Perineal tears and episiotomy during childbirth

During birth the area between the vagina and anus (the perineum) needs to stretch a lot and it might tear. Some women and birthing people have an episiotomy when they give birth. For some women and those giving birth this is a traumatic emotional as well as physical experience. Here we talk about what happens and what to expect. In our other article we address care and recovery in more detail.

What is the difference between an episiotomy and a perineal tear?

An episiotomy is a cut made by a health professional, while a perineal tear happens on its own during the second stage of labour. When a baby is being born, the perineum needs to stretch a lot and sometimes tears on its own. If the caregiver feels there may be significant tearing, they may suggest a cut to direct any tearing away from the anus.

How common are tears and episiotomies?

While up to 9 in 10 first time mothers and birthing people have a graze, tear, or episiotomy, most of these heal easily (NHS, 2023). A graze may also be called a first-degree tear. It’s superficial, affecting only the skin, and probably won’t need stitches. It is likely to be sore, but heal quickly (RCOG, No date).

A second-degree tear includes the skin and some muscle and will need stitches. These will be stitched in the same room as you gave birth. They will be sore for a couple of weeks but are unlikely to cause long term problems (RCOG, No date).

A few tears are more significant as they affect the anus, and it is these that the episiotomy is aiming to avoid. They are called third or fourth degree and will be stitched in theatre. They affect 6 in 100 first time mothers, and less than 2 in 100 in subsequent births.

The most severe tears can lead to anal incontinence. Around 7 in 10 women are completely healed 12 months after a repair of third or fourth-degree tear. Some women and their partners find a significant tear distressing and may find it helpful to seek support for birth trauma (RCOG, 2015; RCOG, No date).

For 4-6 weeks after such a tear you should avoid heavy lifting or straining. While there is likely to be no impact of third or fourth-degree tears on subsequent births, you can discuss your preferences with your caregiver (RCOG, No date).

Why is an episiotomy offered?

Episiotomies aim to reduce the chance of more serious tearing and to facilitate vaginal birth with forceps or ventouse. The procedure is only offered when there seems to be a clinical need and after discussion with the woman (NICE, 2023).

The main reasons are:

Forceps or ventouse are being used to help you give birth to your baby.
Your baby is in distress (their heart rate gets much faster or slower) and your caregivers want to help them be born quickly.
You have a serious health condition that requires your baby’s birth to be as quick as possible to minimise risks to you.
Women who have experienced Female Genital Mutilation (FGM).
Episiotomy is not routinely offered to women who have previously had a significant tear.

(NICE, 2023; RCOG, No date)

What to expect during an episiotomy

In labour you should expect your caregivers to discuss ways of reducing the chance of perineal trauma. They may offer a warm compress on the perineum, or massage, if you find either of those acceptable.
If an episiotomy is indicated, this should be explained to you and your consent sought.
If you agree, you will be offered a local anaesthetic for pain relief if you do not have an epidural in place. Only if your baby is at urgent risk will an episiotomy be carried out without anaesthetic.
The cut in the perineum is small and diagonal. It goes from the back of the vaginal opening, at an angle down and to one side.
The doctor or midwife will stitch up the cut after your baby is born using dissolvable stitches.

(NICE, 2023)

What happens next?

Episiotomy cuts are stitched soon after your baby's birth. If you have been in water then there may be a delay to allow the tissues to dry a little.
The cut will bleed to start with, but this should stop with pressure and stitches.
Your wound should heal within a month of your baby’s birth.

(NHS, 2023)

Read more in our article on care and recovery after episiotomy.

What can reduce my chance of tearing?

RCOG recommend perineal massage during pregnancy, especially for first time mothers (RCOG, No date). For more information on how to do it, see our article on perineal massage.

During labour your midwife may suggest puffing out through your mouth. The idea is to allow your perineum time to stretch and help your baby’s head be born slowly (NHS, 2023). Some women find it helpful to use a mirror to help guide their gentle pushing.

This page was last reviewed in May 2024