Why Some Women Tear Even After an Episiotomy

ByHemali Ramchandani
Updated: 27 Nov 2025, 11:00 am

An episiotomy is meant to prevent severe vaginal tearing during childbirth. Yet many women still experience spontaneous extensions beyond the surgical cut. This can happen due to factors like rapid delivery, large baby size, rigid perineal tissue, or the baby’s shoulder positioning. Even with precise medical care, the body sometimes stretches in unpredictable ways, and understanding why this happens helps you know what’s normal, what’s not, and how to heal properly.

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Childbirth puts the perineum, the area between the vagina and anus, under immense pressure. During vaginal delivery, this tissue stretches to allow the baby to pass. Doctors sometimes make a small surgical cut, called an episiotomy, to widen the vaginal opening and reduce the risk of uncontrolled tears.
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However, despite this preventive cut, some women still tear. It’s one of those realities of childbirth that few discuss openly, and one that can feel confusing, even disheartening, especially when you expected protection from it.

Let’s understand why it happens, what increases the risk, and how your body heals after both an episiotomy and additional tearing.

What an Episiotomy Actually Does

An episiotomy is a controlled incision made at the vaginal opening during the pushing stage of labour. Its goal is to:
  • Create more space for the baby’s head and shoulders.
  • Help prevent irregular, jagged tears.
  • Reduce pressure on the pelvic floor in complicated births (like with forceps or vacuum).

There are two main types:
  • Mediolateral episiotomy: The cut extends diagonally from the vaginal opening. It’s most common in Indian and UK hospitals because it reduces the risk of extending into the anal muscles.
  • Midline episiotomy: The cut runs straight toward the anus. It heals faster but carries a higher risk of severe tears.
Episiotomies are now used more selectively than before. Studies show that routine use doesn’t necessarily prevent major tears. In fact, spontaneous tears can still occur even when an episiotomy is performed.

Why Tearing Can Still Happen

Even when a skilled doctor performs an episiotomy, several biological and situational factors can cause the cut to extend or new tears to form elsewhere.
  1. Baby’s size and position: If the baby is large (macrosomia) or in an awkward position (such as facing upward, called occiput posterior), the perineal tissue may overstretch. This can lead to tears above or beyond the original incision.
  2. Speed of birth: Rapid or “precipitous” labour gives tissues little time to stretch gradually. Even with an episiotomy, the sudden force of delivery can cause the incision to tear further or cause new tears in the vaginal wall or labia.
  3. Shoulder dystocia or instrument-assisted delivery: When the baby’s shoulder gets briefly stuck, or when forceps or a vacuum are used, the pulling force can increase tearing. Episiotomies reduce but don’t eliminate this risk.
  4. Tissue elasticity and collagen makeup: Every woman’s connective tissue behaves differently. Low elasticity due to age, genetics, or hormonal factors may mean the perineum does not stretch well despite preparation. Studies on collagen structure in pregnant women show that stiffer tissue correlates with higher tear rates.
  5. Angle or length of incision: The direction and angle of the cut matter. It was found that mediolateral incisions at an angle of 60 degrees are least likely to extend to the anal sphincter. Shorter or too-shallow cuts may not provide enough space and can tear unpredictably.
  6. Second-stage duration: Prolonged pushing increases swelling and tissue strain, while very quick births don’t allow the perineum to adapt. Both extremes can increase tearing risk.
  7. Previous scarring or prior episiotomy: Scar tissue from a prior birth is less flexible. During subsequent deliveries, these areas are prone to re-tear, even with preventive measures.

Types of Tears That Can Occur

Doctors classify perineal tears into four grades, based on depth and structures involved:
  • First-degree: Skin only. Usually heals without stitches.
  • Second-degree: Skin and muscle layers. Often repaired along with an episiotomy.
  • Third-degree: Extends to the anal sphincter. Requires surgical repair.
  • Fourth-degree: Involves the anal canal or rectal lining. Needs specialist repair and longer recovery.
When an episiotomy extends, it’s often from second-degree to third-degree territory. Hospitals in India increasingly monitor for OASI (obstetric anal sphincter injury), a severe but repairable form of tearing.

When an Episiotomy Is More Likely to Extend

Doctors can’t always predict tearing, but some conditions make it more likely:
  • First vaginal birth
  • Instrument-assisted delivery
  • Baby weight over 3.5–4 kg
  • Short perineal body (<3 cm distance between vagina and anus)
  • Rapid crowning or no time for perineal support
  • Pre-existing infection or oedema (swelling)
  • Rigid or scarred tissue from past repair
Sometimes, the extension happens internally, involving vaginal sidewalls or labia, rather than directly at the incision site. This explains why some women have deeper stitches than expected.

How Doctors Try to Prevent Further Tearing

Obstetric teams use multiple strategies to reduce perineal injury, especially during crowning (when the baby’s head is visible at the vaginal opening):
  • Perineal support: Gentle hand pressure on the perineum to control the speed of birth.
  • Warm compresses: Applied during pushing to improve blood flow and elasticity.
  • Guided pushing: Asking you to stop or slow down when the head crowns, allowing gradual stretching.
  • Correct incision angle: Cutting at 60° from the midline if an episiotomy is required.
  • Lubrication: Helps reduce friction during delivery.
Even with all precautions, the physiology of each birth varies. A single extra contraction can change how tissues give way.

Recognising and Repairing Tears After Birth

After delivery, your doctor will examine the perineum carefully, using sterile lighting and instruments, to identify any extensions or additional tears. Stitches are usually done with absorbable sutures under local anaesthesia.

If deeper muscles or the anal sphincter are involved, an obstetrician or surgeon performs a layered repair. You might also receive antibiotics and stool softeners to aid healing and prevent infection.

Recovery timelines differ:
  • Minor tears and clean episiotomy repairs: Heal within 3–4 weeks.
  • Deeper or extended tears: Can take 6–8 weeks or longer.
  • OASI repairs: Require pelvic physiotherapy and follow-up visits for bowel control assessment.

What Healing and Self-Care Involve

Your comfort and recovery depend on both hygiene and circulation in the perineal area. Here’s what helps:
  • Keep the area clean and dry. Use warm water to rinse after urination or bowel movements, and pat gently dry.
  • Use sitz baths. Sitting in warm water for 10–15 minutes twice daily improves blood flow and eases pain.
  • Pain relief. Paracetamol or ibuprofen are generally safe (confirm with your doctor, especially if breastfeeding).
  • Pelvic floor exercises. Kegels strengthen muscles and promote healing.
  • High-fibre diet and hydration. Prevents constipation and strain on stitches.
  • Avoid heavy lifting or sexual activity until cleared at your postpartum check-up.
If you notice foul smell, pus, fever, or painful swelling, report it immediately. These could be signs of infection or wound breakdown.

When to See a Doctor

Always contact your gynaecologist if you experience:
  • Persistent pain beyond two weeks
  • Wound reopening or bleeding
  • Difficulty controlling gas or stool (possible sphincter injury)
  • Fever or foul-smelling discharge
  • Pain during intercourse months later
Early assessment and treatment can prevent long-term pelvic floor issues.
An episiotomy doesn’t guarantee a tear-free birth, but it remains a useful tool when used judiciously. Tearing, even after a preventive cut, often reflects your body’s unique response to labour rather than a medical error. With proper repair, hygiene, and patience, recovery is complete for most women. Understanding what causes it helps you focus less on blame and more on healing, both physical and emotional.

Whether you’re pregnant, a new mom, or navigating postpartum, you don’t have to do it alone. Join our support group to connect, share, and support one another.

FAQs on Why Some Women Tear Even After an Episiotomy


  1. Is tearing worse than an episiotomy?
    Not always. Natural tears are often smaller and heal better than surgical cuts. However, uncontrolled deep tears near the anus can be more complex to repair.
  2. Can perineal massage during pregnancy help?
    Yes. Studies suggest regular perineal massage from 34 weeks may reduce severe tearing and the need for episiotomy, especially in first-time mothers.
  3. Does an epidural increase the risk of tearing?
    Slightly. Epidurals may reduce the urge to push gradually, increasing sudden pressure on the perineum, but this risk is managed with guided pushing.
Disclaimer: Medically approved by Dr Megha Mittal, Senior Consultant - Obstetrics & Gynaecology, Apollo Spectra Hospital, Delhi

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