Episiotomy and Perineal Tears: Recovery, Pain Relief, and What to Expect

Fact-Checked & Transparent: This article is fact-checked against current CDC, WHO, ACOG, and NHS guidelines. All health information is based on authoritative medical sources. Last verified: June 2026.

⚠️ MEDICAL DISCLAIMER

This article is educational information only. It is NOT a substitute for professional medical advice, diagnosis, or treatment.

Always consult your pediatrician or healthcare provider before making any medical decisions for your baby or child. Every baby is unique, and professional medical guidance is essential.

In case of emergency, call 911 or your local emergency number.

What Is an Episiotomy?

An episiotomy is a small surgical cut made to the perineum — the tissue between the vaginal opening and the anus — during the second stage of labour, as the baby's head is crowning. The cut is made with scissors under local anaesthetic and is intended to create a controlled, clean opening rather than allowing the tissue to tear in an unpredictable direction.

Episiotomies are no longer routine. In the UK, the NHS advises that they should only be performed when clinically necessary, and the same position is held by the American College of Obstetricians and Gynecologists (ACOG). The shift away from routine episiotomy followed evidence showing that it did not prevent severe tears and in many cases caused more damage than a natural tear would have.

When an Episiotomy May Still Be Needed

There are specific circumstances in which an episiotomy remains appropriate. These include an instrumental delivery (forceps or ventouse), when the baby is in a difficult position, when there are signs of fetal distress and delivery needs to happen quickly, or when the perineum appears to be on the verge of a severe spontaneous tear that would be more complex to repair.

If you have an episiotomy during labour, your midwife or doctor will explain the reason. You have the right to ask questions even in the moments before delivery, and your birth preferences should note whether you have strong views on this.

Natural Perineal Tears: The Four Degrees

Around 9 in 10 women who have a vaginal birth sustain some degree of perineal tear. The NHS classifies these into four categories:

First-degree tears involve only the skin of the perineum and the vaginal mucosa. They are superficial, often heal without stitches, and typically cause minimal long-term problems.

Second-degree tears extend into the muscle of the perineum as well as the skin. These are the most common type requiring stitches. They heal well with appropriate care, though recovery takes several weeks.

Third-degree tears involve the perineal muscles and extend into the anal sphincter. These are classified as OASI (obstetric anal sphincter injuries) and require specialist surgical repair in theatre under anaesthetic.

Fourth-degree tears extend through the anal sphincter into the rectal mucosa. These are less common than third-degree tears and also require immediate specialist repair.

OASI injuries affect approximately 3 in 100 women having a vaginal birth in the UK, according to NHS England data. Risk factors include a first vaginal birth, a large baby, a long second stage of labour, and instrumental delivery. Women who sustain an OASI tear receive additional postnatal support, dietary advice, and follow-up appointments.

Immediate Care After Birth: The First 24 to 48 Hours

The first couple of days after a perineal injury are often the most uncomfortable. Swelling, stinging, and a throbbing pain are typical. Several straightforward measures help considerably.

Ice packs or cold compresses applied to the perineum in the first 24–48 hours reduce swelling significantly. Wrap ice in a cloth or use a maternity ice pad — do not apply ice directly to skin. Use for 10–20 minutes at a time.

Cooling spray can provide local numbing relief. Some maternity units provide these; witch hazel spray or a perineal cooling spray from a pharmacy can also help.

Salt or Epsom salt baths are a widely used comfort measure. The NHS does not advise against them. A shallow bath with a handful of Epsom salt (magnesium sulphate) helps keep the area clean and may reduce inflammation. Sit in the bath for 10–20 minutes and pat dry gently with a clean towel afterward.

Keeping the area dry between hygiene measures matters. Moisture around stitches can slow healing. Change maternity pads frequently, and if possible allow brief periods of air exposure while lying down.

Urinating after birth often stings over a perineal wound. Pouring a jug of warm water over the area as you urinate can dilute the urine and reduce stinging significantly. Staying well hydrated so urine is more dilute also helps.

Pain Management in the First Week

Pain in the first 1–2 weeks can be significant, particularly with second-degree tears and episiotomies. Adequate pain relief is important — undertreated pain interferes with sleep, breastfeeding, and mobility.

Paracetamol and ibuprofen are both safe to take while breastfeeding, according to NHS guidance. Taking them regularly (rather than waiting until pain becomes severe) maintains a steadier level of pain control. Paracetamol can be taken up to four times a day; ibuprofen up to three times a day with food. Combining both provides better relief than either alone, as they work through different mechanisms.

Speak to your midwife or GP if over-the-counter pain relief is insufficient. In hospital, stronger options may be available. After discharge, your midwife can advise on appropriate next steps.

Local anaesthetic sprays containing lidocaine are available from pharmacies and can provide topical numbing at the wound site for short periods.

Avoiding constipation is crucial. Straining at the toilet puts pressure on stitches and delays healing. Drink plenty of water, eat high-fibre foods, and ask your midwife or GP about a gentle laxative such as lactulose if needed — it is safe postpartum and in breastfeeding.

Pelvic Floor Exercises After a Perineal Tear or Episiotomy

Many women assume they should not do any pelvic floor exercises until their stitches have healed. This is a misunderstanding. The NHS advises that gentle pelvic floor contractions can and should begin as soon as possible after birth — even with stitches in place.

Gentle Kegel exercises promote blood flow to the perineum, which supports tissue healing and helps reduce swelling. They also begin rebuilding the muscle strength that was lost during delivery. Start with very light contractions in the first few days — a gentle squeeze and release, held for 2–3 seconds. Build up gradually as comfort allows.

If doing pelvic floor exercises causes a sharp increase in pain, pause and discuss this with your midwife. Mild discomfort during exercise is expected; significant pain is a signal to seek assessment.

When Stitches Dissolve

Stitches used for perineal repairs are dissolvable. They do not need to be removed. The NHS advises that they typically dissolve within 2–4 weeks, though some stitches may take longer. It is common to notice small pieces of stitch material in the bath or on a pad as they break down.

The area may feel itchy as the stitches dissolve — this is a normal part of healing. Resist the urge to scratch. A cool compress or a short soak in a bath can relieve itching.

Warning Signs: When to Be Concerned

Most perineal wounds heal without complication, but infection or wound breakdown can occur. Contact your midwife, GP, or go to your local hospital's postnatal unit promptly if you notice any of the following:

• Increasing pain rather than improving pain after the first few days
• Redness, warmth, or swelling around the wound that is getting worse
• Discharge from the wound that is yellow, green, or foul-smelling
• The wound edges appear to have separated (wound dehiscence)
• Fever of 38°C or higher
• Difficulty controlling wind or bowel movements (which may indicate an unrecognised sphincter injury)

Infection caught early responds well to antibiotics. A wound that has opened may need to be assessed to determine whether re-suturing is needed.

Returning to Sex After a Perineal Injury

There is no medical rule dictating exactly when to resume penetrative sex after birth. The widely cited 6-week timeframe is a general guideline, not a clinical requirement. The actual guide is comfort — and comfort is very individual.

Many couples wait longer than 6 weeks. A survey published in the British Journal of Obstetrics and Gynaecology found that a significant proportion of women found sex painful at 3 months postpartum, and many at 6 months. This is particularly common after perineal trauma.

Factors that affect comfort returning to sex include the degree of the tear or episiotomy, scar tissue formation, pelvic floor muscle tension (which can be a protective response to pain), vaginal dryness caused by the low-oestrogen state of breastfeeding, and psychological readiness.

Using a water-based lubricant is helpful. Oestrogen cream prescribed by a GP can address vaginal atrophy if dryness is significant. A women's health physiotherapist can help if scar tissue is causing restriction or pain — scar massage and specific muscle-release techniques are effective treatments.

Long-Term Issues: Scar Tissue and Sexual Pain

Scar tissue from a perineal tear or episiotomy can sometimes cause ongoing discomfort, tightness, or pain during sex. This is not inevitable, but it is common enough that it deserves acknowledgement. The scar may feel raised, sensitive, or restrictive.

Scar massage — gently massaging the healed scar with a neutral oil — can improve tissue mobility and reduce sensitivity. A women's health physiotherapist can teach the correct technique and also perform internal scar work if needed.

Vestibulodynia and vaginismus (conditions involving painful spasm of the vaginal entrance muscles) can develop after birth trauma. Both are treatable with physiotherapy, psychological support, and in some cases topical treatments or medication. Neither is something to simply endure.

In rare cases, a fistula — an abnormal connection between the vagina and the bladder or rectum — can develop after childbirth. Symptoms include urine or stool leaking from the vagina. This requires urgent specialist assessment and surgical repair.

OASI: Extra Care for Third- and Fourth-Degree Tears

Women who sustain an OASI injury (third- or fourth-degree tear) require a higher level of ongoing care. This includes:

• Surgical repair in theatre by a specialist surgeon, under regional or general anaesthetic
• Prophylactic antibiotics to reduce infection risk
• Stool softeners to prevent straining in the days following repair
• A structured follow-up appointment at a dedicated OASI clinic, typically at 6–12 weeks, including examination and pelvic floor assessment
• Referral to a women's health physiotherapist for a guided rehabilitation programme
• Counselling on future birth options — many women with a previous OASI are offered an elective caesarean section in a subsequent pregnancy

The NHS advises women to contact their OASI clinic or GP promptly if they develop bowel control difficulties, pain, or other symptoms after repair.

Frequently Asked Questions

Will I definitely need stitches after a perineal tear?

Not necessarily. First-degree tears that involve only the skin surface often do not require stitches and are left to heal naturally. Your midwife will assess the injury after birth and advise accordingly. Second-degree tears and episiotomies are sutured.

How long does perineal pain typically last?

Mild to moderate pain from a second-degree tear or episiotomy usually improves significantly within 2–3 weeks, though the area may remain tender for 6–8 weeks. Deeper injuries or those with complications may take longer. If pain is worsening at any point, seek medical review.

Can perineal tears be prevented?

There is evidence that perineal massage during the last weeks of pregnancy reduces the risk of severe tearing in first-time mothers. Warm compresses applied to the perineum during the second stage of labour (a technique used by many midwives) also help. Giving birth in an upright or side-lying position is associated with lower rates of severe tearing compared to the lithotomy (lying on the back) position.

Is it safe to use a bath after having stitches?

Yes. A shallow warm bath is safe and can be soothing. Avoid bubble bath, scented products, and very hot water. Pat the area dry gently afterward.

When should I be referred to a specialist after an OASI tear?

You should be given a follow-up appointment automatically if you sustained a third- or fourth-degree tear. If you were not given a referral to an OASI clinic and are experiencing bowel symptoms or ongoing pain, ask your GP to refer you.

Is it normal to feel emotional about perineal trauma?

Completely. Birth injuries, even relatively minor ones, can be distressing — particularly if the birth did not go as expected. Many women feel shock, grief, or anxiety about their body's recovery. Speak to your midwife, health visitor, or GP if difficult feelings persist. Perinatal mental health support is available on the NHS.

Key Takeaways

• Episiotomies are not routine in the UK or US — they are performed only when clinically indicated during labour, not as a preventive measure.
• Natural perineal tears range from superficial first-degree to severe fourth-degree OASI injuries; the degree determines treatment, aftercare, and recovery timeline.
• In the first 48 hours, ice, salt baths, paracetamol plus ibuprofen (both safe while breastfeeding), and keeping the area dry are the most effective immediate measures.
• Gentle pelvic floor exercises should begin as soon as comfortable after birth — they support healing rather than disrupting it.
• Warning signs of infection include worsening pain, fever, discharge with odour, or wound edges separating — all warrant prompt medical review.
• Most women can return to sex when comfortable (often beyond 6 weeks); scar tissue and vaginal dryness are treatable with physiotherapy and GP support.

📋 SOURCES & FACT-CHECKING

This article is compiled and verified against these authoritative sources: - CDC (Centers for Disease Control & Prevention) - WHO (World Health Organization) - ACOG (American College of Obstetricians and Gynecologists) - NHS (National Health Service) - AAP (American Academy of Pediatrics)

Last verified: June 2026

Educational content only. Always consult your pediatrician for medical decisions.

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