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Objective: Women's levels of resilience and attitudes towards perineal lacerations vary greatly. Some women see them as part of the birthing process, while others react with anger, depressed mood or even thoughts of self-harm. A previous study has reported increased risk of postpartum depressive (PPD) symptoms in women with severe perineal lacerations. The aim of this study was to assess the association between severe obstetric perineal lacerations and PPD. A secondary objective was to assess this association among women with low resilience.Design: Nested cohort study.Setting: Uppsala, Sweden.Sample: Vaginally delivered women with singleton pregnancies (n = 2990).Methods: The main exposure was obstetric perineal lacerations. Resilience was assessed in gestational week 32 using the Swedish version of the Sense of Coherence Scale. A digital acyclic graph was used to identify possible confounders and mediators. Logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI). A sub-analysis was run after excluding women with normal or high resilience.Main Outcome Measures: Postpartum depression, assessed with the Depression Self-Reporting Scale, completed at 6 weeks postpartum.Results: There was no significant association between severe obstetric perineal lacerations and PPD at 6 weeks postpartum. However, a significant association was found between severe lacerations and PPD in women with low resilience (OR = 4.8, 95% CI 1.2-20), persisting even after adjusting for confounding factors.Conclusion: Healthcare professionals might need to identify women with low resilience, as they are at increased risk for PPD after a severe perineal laceration.Tweetable Abstract: Severe perineal lacerations associated with postpartum depression in women with low resilience in a Swedish cohort. [ABSTRACT FROM AUTHOR]