Perineal tears

What is a perineal tear?

Your perineum is the area between your vaginal opening and anus. Tears usually happen spontaneously (on their own) as the vagina and perineum stretch during the baby’s birth. 

Tears can also happen inside the vagina or other parts of the vulva, including the labia (the inner and outer lips of the vagina).

Some women refer to third- and fourth-degree tears as ‘birth injuries’ as they don’t feel ‘tear’ really conveys what’s happened to them. We will use the medical term perineal tears here. 

Are perineal tears common?

Up to 9 in 10 first-time mums who have a vaginal birth will have some sort of tear, graze or episiotomy. The Royal College of Obstetricians & Gynaecologists says that, for most women, these tears are minor and heal quickly. 

What are the types of perineal tear?

First-degree tears are small and only affect the skin. They usually heal quickly and without treatment. They are very unlikely to cause long-term problems, but they can be very sore.

Second-degree tears affect the muscle of the perineum and the skin. They usually require stitches. Second-degree tears are unlikely to cause long-term problems, but can be very sore.

Third-degree tears extend into the muscle that controls the anus (the anal sphincter). 
Fourth-degree tears extend further into the lining of the anus or rectum.

Third- or fourth-degree tears can occur in 6 out of 100 births (6%) for first-time mothers and less than 2 in 100 births (2%) of births for women who have had a vaginal birth before.

A rectal buttonhole is a rare injury that occurs when the anal sphincter does not tear, but there is a hole between the back passage and the vagina. This means that wind and faeces may be passed through the vagina instead of through the anus.

What makes a perineal tear more likely?

There’s often no clear reason why third- and fourth-degree tears happen. But they are more likely if:

• this is your first vaginal birth
• your baby is over 4kg (9lb)
• you have a long second stage of labour (also known as the pushing stage)
• your baby’s shoulder gets stuck (known as shoulder dystocia)
• your midwife or doctor needs to use forceps or a ventouse to deliver your baby (assisted birth) 
• your baby is occipito-posterior (facing the opposite way with their backs to your back) or breech 
• your labour is very quick (known as precipitous birth).

Find out more about getting your baby into the best birth position.

How can I avoid a perineal tear?

There are some things that can reduce your risk of tearing during childbirth. You can talk to your midwife about these at any time during your pregnancy. You can also find out more during antenatal classes. 

Perineal massage

Massaging the perineum in the last few weeks of pregnancy can reduce the chances of tearing during birth. The Royal College of Gynaecologists and Obstetricians has a guide on how to massage your perineum.

Birth position

Kneeling down, being on all fours or lying on your side during labour may reduce the risk of tearing. Find out more about positions during labour.

How your midwife can help

Your midwife will also help you avoid a tear during labour. When the midwife can see your baby’s head, they will ask you to stop pushing and to pant or puff a couple of quick short breaths, blowing out of your mouth.

This will help your baby’s head emerge slowly and gently, giving the skin and perineum muscles time to stretch without tearing. 

Your midwife or doctor may also gently place a warm compress on the perineum as the baby’s head comes out. This may not stop tearing but may reduce the severity of the tear. You can ask your midwife about this.

Where you give birth

It’s also been suggested that giving birth at home or in midwife-led unit may help reduce the risk of tearing. This may be because some women feel more relaxed in these environments.   

Try not to get anxious about what’s best because your midwife can explain the different options for where to give birth. They can also give you more information about the and the pros and cons of each choice. Find out more about where you can give birth. 

Some research has suggested that having a water birth can help you avoid tearing. But there is not enough evidence to prove this is true. 

How does a tear differ from an episiotomy?

A tear happens on its own (spontaneously) as the baby stretches the vagina during birth. An episiotomy is a cut made by a midwife or doctor into the perineum and vaginal wall to make more space for your baby to be born. A doctor will most likely do an episiotomy if you are having an assisted vaginal birth. Episiotomies are only done with your permission (consent).

It is possible for an episiotomy to extend and become a deeper tear. If you have had an episiotomy, you will need stitches to repair it.

A midwife may also do an episiotomy, either to prevent a more serious tear or if they need to speed up delivery because they are concerned about the baby’s wellbeing. This can only be done if they can see the baby’s head coming out of the birth canal (crowning). Your midwife will ask for your permission (consent) before doing this.

Will I feel a tear happening during childbirth?

During the second stage of labour (also known as the pushing stage), your body will guide you on how and where to push. As the baby’s head meets your perineum (the area between your vagina and anus), the urge to push becomes stronger, and the sensation that you want to open your bowels increases. Often your body will push or bear down without you even realising it. It is an instinctive reflex and is almost impossible to stop, so it is best to go with it. 

Due to the amount of pressure caused by your baby’s head on your perineum, it is unlikely that you will feel any tearing. But everyone’s birth is different and some women may find that they feel a lot of stinging, especially as the head is crowning (when your baby’s head can be seen coming out of the birth canal). 

Your midwife will guide you through this time to slow the crowning of the baby’s head and allow the muscles to stretch slowly as the head is delivered. 

How will I know if I have torn?

Your midwife or doctor will check you over immediately after you have your baby. They will record your temperature and check your pulse and blood pressure. They will also need to check your genital area to see if it has torn and whether you need stitches. This may include a rectal examination, where the midwife or doctor uses their finger to check for any problems inside your bottom (rectum). 

Your midwife or doctor should explain to you what they are going to do. They will ask you to move or help you get into a comfortable position so they can see the area clearly.

You may be offered some gas and air while they do an internal examination to check for vaginal tearing.  

Can I hold my baby while I’m being examined?

Yes, you can usually hold your baby while you are being examined.

Your healthcare team should encourage you to have skin-to-skin contact with your baby as soon as possible after the birth, unless there is a medical reason why it’s not possible. Skin-to-skin means having your baby on you, their naked skin next to yours with a blanket over both of you for warmth, (you can put it in your birth plan). Find out more about the benefits of skin-to-skin.

You may not be able to hold your baby if you have bleeding that needs urgent attention. If you can’t hold your baby, your birthing partner will be the next best thing.

If I need stitches, will these be done straight away?

Unless your midwife or doctor thinks you need to be moved (see below), any stitches you need will be done straight away. This will reduce any chance of infection or blood loss. 

Will I have to be moved if I have torn?

Your midwife or doctor can usually assess the genital area and do any stitches where you have given birth. If you have not given birth on a labour ward in a maternity unit, you may need to be moved there if:

• your healthcare professional needs support with their assessment from a more senior midwife or doctor
• your repair needs more surgical expertise.

If you have sustained a third-degree, fourth-degree or rectal buttonhole, you will be transferred to an operating theatre as soon as possible after your baby is born. 

Will the stitches hurt?

If you’ve had a small tear, you’ll be given a local anaesthetic to numb the area so you won’t feel any pain during the procedure. 

You may need to put your legs into stirrups while the stitching is carried out. The midwife or doctor should check that you are comfortable. If the pain relief doesn't seem to be working properly at any stage, you should let the midwife or doctor know. They can give you more anaesthetic if needed. 

You may be given a regional anaesthetic (designed to numb your genital area) or spinal anaesthetic if you have significant trauma and you need to go to an operating theatre at hospital.  If you had an epidural for labour, that can usually be used to provide pain relief for the procedure, instead of having another type of anaesthetic. 

After your stiches are put in place, you may be offered a small rectal suppository (a tablet that goes into your bottom). This may help calm any inflammation and pain. 

You should be given information about the extent of the trauma and how to look after yourself at home. 

How long will it take for the stitches to heal?

It is normal to feel pain or soreness for 2 to 3 weeks after having any tear. The stitches may also irritate and it may sting when you wee. They may also feel a little itchy.

The skin part of the wound usually heals within a few weeks of giving birth.  If you have a third or fourth degree tear this may take longer to heal and you may be given antibiotics to prevent infection in the area of the stitches. 

Find out more about recovering from a perineal tear at home.

I feel traumatised by my birth experience. How do I cope with this?

Tearing during labour, especially if you have a third- or fourth-degree tear, can be very distressing. Your partner (if you have one) may also be traumatised. 

Some women who experience any birth trauma may develop post-traumatic stress disorder (PTSD). PTSD is an anxiety disorder caused by very stressful, frightening or distressing events.  This may lead to fear of childbirth in the next pregnancy. 

PTSD can develop immediately after an event or it can happen weeks, months or even years later.

It can be very difficult to come to terms with a traumatic event, but PTSD is treatable.  The important thing is to try and confront your feelings with help from healthcare professionals. 

Find out more about post-traumatic stress disorder. 

More support and information

The Masic Foundation supports mothers who have suffered from an injury during childbirth, known as a third- or fourth-degree tear, that results in incontinence. They also have a free helpline for anyone who wants to talk about their treatment or the treatment of loved ones. Call 0808 164 0833 24 hours a day to leave a message and a trained volunteer will get back to you. 

The Birth Trauma Association (BTA) supports women who suffer birth trauma – a shorthand term for post-traumatic stress disorder (PTSD) after birth.

The Birth Tear Support Facebook group is a support group for women who have suffered from severe tearing or episiotomies.