Perineal tearing during birth: causes, prevention, and recovery

You’ve probably spent plenty of time preparing for labor — practicing breathing techniques, thinking through your birth plan, and picturing what those first contractions might feel like. It’s also common to worry about tearing during childbirth. The idea can sound scary if you’re not sure what it really means or what recovery involves.

Perineal tears are very common during vaginal birth, occurring in up to 90% of vaginal deliveries. Most are minor and heal well with simple treatments, such as pelvic floor physical therapy and targeted exercises. “Your body is designed to adapt to birth,” says Alexandra Jones, PT, DPT, a pelvic floor physical therapist at Hinge Health. “While we can't eliminate every risk, there are practical ways to prepare during pregnancy and support your recovery afterward.”

Ahead, learn what perineal tearing is, which factors may increase your risk, and simple strategies that Hinge Health pelvic floor physical therapists recommend to help support your body before, during, and after delivery.

What is perineal tearing?

A perineal tear is a tear (or laceration) in the tissue between your vaginal opening and your anus, called the perineum. It most commonly happens during vaginal delivery as your baby’s head stretches the vaginal opening and surrounding tissue.

Perineal tears are especially common during a first vaginal birth. In some situations, your healthcare provider may make a small surgical cut in the perineum, called an episiotomy, to help facilitate delivery.

Many tears only involve the skin and heal with little intervention. Others extend into deeper muscles and require stitches or additional treatment.

Degrees of perineal tears

Healthcare providers classify perineal tears based on how much tissue was affected. These include:

• First-degree tear. This affects only the skin around the vaginal opening and perineum. These small tears often heal within a few weeks and may not require stitches.

• Second-degree tear. This extends into the muscles beneath the skin. These tears usually require stitches and typically heal within three to four weeks.

• Third-degree tear. This extends into the anal sphincter muscles. These tears require surgical repair and generally take four to six weeks or longer to heal.

• Fourth-degree tear. This is the most severe type, extending through the anal sphincter into the rectum. Fourth-degree tears are repaired in the operating room and often require a longer recovery.

First- and second-degree tears are by far the most common. Third- and fourth-degree tears occur in approximately 4% to 11% of vaginal deliveries in the United States.

Causes of perineal tearing during birth

Perineal tears happen as the tissues around the vaginal opening stretch to allow your baby to be born. “Most of the time, it’s not caused by one single thing,” says Dr. Jones. “It’s usually a combination of labor mechanics, your baby’s position, tissue elasticity, and your own anatomy.”

Factors that may increase the likelihood of tearing include:

• First vaginal delivery. This is one of the strongest risk factors because the tissues haven’t previously stretched during childbirth. “With each additional vaginal birth, the risk of significant perineal trauma generally decreases,” says Dr. Jones.

• Larger baby size. Babies weighing more than about eight to nine pounds may increase the amount of stretching required during delivery.

• Baby’s position. Babies facing upward (instead of toward your back) can place more pressure on the perineum and sometimes make pushing more challenging, explains Dr. Jones.

• Assisted delivery. Forceps-assisted deliveries carry a higher risk of more significant tears than spontaneous vaginal births or vacuum-assisted deliveries.

• Rapid or prolonged second stage of labor. When the pushing stage happens very suddenly, the tissues may have less time to gradually stretch. On the other hand, a prolonged second stage of labor can also increase stress on your perineum.

• Shoulder dystocia. If a baby’s shoulder becomes temporarily stuck after the head is delivered, additional maneuvers may be needed to complete the birth, increasing strain on surrounding tissues.

• Lack of perineal tissue elasticity. Everyone’s connective tissue is different. Genetics, age, and other individual factors can influence how easily the perineum stretches during labor.

How to prevent perineal tearing during birth

There's no way to completely prevent perineal tearing. So the goal isn’t necessarily to avoid tearing altogether. Instead, these simple strategies may help your tissues stretch more comfortably and may reduce the likelihood of more severe tears.

• Perineal massage. This targeted massage gently stretches the tissues around the vaginal opening, helping improve mobility and flexibility before labor. It can be started around 34 weeks of pregnancy and may also be used during labor. “Prenatal perineal massage also helps people become more familiar with the sensation of pressure and stretching,” says Dr. Jones. “That familiarity may reduce fear and muscle guarding during delivery.”

• Pelvic floor physical therapy. One of the main goals of pelvic floor physical therapy (PT) during pregnancy is to help you learn how to relax your pelvic floor muscles leading up to childbirth, which can help reduce the risk or severity of tearing, says Dr. Jones. A pelvic floor PT can help you ease pelvic floor tension, coordinate breathing with pelvic floor movements, reduce muscle guarding or fear-based muscle tension, and learn pushing mechanics that help reduce strain on the perineum. You can see a physical therapist in person or use a program like Hinge Health, where you may access a PT via telehealth/video visit.

• Diaphragmatic breathing. Deep belly breathing helps your diaphragm and pelvic floor work together. “During an inhale, the pelvic floor naturally lengthens a little,” Dr. Jones explains. “Practicing that relationship before labor may make it easier to relax those muscles during delivery.”

• Explore different birthing positions. No single labor position completely prevents tearing, but some positions may place less stress on the perineum for certain people. Upright positions, squatting, kneeling, or side-lying may allow tissues to stretch differently than lying flat on your back. “Research is mixed, and there isn’t one position that’s best for everyone,” says Dr. Jones. “The safest and most comfortable position depends on the individual and how labor is progressing.” Your healthcare provider can help find the birth position that’s safe and effective for you.

• Practice controlled pushing. Pushing slowly and steadily during contractions gives tissues more time to stretch than forceful, prolonged breath-holding. Your healthcare team can help coach you through the pushing stage using techniques that are appropriate for your labor.

• Apply a warm compress to the area during delivery. Applying warm compresses to the perineum during the pushing stage may improve circulation, encourage relaxation of the tissues, and reduce the likelihood of more severe tears. While it won’t eliminate the risk of tearing, it’s a simple strategy many birth teams use to help support the perineum during delivery.

Treatments and recovery from perineal tears

Recovering from a perineal tear can be uncomfortable, especially during the first few weeks of postpartum. How long recovery takes depends on the severity of the tear. Minor tears often heal within several weeks, while more extensive third- and fourth-degree tears usually require a longer recovery and closer follow-up.

Most people improve steadily with time. In addition to allowing your body to heal, your healthcare provider may recommend strategies to ease discomfort, restore pelvic floor function, and help you return to your usual activities with confidence. These strategies include:

• Pelvic floor physical therapy and targeted exercises. Physical therapy and guided pelvic floor exercises can help restore strength and endurance in the pelvic floor and other muscles affected by pregnancy and delivery. Depending on your symptoms, therapy may also help improve bladder or bowel function, reduce discomfort with daily activities or sex, and build confidence as you return to exercise. Always check with your healthcare provider or care team before starting any postpartum exercise. You can see a physical therapist in person or use a program like Hinge Health, where you may access a PT via telehealth/video visit. 

• Keep the area clean. Use a peri bottle (squeeze bottle) with warm water after using the bathroom, then gently pat the area dry instead of wiping. Practicing simple hygiene habits like this one can help reduce irritation and support healing.

• Soothe the area with holistic remedies. This can look like applying cold therapy to the area to ease swelling and quell pain, or taking a sitz bath in warm, shallow water for about 10 to 15 min. Some people also find relief from using a ring pillow when sitting. 

• Take over-the-counter (OTC) medication as needed. Pain relievers such as ibuprofen (Advil, Motrin) and acetaminophen (Tylenol) are generally considered safe to use for postpartum pain relief — including while breastfeeding — but always check with your provider.

• Manage constipation. When you’re backed up, it can place extra pressure on healing tissues and make bowel movements more uncomfortable. Aim for 25 to 35 grams of fiber each day from foods like fruits, vegetables, beans, and whole grains, and stay well hydrated. Your healthcare provider may also recommend a stool softener during early recovery.

• Ease back into movement. You may need to avoid heavy lifting and strenuous exercise until your healthcare provider says it's safe. But that doesn’t mean you should avoid movement altogether. Gentle activity, especially walking, increases circulation, reduces stiffness, and supports healing. “Healing tissues generally respond better to gradual, supported movement than complete avoidance,” says Dr. Jones. Start slowly and build your activity as your comfort improves.

When to see a healthcare provider

Most perineal tears heal steadily over the first several weeks. But contact your healthcare provider if your pain is severe, getting worse instead of better, or making it difficult to care for yourself or your baby.

It's also important to seek care if you have:

• Fever (100.4°F or higher) or chills

• Increasing redness, warmth, swelling, or drainage around the tear

• Sudden or worsening pain

• Foul-smelling vaginal discharge

• Heavy bleeding or passage of large blood clots

• Painful urination or urinary incontinence

• Severe pain with bowel movements or difficulty controlling your bowels

PT tip: Don’t be afraid to move

“It makes sense to feel nervous about walking, exercising, or even sitting after a tear,” says Dr. Jones. “But gentle movement, breathing, and gradually returning to activity are all important parts of recovery.”

While you should always follow your provider's postpartum guidance, avoiding movement completely can actually make you feel stiffer and more uncomfortable. With time, proper care, and gradual activity, most people heal well and return to the activities that matter most to them.

How Hinge Health can help you

If you have pelvic pain, bladder, bowel, or other pelvic symptoms that are affecting your quality of life, you can get the relief you've been looking for with Hinge Health’s online exercise therapy program.

The best part: You don’t have to leave your home because our program is digital. That means you can easily get the care you need through our app, when and where it works for you. Through our program, you’ll have access to therapeutic exercises and stretches for your condition. Additionally, you’ll have a personal care team to guide, support, and tailor our program to you.

See if you qualify for Hinge Health and confirm free coverage through your employer or benefit plan here.

This article and its contents are provided for educational and informational purposes only and do not constitute medical advice or professional services specific to you or your medical condition.

References

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3. Okeahialam, N. A., Sultan, A. H., & Thakar, R. (2023). The prevention of perineal trauma during vaginal birth. American Journal of Obstetrics and Gynecology, 230(3). doi:10.1016/j.ajog.2022.06.021

4. Perineal Tear: What to Expect at Home | Kaiser Permanente. (n.d.). Healthy.kaiserpermanente.org. https://healthy.kaiserpermanente.org/health-wellness/health-encyclopedia/he.perineal-tear-what-to-expect-at-home.abn2976

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6. RCOG. (2023). Perineal tears during childbirth. RCOG. https://www.rcog.org.uk/for-the-public/perineal-tears-and-episiotomies-in-childbirth/perineal-tears-during-childbirth/