Perineal tears

What is a perineal tear?

A perineal tear is a tear in the skin, muscles and other soft tissues that separate your vaginal opening and your anus (back passage). This area is called the perineum — the area between the vagina and anus.

During labour, the skin and muscles between your vagina and anus stretch so your baby can be born. Sometimes the area gets torn, which is called a perineal tear.

What are the different types of perineal tears?

About 8 in 10 women will have some form of perineal tear when they have a vaginal birth.

Perineal tears are graded from 1 to 4, depending on the severity and which tissue is affected.

First degree tears are small and skin-deep and can often heal without stitches.

Second degree tears are deeper and affect the muscles of the perineum. Stitches are usually recommended. Although sometimes a small second-degree tear can heal well without stitches.

Third-degree tears extend downwards from the vagina through the deeper muscles to the anal sphincter (the part that keeps the anal canal closed).

Fourth-degree tears affect the lining of the anus or rectum.

Types of perineal tears and how they are treated.

Type of tear	Where it occurs	Treatment
First degree	Skin of the perineum or labia	May need stitches
Second degree	Muscles of the perineum	Usually needs stitches
Third degree	Muscles controlling the anus	Surgical repair
Fourth degree	Lining of the anus	Surgical repair

What is the difference between a perineal tear and episiotomy?

A perineal tear happens when the skin between the vagina and anus tears.

An episiotomy is an intentional cut made by a doctor or midwife during delivery. An episiotomy is done using surgical scissors, when the perineum has stretched and the baby's head is crowning.

What makes a perineal tear more likely?

A perineal tear is more likely if:

• this is your first baby
• you are of Southeast Asian background
• you have had a third or fourth degree perineal tear before
• your baby weighs more than 4kg (9lb) or is in a position with their back against your back (posterior)
• your baby's shoulders become stuck during birth
• you need forceps or other instruments to assist your birth

How can I lower my chance of a perineal tear?

During the later stages of pregnancy, regular pelvic floor exercises and perineal massage from 35 weeks, may help prevent perineal injury.

It's also a good idea to talk to your midwife or doctor about your risk factors. Ask about the strategies used in your chosen hospital or birth centre to lower the likelihood of having a serious tear.

Will I need stitches if I have a perineal tear?

First- and second-degree perineal tears are common and most heal well either naturally or with stitches. Depending on the location and extent of the tear, you may need stitches. These are done soon after the birth. Talk with your doctor or midwife about what is right for you based on the type of tear you have and your preferences.

What happens if I have a tear?

After your baby is born, your doctor or midwife will check your perineum for any tears or grazes. Sometimes it's obvious during birth that the perineum has torn, but not always. That's why it's important to be carefully checked after your baby is born.

If a tear is found, your doctor or midwife will see what type of tear you have and will discuss the best way to repair it. You should be given enough information to be able to give your informed consent. Your doctor or midwife will not fix a tear without talking to you first.

Most first- and second-degree tears can be repaired in the same room where you gave birth. If you had an epidural, this will keep running to give you pain relief while the sutures (stitches) are being put in. Otherwise, a local anaesthetic will be injected into your perineum near the affected area to numb it before suturing begins.

To reduce the chance of incontinence (bladder or bowel weakness), all third- or fourth-degree tears are recommended to be repaired surgically. This is often done in an operating theatre where there is good access to pain relief and all the lighting and tools the surgical team need to repair the sphincter and perineum.

Once your doctor or midwife has finished stitching, they will usually offer you pain relief medicine. They will put a pad and some ice on your perineum to help with any swelling. Your doctor or midwife may offer to do a rectal examination (where they to insert a finger into your anus) after the stitching is done to make sure no tears have been missed.

How will I feel if I have a perineal tear?

Some women who have a third- or fourth- degree tear might feel:

• vulnerable, embarrassed, alone
• anxious, helpless, scared
• bad about their bodies
• that they don't want to have sex
• worried about future births

If you have any of these feelings, you can talk to doctor, midwife or obstetrician.

How long will it take to heal from a perineal tear?

It's normal for you to feel pain or soreness around the tear or cut for 2 to 3 weeks after giving birth, especially when walking or sitting. The skin stitches usually dissolve within 3 weeks. It may take you up to 6 to 8 weeks to fully heal.

What can help my recovery after having a tear?

There are a few things you can do to help your perineal area heal. Keep in mind that everyone is different and it is best to follow the instructions your healthcare team gives you.

Here are some self-care tips:

• Try to rest as much as possible and lie on your side if you can.
• Avoid positions and activities that put pressure on the muscle or reduce blood flow to the area, like sit-ups, lifting and high-impact exercise.
• Keep the tear clean and dry — shower daily and gently pat the area dry.
• Avoid using any cream, ointments or powder on the area, unless you've been told to by your healthcare provider.
• Change your pads often.
• Start gentle pelvic floor muscle exercises 2 to 3 days after your baby's birth, or when it's comfortable for you to do so.

Here are some ways to stay comfortable when using the toilet:

• Avoid becoming constipated, drink plenty of water and try to eat a diet high in fibre (like fruit, vegetables and wholegrains).
• Take your time when emptying your bladder and bowel, and avoid pushing or straining.
• When you're sitting on the toilet, use a foot stool or lift your heels up so that your knees are above your hips.
• Try to drink plenty of water so your urine is less concentrated. This can help reduce stinging.
• Try leaning forward on the toilet when you pass urine, this will keep the urine away from the tear and reduce stinging.

Learn more about scar healing and recovery.

When can I have sex?

There is no standard waiting period before women can resume sex after having a baby. However, most maternity care providers recommend waiting until:

• after the bleeding has stopped
• after a perineal tear has healed
• you feel interested in having sex.

For many people who have given birth, this happens within 1 to 3 months after having their baby.

Ultimately, you should only resume having sex when you feel ready.

Can I have a vaginal birth in the future?

Some women are advised not to have a vaginal birth again if they had a third- or fourth- degree perineal tear. This is different for each person and will vary depending on your circumstances and preferences. Your doctor or maternity care provider can guide you about what is right for you.

When should I see a doctor?

Most women are advised to have a postnatal check 6 weeks after their baby's birth.

You should talk to your doctor earlier if you are concerned about how your perineum is healing. You should also talk to your doctor if you have other concerns with your vagina, bladder or bowel after birth, like:

• you develop a temperature
• you notice an unusual smell or discharge from the tear
• your perineum becomes inflamed, swollen or red
• your perineal tear is still giving you pain after 2 to 3 weeks
• you can't control your bowels or passing wind
• sex is painful for you
• you have a heavy, dragging feeling in your vagina

Who can I speak to if I'm not satisfied with my healthcare?

If you aren't satisfied with your healthcare, there are people you can speak to, like:

• your doctor or midwife
• the health complaints agency or health department in your local state or territory
• the Australian Health Practitioner Regulation Agency (AHPRA), if you have a concern about the unsafe behaviour or practice of a registered health practitioner
• the National Health Practitioner Ombudsman

You can ask your doctor or midwife for a debrief if you aren't sure about something that happened to you, especially during labour, birth or in an emergency. You can ask questions so that you better understand what happened.

Resources and support

• Talk to your doctor, midwife or obstetrician.
• Continence Health Australia gives information and support to people with bowel and bladder problems. You can call the helpline on 1800 33 00 66.
• Visit Birth Trauma Australia for information and support, like peer-to-peer support.
• Visit PANDA (Perinatal Anxiety and Depression Australia) for information and support after a traumatic birth. You can call the PANDA national helpline on 1300 726 306.
• ForWhen on 1300 24 23 22 (Monday to Friday 9am to 4:30pm).
• Beyond Blue on 1300 22 4636.
• Call the National Domestic Family and Sexual Violence Counselling Service on 1800 RESPECT or 1800 737 732 (24 Hours a day, 7 days a week).