Perineal tears and episiotomy: degrees, repair and recovery

The perineum is the area between the vaginal opening and the anus. Tears are graded by how deep they go, as both the RCOG and Tommy's describe. Tears can also happen inside the vagina or on the labia, Tommy's adds.

An episiotomy is a cut made through the vaginal wall and perineum by a doctor or midwife to give more space for the baby. The NHS says it is not done routinely in England and that your doctor or midwife will discuss it with you. NICE, as quoted by the NHS, recommends one might be done if the baby is in distress and needs to be born quickly, if forceps or ventouse are needed, or if there is a risk of a tear to the anus. Tommy's adds that it is only done with your consent and can only be done once the head is crowning.

The NHS says a local anaesthetic numbs the area, or an epidural can be topped up, and that a small diagonal cut is made and repaired with dissolvable stitches, usually within an hour of the birth. Research cited by the NHS suggests an episiotomy may prevent third-degree tears in some births, particularly forceps deliveries. The RCOG warns that an episiotomy can sometimes extend into a deeper tear.

Tommy's says there is often no clear reason for third- and fourth-degree tears, but they are more likely at a first vaginal birth, with a baby over 4 kg, a long pushing stage, shoulder dystocia, Asian ethnicity, forceps or ventouse, a baby facing back-to-back or breech, or a very quick labour.

Ways that may reduce tearing, according to the NHS and Tommy's: perineal massage in the last weeks of pregnancy (the NHS says most benefit was in women who did it daily), kneeling, all fours or side-lying positions in labour, a warm compress as the head emerges, and your midwife guiding a slow, controlled birth of the head by asking you to pant rather than push. Tommy's adds that giving birth at home or in a midwife-led unit may be linked to less tearing, while evidence that water birth helps is not strong enough to prove.

Your midwife or doctor checks you after the birth and, as Tommy's explains, may include a rectal examination to look for a deeper tear. You can usually hold your baby while this happens.

A third- or fourth-degree tear or rectal buttonhole is usually repaired in theatre as soon as possible, under a spinal or epidural anaesthetic, or rarely a general anaesthetic, the RCOG says. You may have a drip and a bladder catheter until you can walk to the toilet. Afterwards you should be offered painkillers such as paracetamol and ibuprofen, advised to take a course of antibiotics to reduce infection risk, advised to take laxatives to make opening your bowels easier, and offered a physiotherapy appointment. The RCOG says none of this prevents breastfeeding, though sitting can be uncomfortable so other positions may help.

For an episiotomy, the NHS says it is common to feel pain, and that paracetamol is safe while breastfeeding; ibuprofen is thought to be safe, but check with a doctor first, and aspirin is not recommended. It lists cold packs wrapped in a towel, airing the stitches for about 10 minutes once or twice a day, pouring warm water over the area when passing urine or after the toilet, and holding a clean pad against the cut when opening your bowels. It says pain beyond 2 to 3 weeks should be mentioned to a health professional.

After a third- or fourth-degree tear the RCOG advises washing daily with water only, changing pads regularly and avoiding strenuous activity or heavy lifting for 4 to 6 weeks. Stitches dissolve and you may feel some for up to 3 months. It recommends drinking plenty of fluid, eating a balanced diet, sitting with your feet on a stool when opening your bowels, and starting pelvic floor exercises as soon as you can. Tell your healthcare professional if symptoms continue after 6 months.

The NHS says to call your midwife or GP if stitches become more painful, there is smelly discharge, or the skin around the cut or tear is red and swollen, as these can mean infection. The RCOG says to see a healthcare professional about any bleeding from the tear, any smell or any increase in pain. Difficulty controlling your bowels or wind (anal incontinence), leaking faeces, passing wind or stool through the vagina, or low mood and anxiety after a traumatic birth are all things the RCOG says to raise with your team; specialist physiotherapy or surgery is available for anal incontinence, and extra mental health support exists for those affected.

A fever, feeling very unwell or a rapidly worsening wound should be treated as urgent: contact your midwife, NHS 111 or your maternity unit straight away, or call 999 if you are seriously unwell.

The RCOG says you may be offered a hospital follow-up 6 to 12 weeks after the birth to check healing and ask about bowel control, and that you can use this appointment to discuss the birth. If you have recovered well and have no symptoms you may consider a vaginal birth next time; if symptoms continue, you may prefer a planned caesarean. The RCOG says evidence on whether the risk of a repeat tear is increased is limited, but suggests 7 to 10 in 100 women who had a third- or fourth-degree tear at a first birth have a similar tear at the next vaginal birth. Forceps, a baby over 4 kg and Asian ethnicity are listed as risk factors for a repeat tear.

The NHS adds that pain during sex is common in the first months after a tear or episiotomy, that there are no rules about when to restart, and that you can become pregnant about 3 weeks after birth, so contraception should be considered.