Perineal Tears and Perineal Tear Degrees: An Overview
Perineal tears are graded in four degrees. A first-degree tear involves only the skin and usually needs no stitches; a second-degree tear reaches the deeper tissue and usually needs stitches; a third-degree tear extends to the anal sphincter; and a fourth-degree tear reaches the rectum or anal canal. Tears are common, affecting roughly 60–80% of first vaginal births, but most are first- or second-degree and resolve without serious complications.
Most women who give birth vaginally will experience some degree of tearing of the perineum. Tears range from a small, superficial graze to deep lacerations affecting the pelvic-floor muscles, and happen for many reasons: limited elasticity in the perineal muscles, overstretching without the muscles softening, the management of labor, and more.
What are the degrees of perineal tears?
Perineal tears fall into four classifications with different levels of discomfort or complication. In most cases tears are moderate and not associated with serious health complications.
| Degree | What's involved | Stitches? | Recovery |
|---|---|---|---|
| First | Skin/vaginal lining only; no muscle | Usually none | Days |
| Second | Lining plus deeper tissue of the vagina | Usually yes | A few weeks |
| Third | Extends to the anal sphincter | Yes, with anesthesia | Weeks to months |
| Fourth | Anal sphincter through to the rectum/anal canal | Yes, surgical repair | A few months |
Moderate perineal tears (first and second degree)
One U.S. study found first- and second-degree tears are the most common complications of vaginal deliveries in the United States.
First-degree perineal tears
First-degree tears involve only the superficial skin lining. The vaginal lining is disturbed but no muscle is damaged. Recovery is straightforward, usually without stitches, and the area typically settles within days. A woman might feel slight discomfort when sneezing or during bowel movements until it's fully healed.
Second-degree perineal tears
Second-degree tears affect the vaginal lining plus deeper tissue, such as the submucosal tissue of the vagina, and usually require stitches after a vaginal birth. Recovery may take a few weeks and can include discomfort when urinating, during bowel movements, and when sneezing.
Severe perineal tears (third and fourth degree)
Third- and fourth-degree tears are considered severe. According to the Royal College of Obstetricians and Gynaecologists (UK), this level of tearing occurs in about 3 of 100 women delivering vaginally. It's about three times more common with a first vaginal birth (6 in 100, versus 2 in 100 for those who've given birth vaginally before). Data shows 60–80% of cases are symptom-free one year after childbirth.
Third-degree perineal tears
Third-degree tears are deep and can involve the anal sphincter. Stitches and local anesthesia are part of the repair. Recovery takes longer, with pain that can persist for weeks to months, and discomfort during intercourse, bowel movements, and sitting.
Fourth-degree perineal tears
Fourth-degree tears are the most significant. They start at the anal sphincter and extend to the rectum or anal-canal lining. Recovery may take a few months. A woman with a 4th-degree tear may experience fecal incontinence, fecal urgency, pain during intercourse, chronic perineal pain, and fistula formation.
To learn more about the consequences of fourth-degree tears, read: "This Is What It's Really Like to Have a 4th-Degree Tear in Childbirth."
Can you lower the chance of perineal tears?
As with much of childbirth, the type of tear you may experience is largely unpredictable. But there are a few things that may help — see our guide to things that may help during childbirth. Perineal stretching is one of them.
Perineal massage in the weeks before labor
Perineal massage is among the techniques most discussed in research, particularly in relation to third- and fourth-degree tears. It can be done once or twice a day, generally started from around the 35th week of pregnancy. Some studies also look at how it relates to comfort afterward. Read the ultimate guide to perineal massage.
Warm wet towels during labor
A warm, wet towel is also used during labor to relax the perineal muscles. Gently placed over the perineal area, it softens the skin and increases flexibility so the tissue stretches more easily.
Perineal massage during labor
In its 2018 guidelines, the World Health Organization discusses perineal massage during the second stage of labor. It's usually done by the midwife inserting two fingers into the vagina, pressing down toward the rectum and moving side to side, using a perineal massage oil (such as almond oil). If recommended, add oil to your maternity checklist. Read more about perineal massage during labor.
Given how common perineal tears are, and the consequences of severe ones, it's worth becoming informed about this simple, time-honored technique.
Frequently asked questions
What are the four degrees of perineal tears?
First (skin only), second (deeper vaginal tissue), third (to the anal sphincter), and fourth (through to the rectum/anal canal).
How common are perineal tears?
Common. Roughly 60–80% of first vaginal births involve some tearing. Most are first- or second-degree.
How common are severe (3rd/4th degree) tears?
About 3 in 100 vaginal births overall. Around 6 in 100 first births versus 2 in 100 for women who've given birth vaginally before.
What is a fourth-degree tear?
The most extensive tear, running from the anal sphincter through to the rectum or anal-canal lining. Recovery can take a few months.
Do first-degree tears need stitches?
Usually not. They tend to resolve on their own within days.
The perineal massage tool from Perimom is designed for independent use during pregnancy, making perineal massage easier to do as you prepare for birth.
