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 reflect whether the birth was successful or not.
More important than self-blame are three practical points: the exact degree should be documented, the wound must be treated appropriately, and you need a postnatal plan that supports healing rather than repeatedly pushing your limits.
Degrees 1 to 4 and why that matters for follow-up care
The grading by severity 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
Skin and mucosa are affected. This can cause burning and discomfort when sitting, but it often heals relatively quickly.
Perineal tear degree 2
Perineal muscles are additionally involved, but not the anal sphincter. Healing is often noticeable for a longer time, especially if swelling or bruising occur.
Perineal tear degree 3 and 4
Here the anal sphincter is involved; in degree 4 the bowel 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 otherwise later problems with controlling wind or stool may become more likely.
A clear overview of OASI, repair and typical follow-up care is available from RCOG. RCOG: Third and fourth degree tears OASI
Why a perineal tear happens
A perineal tear usually occurs in the expulsive phase, when the head or shoulders are born. Stretching, speed, tissue tension and birth mechanics act together. There is rarely a single cause.
Situations in which the risk can be higher include instrumental births, a very rapid birth, a prolonged expulsive phase or situations with high pressure on the perineum. This is not a prediction, but an explanation of why perineal protection and good support are especially important in those cases.
Care immediately after birth
After birth the perineal area is examined. Smaller tears are stitched or managed conservatively depending on location, bleeding and wound edges. Deep injuries must be reliably identified so that suture technique, pain management and follow-up care match the findings.
For OASI, repair usually takes place under appropriate conditions, often in an operating theatre. Afterwards bowel regulation, pain management and structured checks are often part of care. ACOG emphasises in its recommendations how crucial correct diagnosis and appropriate 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 using the toilet is common. Burning when urinating can occur when urine contacts irritated mucosa. For many people this gets noticeably better within days; deeper tears tend to take weeks to improve.
Swelling and bruising
Swelling is expected after tissue trauma. A haematoma can feel like a hard, 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 checked.
Sutures, pricking and an unfamiliar sensation
Sutures can prick or pull, especially when sitting. This is often temporary. Some sutures dissolve on their own. 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 tense or strain strongly, pain often increases. A soft stool is usually the best relief, especially after OASI. This is not a comfort issue but wound protection.
Practical relief in everyday life
In the postnatal 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 anxiety each time.
Cooling, positioning, avoiding pressure
- Cooling can reduce swelling and pain in the first days, especially after activity.
- Sitting sideways, short sitting periods and frequent position changes are often more helpful than long endurance.
- Side-lying with a pillow between the legs can relieve pressure when lying is uncomfortable.
Toilet visits without extra strain
- Lukewarm water over the intimate area can reduce burning when urinating.
- Gentle cleaning is better than vigorous wiping, especially when the wound is sensitive.
- If you notice you are straining, a break is often preferable to forcing pressure.
Measured movement instead of all or nothing
Total immobility makes many things harder: the bowel becomes slower, the pelvic floor feeling becomes less reliable, and mentally things feel more constrained. Short, regular walks are often the better strategy. If you feel much worse in the evening than in the morning, the day’s load was probably too high.
Pelvic floor, postnatal recovery and physiotherapy
The pelvic floor is affected after every pregnancy, regardless of whether a tear occurred. After a perineal tear it may be more sensitive or feel unstable. Postnatal recovery is then less about intense training and more about dosing: start gently, watch symptoms and do not work 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 leaflet on degrees 3 and 4 summarises follow-up care, 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. These signs suggest a complication or that the situation should be medically reassessed.
- Fever, chills, pronounced feeling of illness
- Wound becomes clearly red, hot, oozes or smells unpleasant
- Pain that gets worse over days instead of better
- Strong, increasing swelling or a tender lump that changes quickly
- New problems with controlling wind or stool, especially after OASI
If you are unsure, an early consultation is usually the quicker route. Many problems can be stabilised more quickly in the postnatal period than later under ongoing stress.
Prevention for the next birth: what the evidence shows
No one can completely prevent a perineal tear. However, there are measures that in studies are associated with fewer severe injuries or fewer episiotomies and that many people can implement.
Perineal massage during pregnancy
A Cochrane review describes that antenatal perineal massage can reduce the likelihood of perineal trauma, especially episiotomy, and that persistent perineal pain is reported less often. Cochrane: Antenatal perineal massage
Warm compresses and perineal support during the second stage
A Cochrane review on techniques in the second stage finds evidence that warm compresses and perineal support can lower 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 is handled in the delivery room.
- 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 cause severe pain even with smaller tears.
- Myth: A perineal tear always heals quickly and completely without follow-up. Fact: Many heal well, but after OASI structured follow-up is essential.
- Myth: You just have to get through bowel movements. Fact: Straining and fear often increase pain; soft stool and rest are usually the better approach.
- Myth: Scar care means constantly doing something. Fact: In the beginning protection and rest matter; later gentle mobilisation can help, while overactivity irritates tissue.
- Myth: Foul smell is always normal in the postnatal period. Fact: A bad smell together with pain or fever can be a warning sign.
- Myth: Movement is always bad after a perineal tear. Fact: Measured movement is often helpful; overloading is the problem.
Conclusion
A perineal tear is a common birth injury with very varied severity. For most people: it improves step by step when pain, toilet visits and daily life are supported realistically. For deep tears structured follow-up is especially important.
If you remember two things: watch the trend over several days and take warning signs seriously. Seeking help early is not an overreaction but sound postnatal care.
