy: From 35 weeks onwards, you or your partner can use daily perineal massage until your baby is born, which may reduce your risk of tearing. This is particularly beneficial for first-time mothers^[7]. To perform perineal massage, sit in a warm bath before you start to help you relax. Use a lubricant like vitamin E oil, almond oil, or olive oil. Place your thumbs inside your vagina and press down towards the anus and to the sides of the vaginal walls. Hold this position for about 1 minute until you feel a stretching sensation. Then gently massage the lower half of your vagina using a U-shaped movement for 2 to 3 minutes. Repeat this 2 to 3 times^[7].

During labor: Techniques used by your healthcare provider during the second stage of labor, such as perineal support and massage and the use of warm compresses, can help reduce the risk of severe tearing^[2].

When to call for help

Follow-up care is a key part of your treatment and safety. Be sure to make and go to all appointments^[8].

Call anytime you think you may need emergency care. For example, call if you passed out (lost consciousness)^[8].

Contact your doctor, midwife, or nurse advice line if you have signs of heavy bleeding, such as soaking through one or more pads in an hour or passing blood clots bigger than an egg, feeling dizzy or light-headed, feeling so tired or weak that you cannot do your usual activities, a fast or irregular heartbeat, or new or worse belly pain^[8].

You should also contact your healthcare provider if you have symptoms of infection, such as increased pain, swelling, warmth, or redness; red streaks leading from the wound; pus draining from the wound; a fever; vaginal discharge that smells bad; or if your stitches get more painful^[5][8].

If pain lasts longer than 2 to 3 weeks after an episiotomy or tear, speak to a doctor, health visitor, or another health professional^[5].