5 Tips for Perineal Healing Postpartum
The possibility of tearing is probably the number one fear of pregnant women – how the heck am I going to push a baby out of my vagina and stay in one piece!?!
Episiotomy used to be a routine procedure that was once thought to help increase the space for the baby to emerge and protect women from dysfunction created by tearing. It turns out the procedure designed to protect actually created more dysfunction and perineal trauma. Thankfully, the procedure is rarely performed these days.
Tearing, while not ideal, is better than an episiotomy. Tears are classified in 4 degrees of severity with 4th degree being the worst. A 1st degree tear involves the fourchette (where the labia minora meet posteriorly), the perineal skin and the vaginal mucosa (membranes or linings). A 2nd degree tear involves the above mentioned areas and extends to the perineal or pelvic floor muscles. A 3rd degree tear involves the fourchette, membranes, muscles of the pelvic floor and the anal sphincter. A 4th degree tear involves all of the above including the rectal mucosa (membranes). Having an episiotomy can increase the likelihood of suffering from a 3rd or 4th degree tear.
Tearing and episiotomy can be avoided or minimized through things like perineal massage, optimizing birth position, caregiver support such as warm compresses and oil, and not pushing while the head is crowning. There are however instances when tearing does occur despite all of the best intentions and preparation. Even if a woman births through an intact perineum, the tissue and muscles need time to heal and recover. Below are some of my favourite postpartum healing tricks.
Rest and Ice for the first 24 hours
Like any swollen tissue, the perineum and pelvic floor respond well to ice to reduce inflammation and pain. Ice should not be applied directly to the skin so using a thin panty or baby washcloth as a layer will protect the delicate area. You can use a bag of frozen peas or crushed ice but what I found easiest was to use frozen maxipads or condoms. For the pads, soak in water (or a healing herbal tea of your choice) and then place in a Ziploc bag in the freezer. Take out when ready to use and place inside your underwear with a thin layer on top between the pad and your skin. For the condoms, fill the condom about ½ full and tie the end. Place in the freezer and when ready to use, take out and place inside underwear as above with a thin layer between your skin and the condom. I have also experimented with the Lunapads Postpartum Liner and it works very well (would have been my first choice if I had known about them when I was pregnant). I found that after I took the frozen liner out of the freezer I allowed 2-3 minutes for it to thaw slightly before placing in the underwear.
Rest and Heat 48 hours and beyond
After the initial 24 hour period I suggest switching to soothing gentle heat in the form of warm sitz baths, compresses or peri bottles. You can use an actual sitz bath but I chose to enjoy a full-on bath several times a day. I used a postpartum perineal healing tea from a local health food store and made a big batch of it everyday (actually my mom did – Thanks Mom!!). I kept it in the fridge and added a cup of the tea to each bath I took. You can also soak your Lunapads Postpartum Liner in the mixture and apply directly to the perineum as a compress. Another option is to use the healing mixture in a peri bottle and spray on your perineum after going to the washroom and several times throughout the day. Some common herbs used for perineal healing are comfrey, yarrow, rosemary, goldenseal, witch hazel, thyme, lavender, calendula, myrrh, and aloe vera. You can ask your midwife for her favourites, visit your local health food store or purchase ready-made mixtures from companies that make perineal healing blends such as Earth Mama Angel Baby.
As soon as 24 hours after delivery I recommend women incorporate core breathing throughout their day to help restore function to the deep core system. This will help promote circulation and oxygenation to the healing tissues, it will help regenerate tone and strength to the pelvic floor muscles and it will encourage connective tissue healing and engagement of the deep abdominals to start closing any separation of the muscles. For core breathing I often find the wide leg child’s pose to be the best, but if the perineal area is too sore, a side lying or seated position is wonderful as well. Ensure your sacrum is not tucked under – there should be a gentle curve in your low back. Inhale to expand the rib cage, inflate the belly and create a sense of fullness in the perineum/pelvic floor. Think of creating space between your sitz bones. Now exhale to deflate the belly, bring the ribs back to resting and lift your perineum/pelvic floor. Exhaling through pursed lips, with a gentle sigh or with an ‘ahhhh’ sound can help promote better closure and upward movement of the pelvic floor along with an inward movement of the deep abdominals. Inhale to expand, exhale to engage. Do this for 1 minute at various times throughout the day – just ensure your tailbone remains untucked.
The main focuses of the early postpartum days are rest, healing and breastfeeding. Ideally the rest includes sitz baths and lying down, which will allow the pelvic floor time to heal and recover from the strain of pregnancy and delivery. By lying down and avoiding even gentle impact, it takes the downward pull of gravity out of the equation to allow for optimal healing. Recruit your family and friends to help so you can focus on you and your baby. I recommend light walking after about 4 weeks with gradual increases in length of time, speed of walking or walking on an incline. I feel it is best to avoid high impact activities like running until at least 6 months postpartum or once you have seen a pelvic floor physiotherapist who has determined your core function is ok to return to such activities.
See a Pelvic Floor Physiotherapist
“I never knew there were physiotherapists who work with the pelvic floor." I hear that all the time and I am working hard to increase awareness of pelvic floor health and promote the wonderful professionals available to you and your pelvic floor. Most literature, baby books etc suggest that by 6 weeks postpartum you have a green light to return to activity. This is a very general guideline and an irresponsible one in my opinion. New moms are simply not ready for rigorous activity at 6 weeks, yet I see them lining up for CrossFit, bootcamps and running groups hoping to get back into their pre-pregnancy clothes. Instead, I suggest that at 6 weeks every woman see a pelvic floor physiotherapist. Having an internal assessment and functional testing of your pelvic floor is so valuable and is key to treating and preventing common types of dysfunction, such as incontinence and prolapse. From there you can gradually progress back to the activies you desire.
Rest your body, feed your baby and heal your pelvic floor.