Perineal Health (tears and episiotomies during childbirth)

Perineal Health (Tears and episiotomies during childbirth)

This page explains the different types of tears that can occur during a vaginal birth, how to reduce your risk of deeper tears, and what we can do to help your recovery if you do tear. At Kingston our services include a midwife-led Perineal Health Clinic, Women’s Physiotherapy service and Urogynaecology clinic.

What types of tears may occur during childbirth?

Your perineum is the area between the opening of your vagina and your back passage (anus).

During a vaginal birth, the perineum commonly tears or grazes. Other areas that may tear or graze include inside the vagina or the labia.

Tears are defined by “degree”:

1st degree tear: a small, skin-deep tear which usually heals naturally

2nd degree tear: a slightly deeper tear affecting both the skin and the muscles of the perineum. We advise that all 2nd degree tears are repaired with stitches. This repair can be carried out by a midwife or doctor using local anaesthetic in the room where you give birth.

For some women the tear may be more extensive and we will recommend that it is repaired with stitches in an operating theatre under an epidural or spinal anaesthetic. This operation will be performed by an experienced obstetrician.

3rd degree tear: involves the skin, muscle and external anal sphincter (the muscle that surrounds the anus).

4th degree tear: extends further into the lining of the anus. You can read more about perineal tears here:

How common are perineal tears?

Approximately 80 out of 100 women (80%) who give birth vaginally will experience a tear during the birth of their baby. This may result from tears to tissues, muscles and skin around the vagina and perineum (the skin between the vagina and anus).

For most women these tears are minor and heal quickly following repair with stitches by a midwife or doctor.

About 3 out of 100 women (3%) who give birth vaginally will have a tear that involves the back passage or anal sphincter muscle. This is known as a 3rd or 4th degree tear or obstetric anal sphincter injury (OASI). These tears are repaired in theatre by a senior obstetrician.

What is an episiotomy?

An episiotomy is a cut made by your midwife or doctor into the perineum and vaginal wall to make more room for your baby to be born. An episiotomy will only be done with your consent.
If you have an assisted vaginal birth (where a doctor helps your baby to be born using forceps or a ventouse suction cup) an episiotomy is likely.
An episiotomy may also be recommended to allow your baby to be born more quickly, if there are concerns about their well-being at the end of labour.
You can read more about episiotomies here: Episiotomy | RCOG

What can help prevent tearing during birth?

Perineal massage

Performing daily perineal massage from 35 weeks of pregnancy until your baby is born may reduce your risk of tearing during birth. It helps prepares your perineum to stretch more easily during birth. This is particularly beneficial if this is your first baby.

This video explains how to perform perineal massage. When to start and how to do perineal massage – YouTube or follow the instructions below:

Warm bath

Sit in a warm bath before you start. This may help you to relax before the massage and loosen the muscles around your perineum.

Short nails

The tissues in your vagina and perineum are very delicate. Make sure your nails are short to prevent scratching the skin, or any discomfort to the area.

Comfortable position

You need to be relaxed during the massage, so it’s important you find a comfortable position. The best place to perform this massage is in bed. Prop yourself up with pillows to support your back and bend your knees.


Use a lubricant like vitamin E oil, almond oil or olive oil.


Hold your thumbs in the position shown for about 1 minute (diagram below). Press down towards the anus and to the sides of the vagina walls. Hold your thumbs in this position for about 1 minute. You will begin to feel a stretching sensation. Breathe deeply

Gentle massage

Gently massage the lower half of your vagina using a U-shaped movement for 2-3 minutes. Repeat this 2-3 times.

Repeat daily or when possible

It may take a couple of weeks of daily massage before you notice more elasticity in your perineal area.

Warm compress

A warm compress is a pad, gauze or swab which is warmed in a bowl of water.

We recommend that your midwife or doctor applies a warm compress to your perineum as your baby is being born.

This has been shown to reduce the chance of a 3rd or 4th degree tear, which is a tear that extends to the back passage (anus).

A warm compress may also provide some comfort and support as your perineum stretches to allow your baby to be born.

Positions for labour and birth

Your midwife will support you to birth in your position of choice. Birthing in an all-fours position or lying on your left or right side may help to reduce the severity of tearing during birth.

Attend our online Pelvic Health classes

Pelvic health is all about looking after the muscles that support your womb, bladder and bowel. These muscles change during pregnancy and childbirth.

We offer two online Pelvic Health classes which you can book to attend during your pregnancy. Each class lasts one hour.

The classes provide advice and support for your pelvic health needs – in pregnancy, during birth, and once you have had your baby.

The classes are run by a physiotherapist and midwife.

Book either class via Eventbrite:

Pregnancy class

We recommend that you attend this class early on in your pregnancy.

The class covers:

  • What may happen to your pelvic floor during pregnancy
  • What pelvic symptoms to look out for
  • When to seek help and advice
  • Ways to help keep your pelvic floor fit and healthy
Labour, Birth and Beyond Class

We recommend that you attend this class in your 2nd or 3rd trimester of pregnancy

The class covers:

  • Ways to help protect your pelvic floor during labour and birth
  • Tips and advice for after you have had your baby.

How should I care for my stitches?

Keeping your stitches clean

  • Wash your hands before and after you visit the toilet. This helps prevent introducing infection to the area when you wipe yourself.
  • Change your sanitary pads frequently, about every 2-4 hours.
  • Shower at least once a day avoiding using soap and disinfectants.
  • Using a clean jug, pour warm water over your perineum when you pass urine. The warm water will provide some comfort.
  • Dry the area using a clean flannel or towel. Keep a separate towel for this area and change it daily.
  • When you are at home and have some privacy, you may find relief by lying in bed without a sanitary pad and letting the perineum ‘air dry’.
  • Avoid wearing tight trousers or jeans.

Occasionally your stitches can come loose or undone, leaving an opening or gap in your wound. This is called a perineal wound dehiscence or breakdown. If this happens and you are concerned, you can call your community midwife. You may be referred to maternity triage or advised to see your GP for possible treatment.

You can read more about perineal wound breakdown here:

Diet and fluids

Drinking plenty of water, about 2-3 litres a day, will help dilute your urine and avoid irritation when you pass urine as well as helping to avoid dehydration.

Eating a healthy balanced diet with increased fibre, including fresh fruit, vegetables, cereals and wholemeal bread, will help with healing and avoid constipation.

Opening your bowels

You can safely open your bowels without any damage occurring to your perineum or stitches after the birth. The first few times you open your bowels you may want to hold a clean sanitary pad against your perineum to protect your stitches and provide some support.

Pelvic floor exercises

Regular pelvic floor exercises will increase the blood flow to the wound and promote healing.

Your pelvic floor can become weak after having a baby. Pelvic floor exercises strengthen the muscles around your bladder, vagina and back passage. Strengthening your pelvic floor muscles improves your bladder and bowel control. It will improve urinary incontinence (leaking) and it will improve having an urgency to pass urine or open your bowels.

This video gives advice about doing pelvic floor exercises effectively:

You can also download the NHS Squeezy app for further guidance: 

What happens if I have a severe perineal tear?

If you sustain a tear that involves the back passage or anal sphincter muscle during the birth of your baby (a 3rd or 4th degree tear), you will receive additional care, advice and support for your recovery. This leaflet will be given to you before going home:

You will be offered an appointment in the Perineal Health clinic about 4 – 6 weeks after the birth. You will be seen in the clinic by the Perineal Specialist Midwife – Katy Wickham

The clinic is held every Thursday in the Willow Building at Kingston Hospital.

Further support and information is available through the Masic Foundation: Home – Aiming to change the lives of women injured during childbirth. (

What kind of birth can I have after a severe perineal tear?

If you have experienced a 3rd or 4th degree perineal tear in a previous birth and are newly pregnant, you will automatically be referred to the Perineal Health clinic at your first antenatal appointment (“Booking appointment”). You will be seen in the clinic at around 24 weeks pregnant.

At this appointment, you will be able to discuss your options based on your individual circumstances and preferences. Many women go on to have a straightforward vaginal birth after a 3rd or 4th degree tear. If you continue to experience symptoms, you may wish to consider a planned caesarean birth.

Can I be referred to the perineal clinic?

You may be referred to the perineal clinic by your Community Midwife if you experience problems with perineal wound healing, infections, or ongoing perineal pain after the birth.

The clinic is held every Thursday in the Willow Building.

We also provide a weekly Consultant-led clinic for women who have sustained a 3rd or 4th degree tear (a tear that involves the muscles surrounding the anus or back passage).

We offer endo-anal ultrasound scans to assess healing of the tear and counsel women regarding future births.  We also see women in their next pregnancy if required.

You can read more about endoanal scans here: Endoanal Scan info Leaflet

If you wish to contact our Perineal Specialist Midwife Katy Wickham please email

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