Perineal care

The perineum is the area which lies between the vaginal opening and the anus. Most women aren’t really conscious of this region until they become pregnant and start reading about childbirth. Then it can become the topic of much conversation and concern.

During childbirth, as the baby’s head descends further towards the vaginal opening, the perineum starts to stretch and become thinner. In most women this stretching is sufficient to allow their baby’s head to emerge and the body to follow.

The length of the perineum varies between individual women and this can impact on the chances of tearing or needing to have an episiotomy. Perineal stretching exercises, when done during pregnancy, can help to increase the capacity of the perineum to stretch during labour. This reduces the likelihood of perineal tearing or the need to have an episiotomy.

What is an episiotomy?

An episiotomy is a surgical cut made in the perineum by the midwife or obstetrician, which makes the vaginal opening larger. When the baby’s head is pressing so firmly against the perineum that there is a risk of it tearing uncontrollably, a cut approximately 2-4 cms long is sometimes made. Local anaesthetic is injected into the perineum before an episiotomy is cut, unless the woman has had an epidural in which case additional numbing of the area may not be necessary.

There is a lot of controversy over how appropriate it is for health care professionals to cut an episiotomy. Some view it as a form of abuse and rarely necessary.

Sutures, or stitches, are necessary if an episiotomy has been cut. These help with healing and to bring the skin edges neatly together. Some women experience a
tear in their perineum during childbirth, which may require stitches.

Generally, the criteria for stitching a perineal tear are:

• If the tear is jagged and the skin edges do not fit well together.
• If the muscle layers within the perineum have been involved.
• If there is a lot of bleeding from the tear. Stitches help to stop bleeding and maximise the chances of quick healing.

Different categories of perineal tearing

• A first degree tear involves injury to the skin.
• A second degree tear involves the muscles of the perineum.
• A third degree tear extends along the perineum and into the anus.
• A fourth degree tear involves the perineum and the anus as well as the bowel tissue.

A midwife or obstetrician can suture an episiotomy or perineal tear. Usually local anaesthetic is given which numbs the area. Nitrous oxide gas is another pain relief option if it is available. Dissolvable suture material is almost always used. This means the stitches do not need to be taken out, and they will start to dissolve from around one week after delivery. Sometimes they can be seen as they come off onto toilet paper, in the shower or onto a sanitary pad. Very occasionally, if they do not dissolve, the sutures need to be removed by a health care professional.

It is common to experience a pulling or tight sensation in the area where the stitches have been inserted. This can be worse when there is localized swelling. Within a few days, this sensation should ease but if it doesn’t, it is important to tell your midwife or obstetrician. Occasionally, tight suturing causes the vaginal opening to become too small which then impacts on normal sexual functioning.

Small vaginal or perineal tears are often left to heal themselves. There has been much research looking at the healing time of tears which have been sutured compared with those which have been left alone to heal. Similarly, pain levels have been monitored and compared in post natal women, within these two groups. It appears that women with sutures experience slightly more pain than those who are left to heal themselves.

Again, individual differences, healing rates, pain thresholds and the type of birth all play a role.

When is an episiotomy done?

• Sometimes an episiotomy is done when the baby has become distressed and it is important for them to be born quickly.
• During a forceps or instrument delivery.
• When a baby is premature or there is a multiple birth.
• When a baby is in the breech position.
• When the baby’s head is very large and there has been no time for the perineum to stretch enough to let it through.

After childbirth

Many women experience pain, tenderness and swelling around the perineal area after their baby is born. Ideally, the perineum remains intact during childbirth, stretching as it needs to to allow the baby’s head and body to be delivered.

What’s normal perineal pain?

• It is common to have some swelling and tenderness in the perineal area after birth.
• An episiotomy or tear which needed sutures can create a great deal of discomfort, especially within the first few days after birth.
• Passing urine can be very painful and cause a stinging sensation.
• Perineal pain tends to peak on the second day after birth though it usually improves within a week.
• Even if there is no visible sign of trauma to the perineum, small grazes can cause stinging until they have healed.
• It can take 4-6 weeks for the perineum to heal completely.

Perineal healing – what helps?

• Ice packs applied to the perineum help to reduce swelling. Ideally they are used within the first 24-72 hours, depending on how soothing they feel. A covered ice-brick or the finger of a disposable glove which has been filled with water and then frozen can be very effective. Alternately, crushed ice in small plastic bag, covered with a wet washer can be useful.
• Hygiene is extremely important and helps to reduce the risk of infection. Showering at least twice each day, washing the perineal area with a mild soap or body wash, patting dry with a clean, soft towel or disposable paper towel will all help with healing.
• When having a bowel motion, support your perineum and stitches by holding a sanitary pad over the perineal area.
• Some physiotherapists use ultrasound therapy over the perineum which helps to reduce swelling and pain. This is generally done 24-36 hours after the birth.
• It is important to wipe yourself properly after emptying your bladder or bowels. Be very careful about wiping from the front towards the back. Showering after a bowel motion is recommended, even if you just wash your lower half.
• Don’t economise on cheaper forms of toilet paper. Aim for comfort over cost, even if you need to quarantine your own supply from the rest of the family!

If you haven’t already tried them you might like to grab a pack of Kleenex Cottonelle Flushable Fresh Wipes. They are lightly moistened wipes that deliver a cleaner, fresher feeling than using dry toilet paper alone and are safe and gentle enough to use while your body is healing. They are also safe to flush, fragrance and alcohol free and will leave you feeling fresh and clean while your body is healing. Available in a 40’s pack for home and a handy 10 pack when you are out and about.

• Keeping the perineal area as dry and clean as possible. Avoid using talcum powder or highly perfumed washes or lotions.
• Change sanitary pads often and dispose of them properly. Hand washing is important to minimize the risk of infection.
• Resting whenever possible. Standing for long periods can lead to swelling and an increase in pain and discomfort. Similarly, sitting in one position can lead to blood congestion in the vulval area. When lying down try lying alternately on each side and resting your upper leg on a pillow.
• Avoid becoming constipated. Drink plenty of water each day, at least 8 glasses a day or more if you are breastfeeding; and eat a diet high in fibre and include fruits, vegetables and protein which will all help with tissue healing. Straining to poo can cause straining of the suture lines and further swelling. Take your time when you go to the toilet and avoid rushing.
• Getting out of bed from your side, rather than from a sitting position. This helps to avoid stretching of the perineal area.
• Doing pelvic floor exercises as soon as possible after your baby is born. Link in with the physiotherapy department of your maternity hospital and/or check http://www.holditsister.com/post-birth-recovery
• If you are bothered by stinging when passing urine, try standing a warm shower or pouring warm water over your vulval region as you wee. A plastic squirt bottle filled with warm water can be useful.
• Avoid resuming sexual intercourse until you feel comfortable and your perineum has healed. Many women find it takes at least six weeks for their vaginal and perineal area to stop feeling some degree of tenderness.

You may find you need to take pain relief medication in the first week or so after birth. Speak with your midwife or obstetrician about what’s right for you. Bear in mind that many medications are excreted in breast milk so be careful about the type, dose and frequency of what you are taking. Check the National Prescribing Service at http://www.nps.org.au

What doesn’t help the perineum to heal?

• Salt baths and/or long soaking in hot baths.
• Sitting on a circular air or rubber ring.
• Resuming sexual intercourse before the perineum has fully had a chance to heal.
• Heat packs.
• Antibiotics – unless there is an infection present.
• Lifting or straining. Avoid picking up heavy loads, toddlers, older children or moving furniture.
• Vigorous exercise, squatting or any movement in which the legs are straddled and the perineal area needs to stretch before it has healed
• Using tampons.
• Being economical about how many sanitary pads you are using. It is important to try and keep the perineal area clean and dry, so replace pads every 2-3 hours or more regularly if they are soaked.

What do I need to be aware of?

• Passing large blood clots. After sitting or lying still for a long period of time, it can be normal to pass blood clots. However, if you pass a lot of them or they continue, or you are worried see your doctor.
• Pain in the perineal area which does not ease. Throbbing, aching, abdominal pain or continual discomfort which is not improving needs to be checked by a health care professional.
• An offensive or smelly vaginal discharge.
• If you develop ongoing pain, stinging or scalding when you pass urine. This can be a sign of a urinary tract infection.
• A pulling sensation on your perineum which makes movement and walking difficult.
• Developing an elevated temperature or feeling as if you have an infection. A normal temperature range is up to 37.3 degrees Celsius.

You will need to make an appointment to see your midwife, obstetrician or GP six weeks after your baby is born. They will check to see if your perineal area has healed. If, in the meantime you are at all concerned about any aspect of your recovery, do not hesitate to get yourself checked.