Perineal Recovery After Birth: Tears, Stitches, and Healing

Up to 85% of women who have a vaginal birth experience some degree of perineal trauma. Despite being extremely common, it's rarely discussed with the same openness as other birth experiences. Here's what you need to know.

Types of perineal tear

Tears are classified by degree:

First degree: Skin only — the perineal skin tears but not the underlying muscle. Often doesn't need stitches and heals well on its own.

Second degree: Skin and the perineal muscle underneath. Most common type requiring stitches. Heals well with appropriate care.

Third degree: Skin, muscle, and extending to the anal sphincter (outer muscle ring of the anus). Less common — about 1–3% of vaginal births. Requires surgical repair, usually in theatre. Carries a risk of longer-term complications.

Fourth degree: As above, extending through the anal sphincter into the rectal mucosa. Least common. Requires surgical repair.

Third and fourth degree tears are collectively called OASI (Obstetric Anal Sphincter Injuries). The risk factors are first birth, large baby, instrumental delivery (forceps or ventouse), and shoulder dystocia. They can be identified at birth and repaired immediately.

Episiotomy: A surgical cut made at the perineum to facilitate birth or assisted delivery. Heals in the same way as a second or third degree tear.

Stitches: what to expect

Stitches are usually dissolvable — they absorb over 2–6 weeks. You don't need to have them removed.

First week:

• Significant soreness — expect this
• Swelling and bruising
• Discomfort sitting, walking, and moving bowels

What helps:

• Ice packs in the first 24–48 hours — a maternity pad soaked in water and frozen, or frozen peas wrapped in cloth. Use for 15–20 minutes at a time
• Paracetamol and ibuprofen — take regularly, not just when pain is severe, for the first few days
• Pelvic floor exercises — start these as soon as you're able to do them (even a gentle attempt at clenching counts). They increase blood flow and aid healing
• Keep the area clean — wash gently with warm water after using the toilet. A portable shower head or squeezable water bottle is useful. Pat dry rather than wiping
• Urinating: It may sting. Pouring warm water over the area while urinating reduces the sting. If you cannot pass urine 6 hours after birth, contact your midwife.
• Bowel movements: Take a stool softener (lactulose, available over-the-counter) to avoid straining. The stitches won't tear from opening your bowels — they're stronger than that. But straining is uncomfortable and unnecessary.

Using the toilet after stitches

The fear of passing stool with stitches is near-universal. Know that:

• The stitches do not tear
• A softened stool with the help of lactulose is much easier and less uncomfortable
• Supporting the perineum with a clean pad while having a bowel movement can help psychologically and physically
• Delaying the first bowel movement makes it harder — try to go by day 2–3

Healing timeline

• Week 1: Soreness, swelling, bruising — most uncomfortable period
• Week 2: Significant improvement; stitches beginning to dissolve
• Week 3–4: Most external healing complete; may still feel tender internally
• 6 weeks: Usually considered healed, though deep internal healing takes longer

First/second degree tears: Most women feel significantly better by 2–3 weeks.

Third/fourth degree: Recovery is longer — 3–6 months is not unusual for full recovery, and pelvic floor physiotherapy is strongly recommended.

The 6-week check

Mention any ongoing pain or discomfort at your 6-week check. Many women don't — they assume it's normal, or feel embarrassed. It's not embarrassing and it matters. Issues worth raising:

• Pain with sex (common — try again at 3 months if 6 weeks feels too soon)
• Any leaking of urine, wind, or faeces
• Persistent pain beyond 6 weeks
• Feeling that something is different or not right

When to call your midwife before 6 weeks

• Signs of infection: Wound that smells offensive, increasing redness or swelling, discharge, or fever
• Wound that has come apart — stitches separating before healing is complete
• Unable to control wind or faeces — leaking of stool or uncontrollable wind, particularly if this developed after a birth that seemed uncomplicated (possible undiagnosed third-degree tear)
• Pain that is getting worse rather than better after the first week
• Difficulty urinating or passing no urine

Pelvic floor rehabilitation

Begin gentle pelvic floor exercises as soon as possible after birth — even while sore. These are the single most important thing you can do for long-term pelvic health.

See a pelvic health physiotherapist — NHS referral via your GP. This is available to all postnatal women in the UK, though waiting times vary by area. Private physiotherapy is also widely available.

A physiotherapist will assess your pelvic floor, check healing (including internal assessment), and provide a progressive rehabilitation programme. This is not optional after third or fourth degree tears — it's a clinical recommendation.