Vaginal and Perineal Tears After Childbirth

At the risk of stating the obvious, a vaginal delivery requires your vagina to stretch (and stretch…) so it can accommodate the arrival of your baby into the world. And every woman who delivers vaginally — and sometimes even those who experience a lengthy labor before delivering via C-section — can expect some level of perineal postpartum pain. 

It’s rather common, given the pressure from your baby’s head pushing through, to experience tears and lacerations in your perineum, the area between your vagina and your anus, and sometimes your cervix as well. In fact, more than half of all women will have at least a small tear after childbirth. 

Understanding the causes of these tears, as well as the various types you might experience, can go a long way toward helping you to prepare for labor and delivery. And you can also learn how to ease any discomfort you experience and possibly work to prevent tears in the first place. 

What is a vaginal or perineal tear? 

A vaginal or perineal tear or laceration is a rip in the skin and sometimes the tissue or muscle around your vagina and perineum, the area located between the vaginal and anal opening. Vaginal tears are relatively common, occurring in up to half of all women.

What causes vaginal or perineal tears during childbirth? 

Your body is a wondrous machine that’s actually designed for vaginal births, but some babies don’t always exit so easily. During labor and delivery, the vaginal skin will thin out so it can stretch, thereby allowing your baby’s head, body and limbs to slide out. But in some cases, the vagina or perineum tears — and here’s why:

• First birth. Your body may not cooperate the first time you push, resulting in a tear.
• Fast birth. A very quick labor may not allow the skin enough time to thin and stretch.
• A big baby. If your infant weighs more than 8 pounds, a tear is more likely.
• A face-up baby. Also called “sunny side up,” a baby in this position has to extend his head and neck under the pubic bone in order to exit, increasing the risk of a tear.
• Use of forceps or vacuum. These tools may also cause vaginal or perineal lacerations.
• Prior episiotomy. Some vaginal incisions, especially midline episiotomies, can lead to fourth-degree or severe vaginal tearing.  

What are the different types of vaginal tears that can occur during childbirth? 

There are a handful of different types of vaginal tears that can happen during labor and delivery, and their labels are based on severity. Here’s more about each one:

• First-degree tear. This is the least severe and involves a small tear of the perineal skin.
• Second-degree tear. This injury is the most common and is a slightly deeper tear that extends to the skin and muscle of the perineum and sometimes the vagina.
• Third-degree tear. This level can tear into the muscles from the vagina to the anus. 
• Fourth-degree tear. Most severe, though thankfully rare, this injury can extend from the vagina to the anal sphincter muscles and into the rectum.  

How are vaginal tears treated?

Stitches are required to treat tears that are longer than 2 centimeters or about an inch in size, which includes second-, third- and fourth-degree lacerations. A first-degree tear, however, usually heals on its own. You may be stitched up right in the delivery room, though more severe tears are sometimes repaired under anesthesia, possibly by a specialist, in an operating room.

In cases in which a third- or fourth-degree laceration occurs, immediate care should include adequate pain control, steps to avoid postpartum constipation and evaluation for urinary retention. The American College of Obstetricians and Gynecologists (ACOG) support the use of broad spectrum antibiotics to reduce the incidence of postoperative infection for third- and fourth-degree lacerations.

How long does it take for vaginal tears to heal?

Whether you had a vaginal tear or an incision, a new wound like this one will take time to heal, usually seven to 10 days. Stiches used in the repair of various tears will dissolve on their own within six weeks.

The site of the tear, however, will likely hurt for several weeks — and more severe tears may take longer to heal — so take it easy in the meantime. 

How do you care for vaginal tears after childbirth?

As mentioned, your stitches will absorb over time, but you can help your tears heal more quickly by following your practitioner’s instructions for postpartum perineal hygiene. Here’s how to keep this area healthy, prevent infection and promote healing:

• Spritz it. Squirt your perineum with warm water in a plastic bottle during and after urinating.
• Dry with care. Use gentle patting — no rubbing — with gauze pads or paper wipes that come with your hospital-approved sanitary pads and change pads at least every four to six hours.
• Keep hands to home. That means, don’t touch! If you're constantly "testing" how the site's healing by probing it, it's going to take longer to get better.
• Air it out. Exposing the area to the air can help it heal more quickly and ease pain.
• Stay regular. The sooner you can get your bowels moving, the better all around (don’t fret if it takes a few days). It’s natural to be scared about splitting your stitches during your first postpartum bowel movement. But don’t worry — you won’t. 
• Eat right. To help move your bowels along, chow down on roughage like whole grains, fresh fruits and veggies, drink plenty of water, and, when you’re ready, take short strolls. 
• Go OTC. If your bowels aren’t cooperating, you might ask your practitioner about an over-the-counter stool softener or mild laxative to ease constipation.
• Do your Kegels. After delivery, continue doing your Kegels as soon as you can — even if you can't feel yourself doing it — as these exercises can stimulate circulation and help you heal faster. They're great for muscle tone and may decrease your risk of incontinence.

How to reduce pain from vaginal tears

The pain is real when it comes to vaginal tears, but there are some ways to get relief:

• Ice. Chilled witch hazel pads, crushed ice in a plastic bag or wash cloth or a maxi-pad lined with a plastic cold pack can fight swelling. 
• Heat. Take a warm sitz bath for 20 minutes three times a day, or apply warm compresses. 
• Numbing. Your practitioner may recommend an anesthetic to numb the area, which are generally over-the-counter options such as sprays and ointments.
• Avoid straining. Don’t plan on activities that could cause strain. Sleep on your side, and try not to stand or sit for long periods of time, which can increase perineal pain. 
• Cushioning. Donut-shaped pillows or rings that are marketed for hemorrhoid sufferers could give you some comfort while you sit. If you had hemorrhoids during pregnancy and are still recovering, you can kill two pains with one pillow!

Is there anything you can do to prevent vaginal tears?

There’s no guaranteed way to prevent vaginal tears during labor and delivery, but doing your Kegel exercises and performing perineal massage in the month or so before your due date may help to make your perineal area softer and better able to stretch over your baby's head as she exits.

Applying warm compresses to the perineum and using perineal massage during labor may also help you avoid tears as can controlled labor, which means pushing only when you feel the urge and allowing your skin enough time to stretch. In women who have not had a previous vaginal birth, a meta-analysis of randomized trials found that perineal massage during pregnancy reduced perineal trauma (mainly episiotomies) but did not reduce first- or second-degree perineal tears, or third- or fourth-degree perineal trauma.

Lastly, there’s some evidence that delivering while on all fours, rather than squatting or lying on your back, can reduce the risk of tears.

And while episiotomies were once standard protocol in order to widen the vaginal opening, this cut doesn’t always prevent tearing and it can even put you at risk for more severe lacerations. In fact, routine episiotomies are no longer recommended by ACOG, though one may be needed due to a baby’s size, position or another situation.

When to call the doctor about a vaginal or perineal tear

If your perineum becomes very red, very painful or swollen, or if you detect an unpleasant odor, you may have developed an infection, so be sure to get in touch with your practitioner. And always make a call if you develop a fever or the pain you experience doesn’t ease, even with medication.