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Are you nervous about tearing during labor and delivery? Are you fearful of the pain and recovery? Yup, I was too (even as a pelvic floor physical therapist). Unfortunately, there is not much education provided to you as a patient during pregnancy about the actual details of vaginal delivery. What is tearing? Is the muscle tearing? The skin? Does it hurt? Will I need stitches? There are so many questions! 

Most of what you may have heard up until this point has come from a close friend or from your deep dive on Instagram or TikTok, and that’s ok! But I want better for you. I want to provide you with the knowledge about what to expect with perineal tearing so that you feel educated and empowered about your birth experience upon leaving the hospital, and so you feel confident in starting your postpartum recovery.

Overview of Anatomy

In order to fully understand the types of perineal tearing that may occur during childbirth, it is important to know exactly WHERE these tears occur so that you can know how best to assist the recovery process. You may also want to check out my blog post on ways to reduce perineal tearing if you have not given birth yet!

Perineal tears occur in the perineum which is the space between your vaginal opening and your anal sphincter.

Here’s a helpful visual.

(Image used with permission from Pelvic Guru®, LLC)

This space is often referred to as the perineal space, and it is the most common area where tearing will occur during a vaginal delivery. The perineal space creates a boundary from the anterior (front) portion of your pelvic floor called the urogenital triangle, and the posterior (back) portion of your pelvic floor called the anal triangle.

Who knew the pelvic floor had a front and back half, right?

During a vaginal delivery, your vaginal opening will stretch around your baby’s head and around 9 in 10 women will experience some form of tearing during this process.

You are not alone.

Now, the severity of your tear will dictate just how long recovery will take. The more severe the tear, the longer the recovery. 

Here’s a quick breakdown of the four degrees of perineal tearing.

• Grade 1 – involves the perineal skin
• Grade 2 – involves the perineal skin and underlying muscle
• Grade 3 – involves the perineal skin, underlying muscle and muscle surrounding the anal sphincter
• Grade 4 – involves the perineal skin, underlying muscle, muscle surrounding the anal sphincter and the lining of the rectum

(Image used with permission from Pelvic Guru®, LLC)

Grade 1 – First Degree

There are four grades of perineal tears that can occur during childbirth and first degree perineal tears are the least severe. 

Remember when you were young and carefree during your childhood? You likely experienced a scrape or two to the knee from playing with your friends or siblings in the backyard. The scrape broke the skin, maybe bled a little, but in the end all it really needed was to be cleaned and covered with a bandaid. Think of this as a first degree tear.

First degree perineal tears only affect the skin of the perineum and can be thought of as small grazes or scrapes. They usually do not require stitches and your provider will likely apply pressure over the tear to stop the bleeding as the wound forms a clot. 

These types of tears heal quickly and do not typically result in long-term complications, but they can still be sore (just like that scraped knee from your childhood).

While recovering from a first degree perineal tear, it is still imperative to refrain from wiping for 1-2 weeks until the stitches dissolve. 

The hospital may or may not provide you with a peri bottle (most US hospitals do provide this), however I still highly encourage you to invest in one of these peri bottles with a long stem to make it MUCH easier to reach and rinse your vulva without having to do some form of gymnastics.

Grade 2 – Second Degree

Of all the four grades of perineal tearing, second degree perineal tears are the most common. First and second degree tears account for the majority of all perineal tears during childbirth.

While first degree tears only involve the skin of the perineum, second degree tears involve both the skin and the muscle beneath. 

Let’s take another trip down my childhood memory lane. I am the youngest of four and basically served as a real-life baby doll to my older siblings growing up. One day we were all playing a game in the family room that involved swinging me around by my feet so that my entire body merely floated above the ground – sounds fun right? It was all fun and games until my head made contact with the foot of the sofa leaving a nice little gash just about my eyebrow. While it bled and seemed absolutely terrifying in the moment, I walked away from the incident with 5 stitches and a cool story to share with friends. Within two weeks I was stitch free and back to our sibling chaos.

That is your second degree tear. 

It breaks the skin and the muscle below, but it usually only requires some local anesthetic and a few sutures while you are performing skin-to-skin with your baby. You may not even realize what is happening!

Just like a first degree tear, a second degree tear is not likely to result in long-term concerns, but it will still be sore for a few weeks requiring the use of a peri bottle to clean after toileting to avoid wiping and agitating the area.

Peri bottle pro tip: fill it with slightly WARM water. Your vulva will thank you.

Grade 3 – Third-Degree

Both third and fourth degree perineal tears are considered more severe and both will require sutures.

Third and fourth degree perineal tears occur in about 6 of 100 births for first time vaginal deliveries and about 2 in 100 births for subsequent vaginal deliveries. A third degree tear extends through the skin and underlying muscle of the perineum as well as the muscle that encircles the anal sphincter.

Often this severity of tearing requires spinal or epidural anesthesia and may be performed in an operating room rather than in the delivery room. 

You will likely experience more discomfort with a third degree perineal tear compared to a first or second degree, and the pain may last 2-3 weeks. Additionally, because of the anal sphincter involvement, it is possible that you may experience fecal incontinence, which is why working with a pelvic floor physical therapist is SO important postpartum. 

It is important to keep the area clean to reduce your risk of infection, so you will want to continue using your peri bottle for hygiene after toileting until your sutures have dissolved. Many of my patients, regardless of tear severity, opt to use the peri bottle for the first six weeks simply because it feels so soothing on your vulva!

Grade 4 – Fourth-Degree

The most severe type of perineal tearing is a fourth degree tear. 

A fourth degree tear is not very common, but it does still occur and should be something you are aware of. These types of perineal tears involve the perineal skin, underlying muscle, muscle surrounding the anal sphincter and lining of the rectum.

Third and Fourth-Degree Perineal Tearing Risk Factors

• First vaginal delivery
• Large baby (>4kg or 8lbs 13 ounces)
• Prolonged labor
• Baby’s position
• Assisted vaginal delivery via use of forceps or vacuum
• Midline episiotomy
• Short perineum

Just like a third degree tear, a fourth degree tear requires sutures that are usually performed in an operating room under spinal or epidural anesthesia. 

You will likely be sore for 2-4 weeks and it is imperative to keep the area clean using your peri bottle as well as to avoid any excessive pressure at the anus (avoid deep squatting for now) to ensure there is no disruption to the suture site. Here is a list of some helpful postpartum essentials!

Please remember, while third and fourth degree tears seem scary and invoke feelings of fear, I want you to know that you have a very low likelihood of developing one of these tears AND if you do…THERE IS HELP! Pelvic floor physical therapists specialize in helping women recover from childbirth trauma including fecal incontinence, urinary incontinence, pain with intercourse, perineal scar massage and so much more!

Other Types of Tearing

Perineal tears receive the bulk of the coverage on the internet regarding tearing during childbirth, and rightfully so as they are the most common. 

But did you know that tearing can involve other structures aside from the perineum?

Types of tearing during vaginal birth:

• Perineal tears – tear in the perineum (what we have been covering)
• Sulcus tears – tear in the upper vaginal wall in the absence of a third or fourth-degree perineal tear
• Clitoral and periclitoral tears – tear involving or around the clitoris
• Periurethral tears – tear around the urethra
• Labial tears – tear in the labia minora
• Vaginal wall tears – tear in the vagina

What to Expect During Recovery

Whether you experience a perineal tear or any other type of tear during childbirth, you want to spend an adequate amount of time healing and recovering.

You can expect to experience some discomfort and pain at varying levels depending on the severity of the tear, but your pain levels should improve with each passing day. Activities such as walking, peeing, pooping, sitting and lifting your baby can all be uncomfortable during the first 1-2 weeks.

It is common to experience pelvic floor dysfunctions such as urinary incontinence (both urge and stress), fecal incontinence, pelvic pain and pain with intercourse following perineal tearing, but please know it does NOT need to be your “new normal.” There is help!

You can work with a pelvic floor therapist to address your concerns as early as you feel comfortable postpartum –  though many therapists will have you wait 6 weeks.
If accessing a pelvic floor therapist is not possible due to location, affordability or availability, my Movement Through Early Postpartum program is perfect for you! Inside the course you’ll find weekly movement and workouts as well as educational modules tackling topics such as perineal tearing, toileting techniques and pain with intercourse. You can begin the program as early as day 1 postpartum whether you have had a vaginal or cesarean delivery to help you recover from labor, reduce pain and rebuild your core, pelvic floor and full body so you can reclaim control of your body after birth and beyond!