Perineal Tears and Stitches

The four degrees, and why the label matters

Perineal tears are graded by how deep they go, and the grade determines both the repair and the follow-up you should get.

• First-degree. The RCOG: "small tears, or grazes, affecting only the skin. They can occur around the labia, clitoris or inside the vagina." These "usually heal quickly and without treatment. They are very unlikely to cause long-term problems, but they can be very sore."
• Second-degree. "Tears affecting the muscle of the perineum and the skin. These usually require stitches." Repair is normally done with local anaesthetic in the room where you gave birth.
• Third- and fourth-degree (OASI). A tear extending into the muscle that controls the anus. The RCOG says these "can occur in 6 out of 100 births (6%) for first time mothers and less than 2 in 100 births (2%) of births for women who have had a vaginal birth before." Repair happens in an operating theatre under spinal or epidural anaesthesia, followed by antibiotics and pain relief.

An episiotomy is a surgical cut, not a tear, and is stitched the same way. If you are not sure what you had, ask — it changes what "normal healing" looks like for you.

What normal healing feels like

The RCOG sets the expectation: "After having any tear, it is normal to feel pain or soreness for 2-3 weeks after giving birth, particularly when walking or sitting. The stitches can irritate as healing takes place but this is normal. The skin part of the wound usually heals within a few weeks of birth, and after that you should feel much less raw and tender."

Two specifics that catch people out:

• Stinging when you pee. Expected. The RCOG's fix: "Pouring body-temperature water over the area when urinating can help." The NHS adds that drinking plenty of water dilutes your urine, which may make it sting less.
• Stitches disappearing on their own. The NHS: "Stitches usually dissolve by the time the cut or tear has healed, but sometimes they have to be taken out." You do not normally need an appointment to have them removed.

Scar tissue may feel uncomfortable "particularly for 2-4 weeks after giving birth," per the RCOG. If that discomfort continues, that is a reason to seek medical attention rather than to wait.

Caring for stitches

The advice from RCOG, NICE, the NHS and the HSE is consistent and unglamorous.

• Water only. The RCOG: "Use only water to keep the area clean. Wash or shower at least once a day and change your sanitary pads regularly." The NHS says to bathe them every day with plain warm water, then "carefully pat yourself dry."
• Hands before and after. Wash before and after using the toilet or changing a pad. NICE makes this an explicit recommendation for staff to pass on.
• Ice, wrapped. The RCOG: "Placing an ice pack wrapped in a towel on your perineum may help. Do not place ice directly onto your skin as this may cause damage." ACOG suggests 10 to 20 minutes at a time, most effective in the first 24 to 72 hours.
• Pain relief. The HSE: paracetamol can help with pain, ibuprofen with pain and swelling, and both "are safe to take when breastfeeding" — but check with a pharmacist, especially if you take other medicines.
• Pelvic floor exercises early. The RCOG: "It is important to do pelvic floor exercises as soon as you can after birth. This strengthens the muscles around the vagina and the anus and helps healing."

Opening your bowels will not burst your stitches

This is the fear that causes the most avoidable damage, because avoiding the toilet causes constipation, and constipation causes straining.

The RCOG is categorical: "If you have stitches, opening your bowels should not open them." The NHS agrees: "If you've had stitches, it's very unlikely you'll break them, or open up the cut or tear again," and suggests holding a pad of clean tissue over the stitches while you go.

The RCOG's technique: feet on a footstool so your knees are above your hips, elbows resting on knees, relax, and "bulge out your tummy by taking big abdominal breaths, which will help expel your stool without straining. Most importantly, take your time and do not rush." Straining weakens the pelvic floor, which is precisely what you are trying to protect. Drink at least two litres of water a day and eat plenty of fibre. After a third- or fourth-degree tear you will normally be given laxatives for the first few days for exactly this reason.

When to call

Contact your midwife, GP or maternity unit the same day if:

• the wound looks red and swollen, is discharging or leaking pus, or smells unusual for you
• pain is increasing rather than easing, or you need more pain relief than before
• you have a fever
• you think the repair has opened
• you are struggling to control wind or bowel movements

NICE takes wound breakdown seriously enough to set a timeframe: "If the perineal wound breaks down or there are ongoing healing concerns, refer the woman urgently to specialist maternity services (to be seen the same day in the case of a perineal wound breakdown)." That is a same-day standard, not a "see how it goes over the weekend" one.

The RCOG's own signs of infection are: red, swollen skin around the stitches; discharge or pus; increased pain or tenderness; a smell that is not normal for you; and fever.

Anal incontinence: say it out loud

The RCOG defines it as "problems controlling your bowels", including "sudden, uncontrollable urges to open your bowels, or not being able to control passing wind." Its message is: "Don't be embarrassed about talking to a healthcare professional if you have these symptoms as support and treatment is available for you."

Most women with a third- or fourth-degree tear "heal completely and have no lasting complications", but a small number have lasting difficulty, and the treatments — physiotherapy to strengthen the anal sphincter, and occasionally surgery — work better the earlier they start. The NHS also asks you to tell your midwife or GP "if poo is leaking or you're pooing when you don't mean to."

Getting back to normal

The RCOG advises avoiding strain or pressure on the anus, high-impact exercise and heavy lifting for four to six weeks, then increasing activity gradually. On sex: "Once your stitches have healed and bleeding has stopped, you can have sex again when it feels right for you." It may feel uncomfortable at first, but "the discomfort should not persist" — if it does, that is a conversation with a clinician, not something to tolerate.

You should be offered a check around six weeks. NICE lists persistent perineal pain as being associated with depression and psychosexual difficulties, so it is a legitimate thing to raise at that appointment even if the wound itself looks fine.