What a perineal tear is
The perineum is the area between the vaginal opening and the anus. During a vaginal birth this tissue can tear when it is stretched strongly. A perineal tear is a common birth injury and does not mean the birth was successful or not.
More useful than self-blame are three practical points: the exact degree should be documented, the wound must be cared for appropriately, and you need a postnatal plan that supports healing rather than repeatedly 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, bruising and individual sensitivity play a large role.
Perineal tear degree 1
This affects skin and mucosa. It can burn and be uncomfortable when sitting, but often heals relatively quickly.
Perineal tear degree 2
In addition, the perineal muscles are affected, but not the anal sphincter. Healing is often noticeable for longer, especially if swelling or bruising occurs.
Perineal tear degree 3 and 4
Here the anal sphincter is involved, and degree 4 additionally involves the rectal mucosa. These injuries are often referred to as OASI, which stands for obstetric anal sphincter injury. With OASI, repair and aftercare are particularly important because without proper management later problems with controlling wind or stool can be 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 during the second stage of labour, when the head or shoulders are born. Stretching, speed, tissue tension and the mechanics of birth interact. There is rarely a single cause.
Situations in which the risk may be higher include instrumental births, a very rapid birth, a prolonged second stage, or when a lot of pressure is focused on the perineum. This is not a prediction but an explanation for why perineal protection and good support are important in such situations.
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 suturing technique, pain management and aftercare match the findings.
OASI is usually repaired under appropriate conditions, often in theatre. Afterwards, stool regulation, pain management and structured follow-up are commonly needed. ACOG emphasises in its guidance how crucial correct diagnosis and specialised repair are for later function. ACOG: Prevention and management of obstetric lacerations
Healing in the postnatal period: what is often normal
Pain, burning, pulling
In the first days pain when sitting, standing up and during toileting is common. Burning when passing urine can occur if urine contacts irritated mucosa. For many people this improves noticeably within days; deeper tears tend to take weeks.
Swelling and bruising
Swelling is expected after tissue trauma. A haematoma can feel like a hard, tender lump and cause severe pain, even if the tear itself is not very deep. If pain is severe, increases suddenly or you feel unwell, it should be checked.
Sutures, poking sensations and an unfamiliar feeling
Sutures can poke or pull, especially when sitting. This is often temporary. Some sutures dissolve by themselves. If you feel something rubbing or stabbing like a small wire, a check 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 strain or bear down, pain often increases. Soft stools are usually the best relief, especially after OASI. This is not a luxury issue but wound protection.
Practical relief in everyday life
In the postnatal period, a practical setup that reduces friction matters more than perfection. The aim is to avoid repeatedly provoking swelling and to make toilet visits in a way that does not create constant anxiety.
Cooling, positioning, avoiding pressure
- Cooling can reduce swelling and pain in the first days, especially after exertion.
- Sitting on your side, short sitting periods and frequent changes of position are often more helpful than long periods of perseverance.
- Lying on your side with a cushion between your legs can relieve pressure if lying flat is uncomfortable.
Toileting without extra strain
- Lukewarm water over the intimate area can reduce burning when passing urine.
- Gentle cleansing is better than vigorous wiping, especially when the wound is sensitive.
- If you notice you are straining, a pause is often better than forcing it.
Measured activity rather than all or nothing
Complete immobility makes many things harder: the bowel becomes slower, pelvic floor awareness can feel reduced, and mentally things feel more constrained. Short, regular walks are often the better strategy. If you are much worse in the evening than in the morning, your daytime load was probably too high.
Pelvic floor, postnatal recovery and physiotherapy
The pelvic floor is strained after every pregnancy, regardless of whether a tear occurred. After a perineal tear it may feel more sensitive or unstable. Postnatal recovery is then less about intensive training and more about pacing: start gently, monitor symptoms and do not push through pain.
After OASI structured follow-up is particularly important because symptoms sometimes only appear when daily life becomes more active again. An NHS information sheet on degrees 3 and 4 summarises aftercare, daily life and typical recommendations well. NHS: Advice following third and fourth degree tears
Warning signs: when you should not wait
Many complaints are uncomfortable but expected. The following signs are more indicative of a complication or that the situation should be medically reassessed.
- Fever, shivering, feeling clearly unwell
- Wound becomes noticeably red, hot, weeps or has an unpleasant smell
- Pain becomes clearly worse over days instead of improving
- Severe, increasing swelling or a tender lump that changes quickly
- New problems controlling wind or stool, especially after OASI
If you are unsure, early contact is usually the shorter route. Many problems in the postnatal period can be stabilised more quickly than if left until later under prolonged stress.
Prevention for a future birth: what the evidence shows
No one can completely prevent a perineal tear. However, there are measures linked in studies to fewer severe injuries or fewer episiotomies that many can reasonably adopt.
Perineal massage during pregnancy
A Cochrane review describes that antenatal perineal massage can 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 on techniques in the second stage finds evidence that warm compresses and perineal massage can reduce the risk of severe perineal trauma. 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 labour ward.
- Ask whether warm compresses are possible.
- If you had an OASI, plan the birth in a subsequent pregnancy early on.
Myths and facts about perineal tears
- Myth: Severe pain automatically means a severe tear. Fact: Swelling or a haematoma can be very painful 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 protection and rest matter; later gentle mobilisation can help, and overactivity can irritate tissue.
- Myth: An unusual smell is always normal in the postnatal period. Fact: A foul smell together with pain or fever can be a warning sign.
- Myth: Activity 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 a wide range of severity. For most people: things improve gradually when pain, toileting and daily life are realistically supported. For deep tears, structured follow-up is particularly important.
If you remember two things: watch the pattern over several days and take warning signs seriously. Seeking help early is not an overreaction but sensible postnatal care.
