A Healthy Perineum Before and After Birth
By: Katherine Dahl, PT, MPT, CD (DONA)
After reading the title, you may be wondering...what on earth is a perineum? And who cares if it's healthy? Well, if you are a woman, or if you are a man who has any important women in your life (wife, daughters, sisters, friends) you should know about this significant part of a woman's body. (Men have perineums, too, but that's a topic for another article.)
The perineum is the area of skin, connective tissue, and muscle that lies between a woman's vagina and anus. The perineum is important because during vaginal childbirth, it is stretched extensively by the baby's emerging head. During this period of stretching, the perineal tissues can sometimes tear (called a "laceration"), or can sometimes be surgically cut by the physician or midwife (a procedure called "episiotomy"). Perineal tears or cuts typically require stitches in order to repair them.
How can you decrease your chances of having a perineal tear? Mild perineal tears are common during birth, and usually heal quickly on their own. To decrease your chances of a perineal tear: improve the extensibility of your skin through good nutrition during pregnancy; do prenatal perineal massage (see below); wait to go into labor spontaneously (your tissues become more supple with each day of pregnancy); choose a birth position such as sidelying or hands and knees, rather than lying on your back; and use spontaneous pushing instead of "purple pushing" (holding your breath and counting to 10).
What is prenatal perineal massage? Prenatal perineal massage is massage or stretching of the perineum, done before you go into labor. Research evidence is inconclusive on whether or not this actually decreases the incidence of tears, but it still has the benefit of getting you used to the intense sensations of perineal stretching, and it brings increased blood flow to the area (like any other area you massage). There is a good description of how to do this at http://pregnancy.about.com/cs/episiotomy/a/perimassage.htm.
How can you decrease your chances of having an episiotomy? Episiotomies were a routine obstetrical procedure for many years, but the research evidence eventually showed that routine episiotomies did not confer any benefit on the mother or baby, and often led to more extensive perineal tears. According to the 2011-2012 "Listening to Mothers" survey data, it is estimated that 25% of women in the U.S. have episiotomies during birth. To decrease your chances of having an episiotomy: choose a maternity care provider who does not perform them routinely; include your preferences about episiotomy in your birth preference plan and discuss it with your care provider; and consider declining the procedure if it is offered to you during labor.
Is perineal massage beneficial during the pushing phase of labor? Research evidence shows mixed results on this question, with some studies showing benefits, and some studies showing harms. In the absence of a clear answer, it is likely better to let the tissues stretch on their own during the vaginal birth process.
How can I help my perineum heal after birth? Whether or not you have a tear and stitches, your perineum will likely be sore after birth due to the stretching of the tissues. After birth, apply ice to the perineum continuously for 24 hours. You can use a hospital glove filled with ice, or a frozen menstrual pad (previously soaked with water and witch hazel). Sitz baths can also be comforting. The midwife at my last birth recommended the following herb bath: Place 1/2 c. sea salt, 1 oz. shepherd's purse, 1 oz. uva ursi, 1 oz. witch hazel bark, 2 oz. comfrey leaf or root, and 1 large bulb garlic into a square of cheesecloth and tie into a bundle. Boil in a pan of water for a while, then remove the herbs. Pour the herb liquid into a container, and add some of the herb liquid to your bath water to soak your perineum. Pelvic floor contractions (a.k.a. Kegel exercises) are also very beneficial after birth, to relieve swelling, to re-active the muscle fibers, and to bring blood flow to the area for healing. You can start Kegel exercises immediately after birth.
What if I still have a painful perineum after several weeks? Report any continuing pain to your maternity care provider at your 6-week postpartum checkup. There are several reasons that you may still have pain, and they should be looked into. A common cause of pain is stitches or scar tissue that hasn't healed properly, and a pelvic PT can help eliminate the pain by doing perineal scar massage.
What is perineal scar massage? When you have a perineal tear or episiotomy, followed by stitches, a scar forms in the tissue. Perineal tears are graded as 1st-, 2nd-, 3rd-, or 4th-degree tears depending on how deep the tear goes into the tissue. Deeper tears require more layers of stitches to repair them, and result in thicker scars, which are more likely to be painful. Perineal scar massage involves massaging the scar in multiple directions to restore the normal mobility of the perineal tissue layers.
If I already have a perineal scar, am I more likely to tear again during a subsequent birth? There is only one research study available on the recurrence of perineal tears, but it showed that a previous scar is NOT a risk factor for a subsequent tear. Also, an interesting animal study showed that even after two severe perineal tears, the perineum was able to heal completely and recover its full function.
If you have any concerns about getting your perineum ready for birth, or perineal pain after birth, contact one of the pelvic PTs at CTS - we can help!
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