Volume 47, Issue 1–2, January–February 2018

Perineal tears – A review

Ryan Goh    Daryl Goh    Hasthika Ellepola   
doi: 10.31128/AFP-09-17-4333   |    Download article
Cite this article    BIBTEX    REFER    RIS

The female perineum is the diamond-shaped inferior outlet of the pelvis. This structure is at risk of trauma during labour because of spontaneous perineal tears of varying degrees or iatrogenic episiotomies. These injuries can result in disabling immediate and long-term complications in the woman.
The aim of this article is to provide general practitioners (GPs) with a good understanding of perineal tears by discussing the different classifications, immediate and long-term management, and recommendations for future deliveries.
Although the majority of perineal tears are managed by obstetricians and gynaecologists, it is important for GPs to understand their management in the event that a patient presents to general practice with concerns during the antenatal or postpartum period.

The female perineum is the diamond-shaped inferior outlet of the pelvis, bordered by the pubic symphysis anteriorly and the coccyx posteriorly.1 Perineal trauma involves any type of damage to the female genitalia during labour, which can occur spontaneously or iatrogenically (via episiotomy or instrumental delivery).2 Anterior perineal trauma can affect the anterior vaginal wall, urethra, clitoris and labia. Posterior perineal trauma can affect the posterior vaginal wall, perineal muscle, perineal body, external and internal anal sphincters, and anal canal. During labour, the majority of perineal tears occur along the posterior vaginal wall, extending towards the anus. These are further described in Box 1.2–4

Box 1. Classification of perineal tears2–4
Degree   Classification
1   Laceration of the vaginal mucosa or perineal skin only
2   Laceration involving the perineal muscles
3   Laceration involving the anal sphincter muscles, being further subdivided into 3A, 3B and 3C:
  3A Where <50% of the external anal sphincter is torn
  3B Where >50% of the external anal sphincter is torn
  3C Where the external and internal anal sphincters are torn
4   Laceration extending through the anal epithelium (resulting with a communication of the vagina epithelium and anal epithelium)


More than 85% of females who undergo a vaginal birth will suffer from some degree of perineal tear,2 with 0.6–11% of all vaginal deliveries resulting in a third-degree or fourth-degree tear.5–7 Fortunately, the incidence of perineal tears decreases with subsequent births, from 90.4% in women who are nulliparous to 68.8% in women who are multiparous undergoing vaginal deliveries.4

Risk factors

While there is a high risk for perineal trauma following any vaginal birth, it is particularly important to note the risk factors that contribute to severe perineal tears (third-degree and fourth–degree). The risks can be best separated into the following subgroups: maternal, fetal and intrapartum risk factors (Box 2).4,7–16

Box 2. Risk factors for perineal tears4,7–16
Maternal risk factors Fetal risk factors Intrapartum risk factors
  • Nulliparity
  • Asian ethnicity
  • Vaginal birth after caesarean section
  • ≤20 years of age
  • Shortened perineal length (<25 mm) 
  • Large fetal weight (>4000 g)
  • Shoulder dystocia
  • Occipo-posterior position
  • Instrumental delivery (eg forceps, vacuum)
  • Prolonged second stage of labour (>60 minutes)
  • Epidural use
  • Oxytocin use
  • Midline episiotomy
  • Delivery in lithotomy or deep squatting position



Given that an episiotomy is considered to be a method to adequately reduce the rates of severe perineal tears, it is important to explore this ‘prophylactic measure’ in further detail. The aim of episiotomy is to increase the diameter of the vaginal outlet to facilitate the passage of the fetal head and, ideally, prevent a vaginal tear.17 Many different types of episiotomy incisions can be used, depending on the situation: midline, modified-midline, mediolateral, ‘J’-shaped, lateral, radical lateral and anterior.18 In Australia, the mediolateral episiotomy is generally preferred.

Despite its common use in obstetrics, there is still conflicting evidence about the effectiveness of mediolateral episiotomy in the prevention of obstetric anal sphincter injuries (OASI). Depending on the study, the mediolateral episiotomy has been found to lower the incidence of OASI in spontaneous vaginal deliveries.19 Other studies, however, have found that episiotomies were not protective against severe perineal lacerations,8,9,20 and can actually increase the risk of third-degree and fourth-degree perineal tears in women who are multiparous.20 This is potentially due to the difficulty in correctly estimating the episiotomy angles in patients, as perineal distension occurs at crowning of the fetal head.11,17

A recent Cochrane review concluded that ‘routine’ episiotomy is not justified for women in whom no instrumental delivery is intended.21 For this reason, The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) does not promote the routine use of episiotomies, and advises that an episiotomy is only recommended if there is:22

  • a high likelihood of third-degree or fourth-degree perineal tear
  • soft tissue dystocia
  • a requirement to accelerate delivery of a compromised fetus
  • need to facilitate operative vaginal delivery or
  • a history of female genital mutilation.

Other techniques

There are many other types of techniques used in obstetrics that have also been used as prophylactic measures for severe perineal tears. In a 2017 Cochrane review,23 several perineal techniques were assessed, including warm compresses, perineal massage, hands on the perineum and Ritgen’s manoeuvre. Surprisingly, only the warm compresses and perineal massage showed a positive effect in reducing third-degree and fourth-degree perineal tears.23 Hands on the perineum and Ritgen’s manoeuvre showed no reduction in the incidence of third-degree and fourth-degree tears when compared with a ‘hands-off’ approach and standard care respectively.23


The perineum should always be thoroughly assessed after a vaginal birth to determine the presence of any lacerations. This examination should include a digital rectal examination to evaluate the tone of the anal sphincter.7 From here, the midwife or obstetrician can decide if conservative or surgical management is required.

Although not a routine practice in Australia, if there is difficulty in diagnosing perineal trauma during the puerperium period, ultrasound investigation of the perineum has been shown to be an effective diagnostic tool.24

Repairing perineal tears

Management of a perineal tear differs depending on the severity of the tear and is  described in Box 3.

Box 3. Immediate management of perineal tears
First-degree These tears are considered minor and are therefore left to the clinician’s discretion to determine if suturing is required.
Second-degree Although these tears are also considered minor, sutures should be placed to facilitate better wound approximation (as there are noticeable benefits at six weeks postpartum35).
Third-degree and fourth-degree These tears should be repaired as soon as possible in an operating theatre, using regional or general anaesthesia, to achieve anal sphincter relaxation.7,25 The obstetric anal sphincter injuries repair should be performed by trained practitioners, as inexperienced attempts can lead to anal incontinence.25

Regardless of the severity of the tear, the following principles should be applied during the repair:7,25

  • The repair should be completed by an experienced clinician, ideally one trained in obstetrics.
  • Good lighting and access are important – ideally, the procedure should be conducted in an operating theatre with the patient in lithotomy.
  • Adequate anaesthesia should be used.
  • Each layer should be repaired independently to restore function.
  • The repair should be conducted in a cephalocaudal (or top-down) direction as this ensures access to superior sites is not restricted.
  • Resorbable sutures should be used, with the knots of each layer buried as this reduces the risk of dyspareunia and vaginal discomfort following the recovery.

Postoperative management


Broad-spectrum antibiotics are recommended in the immediate postoperative period to reduce the risk of infections and wound dehiscence.25


Cold packs should be used topically in 10–20 minute intervals in the first 24–72 hours after surgery.26 Paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) can be used.27 However, limit the use of opioids to reduce the risk of constipation. A urinary alkaliniser can assist in reducing discomfort during toileting.28

Laxatives or stool softeners

Laxatives are recommended following perineal repair as the passage of stool can result in wound dehiscence.25 Stool softeners (eg lactulose) are recommended for around 10 days postoperatively.29 Stool softeners should be titrated to keep the stools soft but not loose.25

Positioning and movement

During the first 48 hours after surgery, the patient should use positions that will reduce perineal oedema. This involves lying on a flatbed while resting, on their side when breastfeeding, and avoiding the overuse of seated positions.28 The patient should also avoid activities that may increase intra-abdominal pressure for the first six to 12 months after delivery.28

Pelvic floor exercises

Pelvic floor exercises should be commenced two to three days postpartum, or when the patient feels comfortable.25 Patients with third‑degree or fourth-degree perineal tears should be referred to a physiotherapist who specialises in perineology, as it can reduce flatal, faecal and urinary stress incontinence.30

Wound care

Ensure that the wound is washed and patted dry after toileting. The patient should inspect the wound daily with the use of a hand mirror for any signs of wound breakdown.


Obstetrician follow-up

Generally, women with OASI repairs are reviewed by the obstetrician six to 12 weeks postpartum,25 when the repair site and anal sphincter tone are assessed.

General practitioner follow-up

The role of the general practitioner (GP) in the postpartum period will be to titrate the analgaesia and laxative/stool softener requirements to facilitate the woman’s recovery, and to inspect the wound for signs of infection. The major indications for a referral to an obstetrician are:

  • wound dehiscence
  • severe dyspareunia
  • constipation, including:
    • excessive straining
    • sensation of incomplete emptying
    • sensation of anorectal obstruction
    • digitation (manual disimpaction)
  • faecal incontinence, including:
    • urge faecal incontinence
    • passive or post-defaecation incontinence.



Fortunately, first-degree and second-degree perineal lacerations are minor and patients usually recover uneventfully. As third-degree and fourth-degree perineal tears are more extensive, there is an increased likelihood of residual defects resulting in ongoing symptoms that can have a significant impact on the woman’s quality of life. The most common long-term problems are dyspareunia, perineal pain, and flatal and faecal incontinence.31 In fact, OASI are strong risk factors for postponed coital resumption after delivery and dyspareunia at one year postpartum.32 However, anal sphincter competence remains the biggest concern as flatal incontinence can be present even 10 years after OASI.33 Despite these concerning potential outcomes following OASI, women should be reassured that 60–80% of women are asymptomatic 12 months after a delivery and an external anal sphincter repair.25 

Future deliveries

Women who have sustained OASI in their previous pregnancy should be thoroughly counselled regarding their mode of delivery, with an elective caesarean section being one of the options.25 If the woman chooses a vaginal delivery, it is important to note that there is insufficient evidence for prophylactic episiotomies in the prevention of another OASI, and should thus only be performed if clinically indicated.25

Resumption of sexual activity

There is currently no evidenced-based research demonstrating the ideal time to resume sexual intercourse following a perineal injury. Thus, the abstinence period is typically determined by the woman during her recovery period. The median time of return to intercourse is six to eight weeks postpartum.34


Dyspareunia is a common postpartum complaint that must be addressed early because of its impact on the woman’s quality of life (ie physical, relational, psychological wellbeing). The following recommendations can be made:25,28

  • Lubrication should be used generously during vaginal intercourse.
  • The woman should be in control of the initiation of intercourse. If the woman is having difficulty obtaining control, consider having the discussion with the woman and her partner together.
  • Experimenting with different sexual positions can facilitate the woman’s comfort.
  • Refer to a physiotherapist with a special interest in dyspareunia, or an obstetrician or gynaecologist.


GPs have an extremely important role in the management of women following perineal repair. This involves, but is not limited to, reassurance of a successful repair, early detection of complications for prompt referrals, and ascertaining and managing any psychological or physiological impact on the woman’s wellbeing.

Competing interests: None.
Provenance and peer review: Not commissioned, externally peer reviewed.
This event attracts CPD points and can be self recorded

Did you know you can now log your CPD with a click of a button?

Create Quick log
  1. Hosseinzadeh K, Heller MT, Houshmand G. Imaging of the female perineum in adults. Radiographics 2012;32(4):E129–68. Search PubMed
  2. Frohlich J, Kettle C. Perineal care. BMJ Clin Evid 2015;2015. Search PubMed
  3. Sultan AH, Thakar R, Fenner DE. Perineal and anal sphincter trauma: Diagnosis and clinical management. London: Springer London, 2007. Search PubMed
  4. Smith LA, Price N, Simonite V, Burns EE. Incidence of and risk factors for perineal trauma: A  prospective observational study. BMC Pregnancy Childbirth 2013;13:59. Search PubMed
  5. Villot A, Deffieux X, Demoulin G, Rivain AL, Trichot C, Thubert T. Management of third and fourth degree perineal tears: A systematic review. J Gynecol Obstet Biol Reprod (Paris) 2015;44(9):802–11. Search PubMed
  6. Williams AB, Bartram CI, Halligan S, Spencer JA, Nicholls RJ, Kmiot WA. Anal sphincter damage after vaginal delivery using three-dimensional endosonography. Obstet Gynecol 2001;97(5 Pt 1):770–75. Search PubMed
  7. Aigmueller T, Umek W, Elenskaia K, et al. Guidelines for the management of third and fourth degree perineal tears after vaginal birth from the Austrian Urogynecology Working Group. Int Urogynecol J 2013;24(4):553–58. Search PubMed
  8. Vale de Castro Monteiro M, Pereira GM, Aguiar RA, Azevedo RL, Correia-Junior MD, Reis ZS. Risk factors for severe obstetric perineal lacerations. Int Urogynecol J 2016;27(1):61–67. Search PubMed
  9. Mikolajczyk RT, Zhang J, Troendle J, Chan L. Risk factors for birth canal lacerations in primiparous women. Am J Perinatol 2008;25(5):259–64. Search PubMed
  10. Landy HJ, Laughon SK, Bailit JL, et al. Characteristics associated with severe perineal and cervical lacerations during vaginal delivery. Obstet Gynecol 2011;117(3):627–35. Search PubMed
  11. Kapoor DS, Thakar R, Sultan AH. Obstetric anal sphincter injuries: Review of anatomical factors and modifiable second stage interventions. Int Urogynecol J 2015;26(12):1725–34. Search PubMed
  12. O'Mahony F, Hofmeyr GJ, Menon V. Choice of instruments for assisted vaginal delivery. Cochrane Database Syst Rev 2010;(11):CD005455. Search PubMed
  13. Gurol-Urganci I, Cromwell DA, Edozien LC, et al. Third- and fourth-degree perineal tears among primiparous women in England between 2000 and 2012: Time trends and risk factors. BJOG 2013;120(12):1516–25. Search PubMed
  14. Richter HE, Brumfield CG, Cliver SP, Burgio KL, Neely CL, Varner RE. Risk factors associated with anal sphincter tear: A comparison of primiparous patients, vaginal births after cesarean deliveries, and patients with previous vaginal delivery. Am J Obstet Gynecol 2002;187(5):1194–98. Search PubMed
  15. McLeod NL, Gilmour DT, Joseph KS, Farrell SA, Luther ER. Trends in major risk factors for anal sphincter lacerations: A 10-year study. J Obstet Gynaecol Can 2003;25(7):586–93. Search PubMed
  16. Williams A, Tincello DG, White S, Adams EJ, Alfirevic Z, Richmond DH. Risk scoring system for prediction of obstetric anal sphincter injury. BJOG 2005;112(8):1066–69. Search PubMed
  17. Ginath S, Elyashiv O, Weiner E, et al. The optimal angle of the mediolateral episiotomy at crowning of the head during labor. Int Urogynecol J 2017;28(12):1795–99. Search PubMed
  18. Kalis V, Laine K, de Leeuw JW, Ismail KM, Tincello DG. Classification of episiotomy: Towards a standardisation of terminology. BJOG 2012;119(5):522–26. Search PubMed
  19. Verghese TS, Champaneria R, Kapoor DS, Latthe PM. Obstetric anal sphincter injuries after episiotomy: Systematic review and meta-analysis. Int Urogynecol J 2016;27(10):1459–67. Search PubMed
  20. Shmueli A, Gabbay Benziv R, Hiersch L, et al. Episiotomy – Risk factors and outcomes. J Matern Fetal Neonatal Med 2017;30(3):251–56. Search PubMed
  21. Jiang H, Qian X, Carroli G, Garner P. Selective versus routine use of episiotomy for vaginal birth. Cochrane Database Syst Rev 2017;2:CD000081. Search PubMed
  22. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Provision of routine intrapartum care in the absence of pregnancy complications. East Melbourne, Vic: RANZCOG, 2017. Search PubMed
  23. Aasheim V, Nilsen ABV, Reinar LM, Lukasse M. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev 2017;6:CD006672. Search PubMed
  24. Faltin DL, Boulvain M, Floris LA, Irion O. Diagnosis of anal sphincter tears to prevent fecal incontinence: A randomized controlled trial. Obstet Gynecol 2005;106(1):6–13. Search PubMed
  25. Fernando RJ, Sultan AH, Freeman RM, Williams AA, Adams EJ. The management of third- and fourth-degree perineal tears. Guideline No. 29. London: Royal College of Obstetricians and Gynaecologists, 2015. Search PubMed
  26. East CE, Begg L, Henshall NE, Marchant PR, Wallace K. Local cooling for relieving pain from perineal trauma sustained during childbirth. Cochrane Database Syst Rev 2012(5):CD006304. Search PubMed
  27. Chou D, Abalos E, Gyte GM, Gülmezoglu AM. Paracetamol/acetaminophen (single administration) for perineal pain in the early postpartum period. Cochrane Database Syst Rev 2013;(1):CD008407. Search PubMed
  28. Department of Health. Queensland clinical guidelines. Maternity and neonatal clinical guidelines: Perineal care. Queensland: Statewide Maternity and Neonatal Clinical Network (Queensland), 2012. Search PubMed
  29. Eogan M, Daly L, Behan M, O'Connell PR, O'Herlihy C. Randomised clinical trial of a laxative alone versus a laxative and a bulking agent after primary repair of obstetric anal sphincter injury. BJOG 2007;114(6):736–40. Search PubMed
  30. Mathé M, Valancogne G, Atallah A, et al. Early pelvic floor muscle training after obstetrical anal sphincter injuries for the reduction of anal incontinence. Eur J Obstet Gynecol Reprod Biol 2016;199:201–06. Search PubMed
  31. Sundquist JC. Long-term outcome after obstetric injury: A retrospective study. Acta Obstet Gynecol Scand 2012;91(6):715–18. Search PubMed
  32. Fodstad K, Staff AC, Laine K. Sexual activity and dyspareunia the first year postpartum in relation to degree of perineal trauma. Int Urogynecol J 2016;27(10):1513–23. Search PubMed
  33. Fornell EU, Matthiesen L, Sjödahl R, Berg G. Obstetric anal sphincter injury ten years after: Subjective and objective long term effects. BJOG 2005;112(3):312–16. Search PubMed
  34. Rådestad I, Olsson A, Nissen E, Rubertsson C. Tears in the vagina, perineum, sphincter ani, and rectum and first sexual intercourse after childbirth: A nationwide follow-up. Birth 2008;35(2):98–106. Search PubMed
  35. Fleming VE, Hagen S, Niven C. Does perineal suturing make a difference? The SUNS trial. BJOG 2003;110(7):684–89. Search PubMed

Labour and deliveryObstetricsPerineal tearspost-operative complicationsSurgery

Download article