Birth Recovery: Healing from a Perineal Tear or Episiotomy

If you experienced a perineal tear or had an episiotomy during childbirth, you're part of a very big club. Up to 90% of people who give birth vaginally have some form of perineal trauma after their first delivery. While the frequency of perineal injury is lower in those who’ve previously given birth vaginally, nearly 70% of subsequent deliveries can still lead to perineal injury.

Of course, just knowing that perineal injuries are a common occurrence doesn't make them any less painful or difficult to manage. Recovering from perineal trauma takes patience and expert care, and at Origin, we’re here to help.

Postpartum perineal healing at a glance

• Perineal tears happen spontaneously during vaginal birth; episiotomies are planned surgical incisions. Both affect the tissue between the vagina and anus and often involve the pelvic floor muscles.
• Tears are graded 1 to 4 based on how many tissue layers are affected. Lower grades (I and II) typically close within 3 to 4 weeks, while higher grades (III and IV) take several months, sometimes longer.
• Early self-care strategies, including icing, rinsing with a peri bottle, wearing supportive underwear, and taking sitz baths, can ease pain and support healing.
• Most perineal injuries affect the pelvic floor muscles, and a pelvic floor physical therapist can provide expert support for retraining those muscles, healing scar tissue, and addressing lingering symptoms such as pain or incontinence.

What is a perineal tear?

A perineal tear is a birth-related injury to the tissues between the vagina and the anus. They can also affect other parts of the genitals, including the labia (the “lips” that make up the vulva).

Tears occur during labor and delivery when stress and stretch forces are greater than the tissues can accommodate.  An episiotomy is different: it’s a surgical incision in the perineum that an OB-GYN or midwife can perform to widen the vaginal opening. 

Unlike perineal tears that happen spontaneously, an episiotomy is a planned, precise incision. However, this doesn’t necessarily mean it’s easier to experience or heal. Healing treatments after perineal tears and episiotomies have a lot in common, so we’ve grouped them together here.

What are the degrees of perineal tearing?

There are 4 degrees, or “grades”, of perineal tear, rated from 1-4 based on the tissues that tore. A higher grade tear involves more tissues, is more severe, and usually takes longer to heal that lower grade tears.

If you experienced perineal tearing during delivery, your provider may have mentioned the grade of the tear(s). Even if they didn’t give you a specific number, they should have assessed the degree of perineal tear and given you clear instructions to promote healing and prevent complications. 

The table below is a basic guide to the grades of perineal tears, but it doesn’t capture every nuance. Every perineal injury is unique, and more severe tears often require specialized care, so it's critical to follow your provider's personalized guidance.

*Remember that every body and every birth injury is unique. These healing times are approximate: yours may be longer or shorter and depend on many factors.

How long does a perineal tear take to heal?

On average, new wounds heal in about 4 weeks. However, perineal tear recovery varies a lot, depending on the grade of tear, the person who experienced it, and their approach to postpartum vaginal healing. Additionally, a wound that is “healed” on the surface can still cause symptoms and discomfort for weeks, months, or even years after it closes.

In general, lower-degree (grades I and II) tears tend to heal faster than the higher-grade tears that injure the anal sphincters. However, complications such as dehiscence (reopening of a closed wound) can delay first degree and second degree tear recovery. With proper repair and care, reopened tear sites heal in an average of 3-4 weeks.

Higher-degree (grade III and IV) take longer to heal fully. A small study of 31 German women with grade III and IV tears found that almost 75% had fully healed by 6 months postpartum. Note that these researchers didn’t check perineal healing at any other times, so it’s likely that some tears healed earlier and others continued healing after 6 months.

How can I help my perineum heal after vaginal birth?

During the early days postpartum, you can assist perineal tear or episiotomy recovery with some simple self-care techniques. These can be particularly helpful during the first 24 to 72 hours after birth when the swelling and tenderness in your vulvar and vaginal tissues is at its highest.

Consider the following info to be a compliment to, not a replacement for, your doctor's instructions, helping you stay comfortable in the first few days and weeks.

Simple self-care strategies for perineal healing

During the first few days postpartum, try using the following 4 strategies to support healing and manage pain.

1. Soothe pain with ice.

Take 10 minutes to ice your vulvar tissues, repeating every couple of hours or whenever you change your pad. Ice packs, frozen peas, or store-bought perineal cooling packs can be a great tool to calm pain and keep swelling at a minimum. 

You can even make your own “padsicle” by soaking a fresh pad in clean water and freezing it. Regardless what method you choose, always keep a layer of fabric between your skin and the cold pack to prevent skin burns.

2. Rinse with a peri bottle instead of wiping with toilet paper.

Avoid pain and protect your healing wound by cleansing your vulva with a peri bottle instead of wiping each time you use the bathroom. Always spray from front to back to avoid introducing fecal germs to your vagina or urethra. 

Try out warm and cool water to see which is more soothing. You may find yourself never wanting to give this habit up!

3. Opt for supportive undies.

Gently compressive undergarments can support wound healing, and improve your comfort as you heal. Look for underwear designed specifically for postpartum support. 

4. Take a sitz bath.

After the first 72 hours postpartum, try soaking your bottom in a warm water bath (often referred to as a sitz bath). The warm water can help relieve pain and improve blood flow to assist with muscle relaxation.

Fill your tub with just enough to cover your bum and relax for 20 minutes if you are able. There are many great recipes online for postpartum sitz baths. For ultimate convenience, consider pre-made products such as Frida Mom All-Natural Herbal + Epsom Salt Sitz Bath Tablets.

Pooping after a perineal injury

After a perineal tear or episiotomy, bruising and swelling can make the first few trips to the bathroom tricky, to say the least. Use the 5 tips below to make things go as smoothly as possible.

1. Up your water & fiber intake.

Healthy poops are easier to pass than dry, hard stool. Staying hydrated and eating plenty of high-fiber fruits and vegetables will ensure that your poops are in prime form.

2. Chew gum.

There is some evidence that chewing gum in the early postpartum hours will speed up your ability to pass gas and have a bowel movement.

3. Prop your feet on a toilet stool.

When on the toilet, try putting your feet up on a Squatty Potty, a small stool, or even a trash can turned on to its side. This will help relax the pelvic floor muscles that need to lengthen to release stool.

4. Practice effective pooping techniques.

Relax your pelvic floor muscles while gently bracing with your abdominals: think “belly big, belly firm”. Avoid holding your breath: instead, exhale like you are blowing out a birthday candle as you push.

5. Press on your perineum.

Cover a clean hand with toilet paper, and apply gentle upward pressure over the vulva and the tissue right behind it (the perineal body) as you pass stool. This will help ease excessive stretch to your injured perineal tissues.

When can I have sex after a perineal tear?

It depends, and you should speak with your OB-GYN or midwife to understand the return-to-sex timeline that’s appropriate for you. Providers typically want to see evidence that the wound site is completely closed and doesn’t show signs of opening when lightly stretched. As you’ve learned, this typically requires a minimum of 3-4 weeks for even the smallest tears, and few providers give the green light for sex until at least 6 weeks postpartum.

When returning to activity after any injury, there’s a difference between “being allowed to do” and “feeling ready to do” the activity. Remember that your provider’s “clearance” is just that: clearance. It means it is safe to have sex without risking injury to your tissues, but it doesn’t always mean that you or your body are ready to do so comfortably.

Be patient with yourself and your healing body. If you’ve been “cleared” for sex but it’s still painful or uncomfortable after the first few attempts, it’s time to talk to a pelvic floor physical therapist. Learn more about how Origin’s expert clinicians can help you navigate the healing perineal tear and sex transition after delivery.

How does pelvic floor physical therapy help with perineal healing?

Pelvic floor therapy after episiotomy or perineal tearing is one of the best ways to get the expert care you need to heal. Episiotomies and all nearly perineal tears (except Grade I) affect the pelvic floor muscles, so those injured muscles need retraining and strengthening. 

More than half of individuals who give birth vaginally experience pelvic floor dysfunction. This type of muscle dysfunction can present as symptoms ranging from painful sex to bladder leaks to pelvic organ prolapse, all of which a pelvic floor physical therapist can help you address. In addition to helping you retrain the affected muscles, your pelvic floor physical therapist can teach you how to encourage scar tissue healing and manage pain and tenderness in the area. 

Remember: while recovering from a perineal tear or episiotomy can feel all-encompassing at first, there's much more to postpartum healing. For example, a third of birthing people still have diastasis recti (separated abs) one year after childbirth. Musculoskeletal problems such as low back pain are also common postpartum. 

At Origin, our pelvic floor physical therapists specialize in a whole-body approach to postpartum recovery: your therapist can help you address all the areas that need attention and care. Learn more and schedule your first postpartum visit at Origin here.

Sources 

Arnold, Michael J et al. “Obstetric Lacerations: Prevention and Repair.” American family physician vol. 103,12 (2021): 745-752.

Hagen, S et al. “Urinary incontinence, faecal incontinence and pelvic organ prolapse symptoms 20-26 years after childbirth: A longitudinal cohort study.” BJOG : an international journal of obstetrics and gynaecology vol. 131,13 (2024): 1815-1823. doi:10.1111/1471-0528.17913

Okeahialam, Nicola Adanna et al. “The prevention of perineal trauma during vaginal birth.” American journal of obstetrics and gynecology vol. 230,3S (2024): S991-S1004. doi:10.1016/j.ajog.2022.06.021

Ramar, Cassandra N., et al. “Perineal Lacerations.” StatPearls, StatPearls Publishing, 11 August 2024.

Smith, Lesley A et al. “Incidence of and risk factors for perineal trauma: a prospective observational study.” BMC pregnancy and childbirth vol. 13 59. 7 Mar. 2013, doi:10.1186/1471-2393-13-59

Sperstad, Jorun Bakken et al. “Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain.” British journal of sports medicine vol. 50,17 (2016): 1092-6. doi:10.1136/bjsports-2016-096065

Stickelmann, Anna-Lena et al. “Obstetric anal sphincter injuries (OASIS): using transperineal ultrasound (TPUS) for detecting, visualizing and monitoring the healing process.” BMC women's health vol. 22,1 339. 10 Aug. 2022, doi:10.1186/s12905-022-01915-7