How can I help my perineum heal after birth?

The pelvic floor is often part of a “forgotten area” of our body, even though its role is absolutely crucial. Working together with other muscles, it helps to stabilise the pelvis and, during birth, it allows the baby to pass through the birth canal.

We usually only start paying attention to this area when something goes wrong and symptoms appear. Yet prevention – keeping the pelvic floor strong and flexible – would mean a great deal for the health of women (and men too). Still, it often isn’t treated as a priority, mainly because of lack of information, even though there are now many recognised specialists working in this field.

The condition of the pelvic floor can deteriorate for several reasons over a woman’s lifetime, and this can bring a range of symptoms that seriously affect quality of life. Any factor that puts horizontal pressure on these stretched muscles gradually weakens them. Because women’s pelvises are generally wider, these stretched muscles can be more vulnerable than in men.

There are methods that can help us prepare the pelvic floor for pregnancy and birth, so that we can do as much as possible to regain the strength of these muscles soon after our baby is born. The most important aim is to make the pelvic floor more flexible, to reduce the risk of injury, and then to train the muscles that have been stretched during birth. Here are a few tried and tested methods to help with this.

What exactly is the perineum?

In women, the perineum is the muscular, connective tissue area between the vagina and the anus, which supports the female reproductive organs. It includes the external genitalia and the pelvic floor muscles. These muscles support the pelvic organs and, while they are healthy and strong, help prevent them from sinking or prolapsing under certain loads. They play a role in voluntary control of urine and stool. Protecting and strengthening them can help ensure they continue to function well after birth and later in life too. So what can we do for them?

Perineal massage before birth

Perineal massage is a technique that women have used for generations to help prevent perineal injury during birth. To protect the pelvic floor as much as possible during labour, there are two abilities we need to develop: elasticity and the ability to relax. A tight pelvic floor is more likely to be injured when it stretches than a flexible one, and it also finds it harder to recoil and regenerate. So we can help it by making it more adaptable.

A gentle massage with oil helps to soften the tissues of the perineum so that, as they stretch, they can let the baby pass through without resistance. Once the tissues become more elastic, they stretch more easily, and with regular massage they also “learn” that, under the pressure of the baby’s head during birth, they should open almost automatically, without resistance. When the rim of the perineum is soft and relaxed, the baby can slide out more easily, and the chance of tearing is reduced. This is a big advantage even if the birth involves an episiotomy or hands-on perineal protection, because further tearing can still happen even with a cut.

How to do perineal massage

You will need a natural oil – such as jojoba, almond or apricot oil – or another oil recommended specifically for perineal massage, starting about 6–8 weeks before your due date. The technique itself is very simple; the mum-to-be can do it herself or ask her partner to help. With an oiled finger inserted into the vagina (about 5–7.5 cm deep), you press down towards the area between the vagina and the anus and gently massage the oil into the tissues.

At first the muscles will feel tight, but with regular practice they gradually relax. Flexible pelvic floor muscles are an advantage both for women who give birth with perineal support and for those who have an episiotomy, because it becomes easier for the muscles and tissues to recover afterwards.

Perineal massage is a very simple method to carry out, but we still recommend that you learn the technique from a reliable professional source, so that you can perform it carefully and effectively.

Birth with episiotomy or with perineal protection?

Both options have advantages and disadvantages. An episiotomy is a cut made from the vaginal opening downwards towards the anus or to the side. It may be needed to protect the perineum of the mother, because more complicated injuries can occur during birth, and sometimes it is also necessary to avoid harm to the baby – for example, if the baby has been in the birth canal for a long time.

With perineal protection, the doctor or midwife supports the perineum with their hand to protect it from tearing. A tear may heal more slowly and leave more lasting damage than a clean cut. With hands-on support, however, a cut can sometimes be avoided. At the same time, an episiotomy itself also carries risks. To be able to decide for or against it, the mother needs to know the potential benefits and risks, based on information provided by her doctor.

Things to watch out for after birth

After the baby is born, mums experience very different levels of discomfort or pain in the perineal area. Some hardly feel anything at all, while others can hardly sit down. These symptoms usually last no more than 2–3 weeks, as any injuries and the episiotomy wound heal.

While you are still in hospital, the external stitches can cause a sharp, pulling pain – it can feel as if you’re sitting on a hedgehog – but this usually eases almost immediately once the doctor removes them. If the pain is still very strong, talk to your doctor about pain relief options.

If you can, try using a postnatal cushion – a small, doughnut-shaped pillow with a hole in the middle – to make sitting more comfortable. There are also cooling cushions available that can give a pleasant, soothing feeling similar to a cool shower.

After an episiotomy it is important to keep the perineal wound clean and dry. A lukewarm (not hot) shower can feel very pleasant during the day: it can ease pain, reduce swelling and keep the area around the wound clean. Sitz baths are not recommended for 6 weeks after birth.

Stool softeners can help make bowel movements easier, so that you don’t have to put strong pressure on the perineal area. Be very gentle when wiping the intimate area, to avoid infecting the wound.

Although there are high-quality, natural, herbal-based products on the market to help perineal healing, it is still better not to use anything other than clean water, to reduce the risk of infection. If you notice any worrying symptoms – increasing pain, redness and inflammation around the wound, discharge, unpleasant smell or a fever – contact your doctor, as these can be signs of infection.

Have you heard of pelvic floor training? If you start exercising your pelvic floor muscles before pregnancy, they can recover more quickly after birth. Through this type of training you also learn how to relax the pelvic floor, which can make labour easier. Pelvic floor exercises can help you manage postnatal urine leakage, strengthen the vaginal muscles again and reduce haemorrhoid symptoms.

Nowadays, excellent complex pelvic floor rehabilitation therapies are available which can provide almost immediate help and relief for mums, even in cases of more serious pelvic floor injuries – such as uterine prolapse, bladder prolapse, rectal prolapse or incontinence. These special therapies use unique tools to help the pelvic floor muscles regain their strength and continue their training as quickly as possible, even in situations where surgery might otherwise seem like the only option.

How can the pelvic floor be injured during birth?

Pregnancy itself can have a negative impact on the pelvic floor, but minor or more serious injuries most often occur during a vaginal birth. In many cases the tiny injuries go unnoticed and simply heal on their own. A young body is generally able to regenerate more easily and more quickly.

During pregnancy, the weight pressing down on the pelvic floor, the stretching of the muscles during vaginal birth, nerve damage or perineal injuries and cuts are among the most common and strongest stresses. Hormonal changes reduce tissue elasticity and muscle tone, and this can be made even worse by the age-related decline in muscle strength. Chronic coughing, constipation and excess weight all place constant strain on the pelvic floor muscles.

So we can see that preparing the pelvic floor for birth, making it more flexible and supporting its recovery after birth are all essential steps in helping a new mum regain the full strength and function of her pelvic floor. If the pelvic floor is strong when you are young, you have a better chance of maintaining pelvic stability later in life too.

However, damage to the muscles and tissues does not always become obvious straight after birth, while you are still in hospital. Often, the first strange symptoms only appear a few weeks later, once the mum has gone home. What might these be?

• leaking urine or urinary dribbling
• difficulty emptying the bladder
• a feeling of a foreign body in the vagina
• a feeling of fullness or pressure in the pelvis
• problems with bowel movements, difficulty holding in stool or wind, urgent need to open the bowels
• reduced sexual sensation, pain during sex
• an uncomfortable feeling of pressure around the perineum when lifting or coughing
• repeated urinary tract infections
• a bulge in the back wall of the vagina
• a deformed vaginal opening, a changed shape of the perineum
• haemorrhoids

We can prepare for birth by increasing the flexibility of the pelvic floor, improving our ability to relax these hidden muscles, and training them in advance. After birth, alongside keeping the perineal area clean, we can also experience the benefits of pelvic floor exercises, as long as we can set aside a little time each day.

Sources:

NHS – Your post-pregnancy body (including perineal pain and pelvic floor exercises)
NCT – Care and recovery after tearing or episiotomy