Avoiding perineal damage, part 1

After giving birth, nearly every mother feels somewhat bruised and sore.  For most moms who have had their baby vaginally, a large portion of this discomfort is in the genital area, and most specifically the perineum, the diamond-shaped area between the vagina and anus.  There are varying degrees of perineal trauma after childbirth:

  • Intact:  There is no injury.  A red, swollen appearance is normal for a day or two.
  • Grazed/scraped:  Just as it sounds – there may be a few tiny tears similar to anal fissures or the miniscule chafing you get as a kid when you stretch your mouth open with your fingers to make a silly face. It is also common for the labia to have tears or abrasions. These require no repair, only good hygiene, and heal well and quickly.
  • First degree:  The skin and underlying tissue are torn.  This probably requires no repair, or at most 1-2 stitches are placed.
  • Second degree:  The skin, underlying tissue, and muscle are torn.  An episiotomy – a deliberate surgical incision of the perineum – is at least a second degree injury in nature.  Repair is usually recommended but with a natural tear is up to the woman to decide.
  • Third degree:  The skin, underlying tissue, and muscle are torn across the perineum and up to the anus.  Interestingly, these tears often start with an episiotomy that continues to split further.
  • Fourth degree:  The skin, underlying tissue, and muscle are torn across the perineum and on into the anus and rectum.  Third and fourth degree tears are extremely rare and require extensive repair.

It should be noted that the perineum normally tears and heals during birth.  In women who are adequately nourished, hydrated, and supported in normal birth (therefore with her normal hormones present), the perineum is elastic and rich in oxygen-carrying blood vessels.  Severe tears are less likely and healing is faster.  However, you can pretty much expect to have some degree of laceration because that is what your body is designed to do – tear.  The goal is to minimize this as much as you can.

When making plans for your birth, what is your goal for your perineum?  It may seem strange, but this should be part of every mother’s birth plan.  Here’s why:

  • Perineal management varies widely from caregiver to caregiver.  If you don’t make a plan, you’re going to get your caregiver’s plan, and it may not be what you want.
  • Tiny lacerations heal in a day or two and can be ignored, but an episiotomy or larger tear can take weeks to heal.
  • While healing from a larger repair, most women experience significant pain, itchy stitches, discomfort when sitting, burning during urination, and a tough time defecating.
  • In the long term, the evidence shows that compared with a natural tear, episiotomy takes longer to heal, causes incontinence, and is associated with painful sexual intercourse for months afterward.
  • It’s your perineum and you have to live with it.

Next post, things you can do before giving birth to avoid perineal damage.


Goer, H.  The Thinking Woman’s Guide to a Better Birth. Perigee Books, 1999.

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