What a perineal tear is
The perineum is the area between the vaginal opening and the anus. During a vaginal birth, the tissue there can tear when it is stretched strongly. A perineal tear is a common birth injury and does not by itself indicate whether the birth was successful or not.
More useful than self-blame are three practical points: the exact degree should be documented, the wound needs appropriate care, and during the postpartum period you need a plan that supports healing rather than constantly pushing your limits.
Degrees 1 to 4 and why this matters for aftercare
The classification by degree describes which structures are affected. It does not reliably predict how much pain you will feel, because swelling, haematomas and individual sensitivity play a large role.
Perineal tear — grade 1
Skin and mucosa are affected. This can burn and be uncomfortable when sitting, but often heals relatively quickly.
Perineal tear — grade 2
Perineal muscles are additionally affected, but not the anal sphincter. Healing is often noticeable for longer, especially if swelling or bruising occurs.
Perineal tear — grade 3 and 4
Here the anal sphincter is involved; in grade 4 the rectal mucosa is also affected. These injuries are often referred to as OASI, which stands for obstetric anal sphincter injury. With OASI, repair and follow-up care are particularly important because without them later problems with controlling gas or stool are more likely.
A clear overview of OASI, repair and typical aftercare is available from the RCOG. RCOG: Third and fourth degree tears OASI
Why a perineal tear happens
A perineal tear usually occurs in the second stage of labour, when the head or shoulders are born. Stretching, speed, tissue tension and birth mechanics act together. There is rarely a single trigger.
Situations in which the risk may be higher include instrumental deliveries, a very rapid birth, a prolonged second stage, or circumstances with high pressure on the perineum. This is not a prediction but an explanation of why perineal protection and good support are important in those moments.
Care immediately after birth
After birth the perineal area is examined. Smaller tears are either sutured or managed conservatively depending on their location, bleeding and wound edges. Deep injuries must be reliably identified so that suture technique, pain therapy and follow-up care match the findings.
OASI repair is usually performed under optimal conditions, often in the operating theatre. Afterwards, bowel management, pain control and structured follow-up are commonly part of care. In its guidance, ACOG emphasises how crucial correct diagnosis and proper repair are for later function. ACOG: Prevention and management of obstetric lacerations
Healing in the postpartum period: what is often normal
Pain, burning and pulling sensations
In the first days pain when sitting, standing up and using the toilet is common. Burning when urinating can occur if urine touches irritated mucosa. For many people this improves noticeably within days; for deeper tears it may take weeks.
Swelling and bruising
Swelling is to be expected after tissue trauma. A haematoma can feel like a firm, tender area and be very painful, even if the tear itself is not very deep. If pain is very severe, increases suddenly or you feel unwell, it should be assessed.
Stitches, poking sensations and an unfamiliar feeling
Stitches can poke or pull, especially when sitting. This is often temporary. Some sutures dissolve on their own. If you feel something rubbing or stinging like a small wire, an assessment can help, because sometimes a small adjustment is possible.
Passing stool is often the hardest moment
Fear of the first bowel movement is common. If you tense up or strain strongly, pain often increases. A soft stool is usually the best relief, especially after OASI. This is not a cosmetic issue but wound protection.
Practical relief for everyday life
In the postpartum period, perfection matters less than a setup that reduces friction. The goal is to avoid repeatedly provoking swelling and to organise toilet visits so you do not build up fear each time.
Cooling, positioning, avoiding pressure
- Cold packs can reduce swelling and pain in the first days, particularly after activity.
- Sitting sideways, short sitting periods and frequent position changes are often more helpful than prolonged sitting.
- Lying on your side with a pillow between your legs can relieve pressure if lying flat is uncomfortable.
Toilet visits without extra strain
- Lukewarm water over the genital area can reduce burning when urinating.
- Gentle cleaning is better than vigorous wiping, especially when the wound is sensitive.
- If you notice that you are straining, it is often better to pause than to force pressure.
Measured activity rather than all or nothing
Total immobility makes many things harder: the bowel becomes slower, pelvic-floor sensation becomes less reliable, and mentally things feel tighter. Short, regular walks are often the better strategy. If you feel much worse in the evening than in the morning, your daily load was probably too high.
Pelvic floor, postnatal recovery and physiotherapy
The pelvic floor is affected by every pregnancy, regardless of whether a tear occurred. After a perineal tear it can be more sensitive or feel unstable. Postnatal rehabilitation is therefore less about intense training and more about pacing: start gently, monitor symptoms and do not push beyond pain.
After OASI, structured follow-up is especially important because problems sometimes only become apparent when daily life becomes more active again. An NHS information sheet on grades 3 and 4 summarises aftercare, everyday life and typical recommendations well. NHS: Advice following third and fourth degree tears
Warning signs: when you should not wait
Many complaints are unpleasant but expected. The following signs suggest a complication or that the situation should be medically reassessed.
- Fever, chills, marked feeling of being unwell
- Wound becoming clearly red, hot, oozing or having an unpleasant smell
- Pain that gets clearly worse over days instead of better
- Severe, increasing swelling or a tender lump that changes rapidly
- New problems controlling gas or stool, especially after OASI
If you are unsure, early contact is usually the quicker route. Many problems can be stabilised in the postpartum period more easily than later under prolonged stress.
Prevention for a future birth: what the evidence shows
No one can prevent a perineal tear with certainty. However, there are measures that in studies have been associated with fewer severe injuries or fewer episiotomies and that many people can reasonably implement.
Perineal massage during pregnancy
A Cochrane review describes that antenatal perineal massage may reduce the likelihood of perineal trauma, particularly episiotomy, and that persistent perineal pain is reported less often. Cochrane: Antenatal perineal massage
Warm compresses and perineal support in the second stage
A Cochrane review of techniques in the second stage finds evidence that warm compresses and perineal support may reduce the risk of severe perineal tears. Cochrane Library: Perineal techniques during second stage
What you can practically take from this
- Discuss during pregnancy how perineal protection will be handled in the delivery room.
- Ask whether warm compresses are possible.
- If you had an OASI, plan birth management in a subsequent pregnancy early on.
Myths and facts about perineal tears
- Myth: Severe pain always means a severe tear. Fact: Swelling or a haematoma can cause severe pain even with smaller tears.
- Myth: A perineal tear always heals quickly and completely without follow-up. Fact: Many heal well, but structured follow-up is crucial after OASI.
- Myth: You just have to get through bowel movements. Fact: Straining and fear often increase pain; soft stool and calm are usually the better strategy.
- Myth: Scar care means constantly doing something. Fact: Early on the priority is protection and rest; later gentle mobilisation can help—overactive treatment irritates tissue.
- Myth: An unusual smell is always normal in the postpartum period. Fact: Foul smell together with pain or fever can be a warning sign.
- Myth: Movement is always bad after a perineal tear. Fact: Measured activity is often helpful; overloading is the problem.
Conclusion
A perineal tear is a common birth injury with very variable severity. For most people: symptoms improve gradually when pain, toilet use and daily life are supported realistically. For deep tears, structured follow-up is particularly important.
Two points to remember: watch the trend over several days and take warning signs seriously. Seeking help early is not an overreaction but good postpartum medicine.
