The perineum, the area between your vagina and anus, can often tear during delivery in order for your baby’s head to pass through the birth canal. If just the skin and some of the tissue under the skin is torn, this is known as either a 1st or 2nd degree tear. A woman with either of these types of tears may not even need stitches but could still experience pain or discomfort and have scarring.
A 3rd or 4th degree tear is present when the skin, underlying tissues, and part or all of the anal sphincter is torn. A woman with this type of tear may have anal incontinence meaning she has only partial or even no control over the passage of solid, liquid, or gas from the anus. Also, the tear may create pain with attempts at sexual activity. These problems can be embarrassing and make it difficult for you to continue with your everyday life. However, you are not alone.
Unfortunately, many women experience these problems after childbirth. The body takes time to heal, up to six weeks or longer if you had a 3rd or 4th degree tear. In general you should see daily improvement when you follow the 'Vulvar and Perineal Care' handout guidelines.
To help you in your recovery, follow the tips below. Remember that it is possible to return to your daily life without pain, to treat bladder and bowel incontinence, and resume a healthy, pleasurable sex life after childbirth.
OK, so I have a perineal tear. What can I do now?
PRACTICE good perineal hygiene techniques. It is difficult for a perineal tear to heal due the normal post-partum discharge called lochia. Wearing a protective pad is common, and worn more often when urinary and/or fecal incontinence is present after delivery. You should be sure to use gentle cleaning techniques for your perineum in order to prevent it from becoming raw, and to keep the tear from reopening. Also, a tear can be reopened with wiping at the toilet, so pat the skin dry from front to back.
DO pelvic floor exercises. Pelvic floor exercises (sometimes called Kegel’s) will help you regain the strength needed to stop the passage of solid, liquid, or gas from the urethra or anus. Also, these exercises will promote blood-flow and healing of the area. If you are experiencing any discomfort or pain with pelvic floor exercise, do not do them. Consult your health care provider.
MASSAGE your perineum. You can perform massage yourself to promote healing and to prevent adhesions. See my article and educational handout on abdominal scar massage, the benefits and techniques apply to the perineum and vulvar area as well. These techniques are usually done 6 weeks after delivery.
See a Women’s Health Physical Therapist. We strongly recommend you consult with a women’s health physical therapist after childbirth. The body has a lot of recovery to do after delivery. Many women don’t even know the consequences of 3rd or 4th degree tear for many weeks after childbirth. A women’s health physical therapist is specially trained in issues related to childbirth. They will evaluate you and let you know how to treat incontinence and perineal pain, assisting you in recovery from childbirth. To find a physical therapist in the United States, visit womenshealthapta.org and choose the “PT Locator” tab or visit Practitioner Directory at HermanWallace.com.
For more information see the download 'Vulvar and Perinenal Care' handout designed as a patient education tool for my practice.
This article was developed with Lindsy B. Campbell, SPT as part of an independent study project with the University of Washington, Department of Rehabilitation Medicine Division of Physical Therapy.
Rathfisch, G. Effects of perineal trauma on postpartum sexual function. Journal of Advanced Nursing. 2010; 66(12), 2640-9.
Groutz A, Hasson J, Wengier A, et al. Third- and fourth-degree perineal tears: prevalence and risk factors in the third millennium. Am J Obstet Gynecol 2011;204:347.e1-4.
Starr JA, Drobnis EZ, Lenger S, Parrot J, Barrier B, Foster R. Outcomes of comprehensive nonsurgical approach to pelvic floor rehabilitation for urinary symptoms, defecatory dysfunction, and pelvic pain. Female Pelvic Med Reconstr Surg. 2013 Sep-Oct; 19(5):260-5.
Wallace, K. Reviving Your Sex Life After Childbirth, Your Guide to Pain-Free and Pleasurable Sex after the Baby. 2014. Visit KatheWallace.com for publication notification.
Photo by footloosiety
What amount of scar massage is effective for abdominal scars?
Following a client’s abdominal surgery, a physical therapist may administer scar massage, or teach a client to perform scar massage. Currently, there are no protocols backed by literature for the correct amount of scar massage to apply specifically to an abdominal scar. However, there are parameters from a handful of studies that may serve as guidelines for determining the dosage of scar massage. The amount of scar massage that was found effective in these studies ranged from 10 to 15 minutes, and it was administered daily to three times per day. Three of the five articles involved the use of silicone gel, something I do not use in my clinical practice.
A critical component of dosing scar massage is to remember that every person with an abdominal scar has a different physiology and structure to her or his scar depending on the type of surgery performed. (Cesarean section, panniculectomy, exploratory, etc.). Clients should be reminded not to induce significant pain or burning during scar massage. Scar massage should not begin until the doctors post-surgical protocols allows. Generally, this is six weeks after the surgery.
During scar massage it is important to keep scar anatomy in mind. Some scars will only be in the most superficial layer of the skin. However, abdominal scars usually reach into deeper layers of our body. In fact, some scars may adhere to the organs and bowels. These deep layers can be reached by working the more superficial layers of the scar first, and progressing deeper with massage pressure only if there is not significant pain or irritation. Scar massage does not need to be too aggressive or last greater than 10-15 minutes.
For more information sign up for my newsletter and email list to download a FREE scar mobilization handout designed as a marketing and patient education tool for my practice. You will also receive the summary of articles referenced in the handout.
References (summaries provided in Download of Scar Massage Research)
- Arung W, Meurisse M, Detry O. Pathophysiology and prevention of postoperative peritoneal adhesions. World J Gastroenterol. 2011; 17(41): 4545-4553.
- Lewit K, Olsanske S. Clinical Importance of active scars: abnormal scars as and the cause of myofacial pain. J Manipulative Physiol Ther. 2004, 27: 399-402.
- Wallace, K. Reviving Your Sex Life After Childbirth, Your Guide to Pain-Free and Pleasurable Sex after the Baby. 2014. Visit KatheWallace.com for publication notification.
Thank you to Katie McGee, DPT for assistance in preparing this summary and the educational handout.
Photo by atomicpuppy68
While the information here is primarily provided as additional material for and linked-to from my ebook, Reviving Your Sex Life After Childbirth (eBook) , it is available to all visitors of KatheWallace.com.
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