Perineal tears and episiotomy: recovery after birth
Why perineal tears happen
During a vaginal birth, the perineum, the tissue between the vaginal opening and the anus, stretches to allow the baby to pass through. For many women this stretch results in a tear, and for others a midwife or doctor may make a deliberate surgical cut called an episiotomy to widen the opening. Both are very common: the NHS reports that most women who give birth vaginally have some degree of perineal tear or are given an episiotomy.
Tears happen more often in first vaginal births than in subsequent ones, and certain factors can increase the likelihood, including a large baby, a fast delivery, a baby in a back-to-back position, and pushing for a long time. The use of instruments such as forceps or a ventouse also raises the chance of a more significant tear. That said, tears can occur in any vaginal delivery, and their occurrence does not mean anything went wrong.
An episiotomy is usually performed when there are signs that the baby needs to be born quickly, when instruments are being used, or when the midwife or doctor judges that a controlled cut is preferable to a ragged tear. The cut is made to one side (mediolateral) to avoid the sphincter. Like a tear, it is repaired with dissolvable stitches immediately after birth.
The four degrees of tear and what each one means for recovery
Clinicians use a four-point grading system to describe how far a perineal tear extends. Understanding the grade of your tear helps you know what repair was done and what to expect during recovery.
A first degree tear involves only the perineal skin. It is often small enough to heal without stitches, and most women find these resolve within a few days with minimal discomfort.
A second degree tear extends through the skin and into the perineal muscle beneath. This is the most common type. It is repaired with dissolvable stitches, usually in the delivery room. Recovery typically takes several weeks and most women manage pain with regular paracetamol and ibuprofen (if there are no contraindications), as well as keeping the area clean and dry.
A third degree tear reaches into or completely through the external anal sphincter, the muscle ring around the anus. A subset of third degree tears also involves the internal sphincter. These injuries are classified as OASI (obstetric anal sphincter injuries) and require specialist repair, which takes place in an operating theatre under regional or general anaesthetic.
A fourth degree tear extends through both sphincters and into the rectal mucosa, the lining of the rectum. Like third degree tears, these need theatre repair by a surgeon with expertise in colorectal or urogynaecological repair. After an OASI, women are typically given a short course of antibiotics, laxatives to keep stools soft during healing, and physiotherapy referral.
What recovery looks like day to day
The first few days after any perineal tear or episiotomy are often the most uncomfortable. Swelling and bruising are normal. Several practical steps help manage pain and support healing in this early period.
Keeping the area clean is important. Rinsing with warm water while passing urine can reduce stinging, and patting dry (rather than rubbing) after bathing protects the stitches. Soaking in a shallow warm bath can ease discomfort, and some women find a cushion or a donut ring useful when sitting.
Paracetamol and ibuprofen, taken regularly rather than waiting for pain to peak, are the NHS-recommended first-line pain relief for perineal repair. If pain is not controlled by these, ask your midwife about additional options.
Constipation puts pressure on the repaired tissue, so maintaining a high-fibre diet, drinking plenty of water, and using a laxative if recommended by your midwife will all help. Try not to strain when opening your bowels. Some women feel reassured by holding a clean pad firmly against the perineum when having a first post-birth bowel movement.
Healing follows different timescales for different women. Most second degree tears and episiotomies feel significantly more comfortable by three to four weeks, though the area may remain tender or itchy while stitches dissolve. Third and fourth degree repairs can take considerably longer to heal fully, and ongoing pelvic floor physiotherapy is usually recommended.
Longer-term recovery and returning to normal activity
Sexual activity after a perineal tear is usually advised to wait until the stitches have dissolved and you feel comfortable, which is often around six weeks but varies considerably. There is no hard rule: what matters is that you feel ready and that any residual tenderness has eased. Using a lubricant can help at first, and if pain during sex persists beyond a few months it is worth raising with your GP or a women's health physiotherapist.
Pelvic floor exercises are recommended by the NHS from as soon as you feel able after birth, including when you have stitches. They can feel strange or weak to start with, particularly after a significant tear, but they play a key role in reducing swelling, improving blood flow to the repair site, and rebuilding the muscle strength needed to prevent long-term problems such as urinary incontinence or prolapse. A women's health physiotherapist can guide you if you are unsure of technique or if exercises feel painful.
For women who have had an OASI (third or fourth degree tear), the NHS and RCOG recommend a formal follow-up appointment at around six to twelve weeks, typically at a specialist clinic. This appointment assesses how well the sphincter has healed and checks for any symptoms of bowel or urinary dysfunction. Women should not hesitate to raise any ongoing symptoms at this point: effective treatment is available and problems identified early are easier to manage.
Frequently asked questions
What is a first, second, third and fourth degree tear?
First degree: skin only, often heals without stitches. Second degree (most common): skin and muscle, repaired with dissolvable stitches. Third degree: extends into or through the anal sphincter. Fourth degree: extends through the sphincter into the rectal mucosa. Third and fourth degree tears need specialist repair in theatre.
How long do perineal stitches take to dissolve?
Dissolvable stitches used for perineal repairs typically dissolve within 2 to 4 weeks. You do not need to have them removed. The area may feel uncomfortable for several weeks but pain should be gradually improving.
When can I do pelvic floor exercises after a perineal tear?
The NHS recommends starting gentle pelvic floor exercises as soon as you feel able after birth, even with stitches. Early pelvic floor exercises support healing, reduce swelling and help prevent long-term weakness.
What should I do if my perineal tear does not seem to be healing?
Contact your community midwife or GP if you notice signs of infection (increasing pain, redness, swelling, discharge or fever), if stitches appear to have opened, or if pain is severe and not responding to paracetamol and ibuprofen.
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