Episiotomy and Perineal Tears: Care, Recovery and Future Birth
Key message: Most perineal tears heal well, but third- and fourth-degree tears involve the anal sphincter and need…
Key message: Most perineal tears heal well, but third- and fourth-degree tears involve the anal sphincter and need specialist repair, antibiotics, laxatives and follow-up. Persistent pain, bowel leakage or wound problems deserve treatment.
Get urgent help: Seek same-day or urgent care for increasing severe pain, fever, offensive discharge, pus, wound opening, heavy bleeding, inability to pass urine, loss of bowel control, severe weakness or feeling very unwell. Chest pain, breathlessness or a swollen painful leg is an emergency.
What are the different degrees of tear?
| Degree | Tissue involved |
|---|---|
| First | Skin and superficial tissue. |
| Second | Perineal muscles but not the anal sphincter. |
| Third | Part or all of the anal sphincter complex. |
| Fourth | Anal sphincter and the lining of the rectum. |
What is an episiotomy?
An episiotomy is a surgical cut in the perineum, usually angled away from the anus, to enlarge the vaginal opening. It is used selectively rather than routinely.
It may be recommended for fetal urgency, assisted vaginal birth or when the clinician believes it may reduce an uncontrolled severe tear in the circumstances.
How are tears repaired?
Second-degree tears and episiotomies are usually repaired with dissolvable stitches using local, epidural or spinal anaesthesia. Third- and fourth-degree tears are repaired in theatre by an appropriately trained clinician, usually with regional or general anaesthesia.
A rectal examination is part of identifying and checking a severe tear and should be explained.
What helps pain and wound care?
- Regular prescribed pain relief.
- Cool packs wrapped in cloth for short periods during the first days.
- Daily gentle washing with water and careful drying; avoid perfumed products.
- Frequent pad changes and hand hygiene.
- Comfortable side-lying or supported sitting positions.
- Contacting care if pain worsens rather than gradually improves.
How are the bowel and bladder protected?
- Drink and eat fibre regularly.
- Use prescribed laxatives after a severe tear and avoid straining.
- Do not delay passing urine; seek help if unable to urinate.
- Report inability to control wind or stool, urgency or leakage.
- Antibiotics are commonly prescribed after third- or fourth-degree tears.
When do pelvic-floor exercises begin?
Gentle pelvic-floor awareness and relaxation can begin when comfortable. Progress gradually; severe pain, inability to relax, heaviness, bladder or bowel symptoms need pelvic-health physiotherapy.
Intensive squeezing is not appropriate when muscles are overactive or the wound is very painful.
Can severe tears be prevented?
- Perineal massage from around 35 weeks may reduce some trauma, particularly in a first vaginal birth.
- A warm perineal compress during the pushing stage may reduce severe tearing.
- Controlled birth of the head and communication about pushing can help.
- Correctly angled episiotomy may be used selectively in assisted birth.
- No method can guarantee that a tear will not occur.
What follow-up is needed after a third- or fourth-degree tear?
- Review of wound healing, pain, bladder and bowel control and sexual function.
- Pelvic-floor physiotherapy.
- Discussion of the repair and the chance of symptoms recurring.
- Referral for specialist testing if bowel symptoms persist.
- A documented plan for future birth.
When can sex and exercise resume?
Resume when bleeding and the wound have healed and it feels comfortable. Lubricant, gradual activity and pelvic-floor support may help. Persistent pain is treatable and should not be accepted as normal.
Return to impact exercise should wait until healing, strength, bladder/bowel function and pelvic symptoms are assessed.
What about a future birth?
Many patients can plan another vaginal birth after a well-healed severe tear without symptoms. Persistent bowel symptoms, abnormal specialist tests, trauma or preference may support planned caesarean discussion.
The decision is individual and should be made before labour.
Frequently asked questions
Do dissolvable stitches need removal?
Usually no; they dissolve over several weeks.
Is pain normal?
Some pain is expected, but increasing, severe or persistent pain needs review.
Can stitches open?
Wound breakdown can occur, particularly with infection; prompt assessment is needed.
Will a third-degree tear cause permanent bowel problems?
Many recover well, while persistent symptoms need specialist treatment.
Must I have caesarean next time?
No. The decision depends on recovery, symptoms, tests and preference.
Your next step
Attend follow-up after a severe tear and seek care early for wound, bladder, bowel, sexual or emotional symptoms. Do not wait for the routine check if pain or infection is worsening.
Medical and content review: Dr Mohamed Abdelghany, Obstetrics & Gynecology Specialist, MRCOG (UK), MSc Obstetrics & Gynecology – Kasr Al-Ainy, Cairo University.
Last reviewed: 23 August 2026.
This information is for general education and does not replace individual medical assessment. Severe, sudden or concerning symptoms should not wait for a routine appointment.
