Perineal care in pregnancy, labour and after birth
This one is a bit of a touchy topic – no one likes talking about, or even thinking about, an injury to any sensitive part of the body. For many women, the thought of experiencing a tear during birth is quite confronting. But I’m going to talk about it – for those of you that are keen and brave enough to read on! If not, here's a quick summary of what lies ahead, or click here to see my top midwife tips!
First, let’s get our anatomy straight - what is that perineum anyway? – so you know exactly what I’m talking about!
Hopefully that clears some things up… it’s a very simple image but there’s not much reason to know things in great detail. Now, when we are talking birth, it is the perineum that is most important! This is the area between the vagina and the anus that stretches a great deal to allow the baby to be born. It is this area that is mostly likely to experience some level of tear during birth.
Now, let’s look at the stats for women having vaginal births – in Australia at least:
Almost 1 in 4 women (24%) will experience no tearing at all. Hooray!
Around the same amount (23%) will only experience a first degree tear or a laceration only (a very thin tear or graze involving only skin)
Almost 1 in 3 (30%) of women will experience a second degree tear (a tear which involves muscle behind the skin)
Just over 1 in 5 (22%) will experience an episiotomy, where the midwife or obstetrician makes a cut into the perineum and vaginal wall during the birth. Episiotomies are generally more painful than first or second degree tears, and studies show they tend not to heal as well.
3% will experience a third or fourth degree tear, whereby varying degrees of the anal sphincter muscle are damaged
This last statistic is not something anyone wants to be a part of; however on the upside of these statistics – almost half of women won’t tear, or will only sustain a small graze. This is the birth club we all want membership to!
How to join this club?!
Ok, let’s look at the research that has been done on minimising tearing, both during the pregnancy and during the birth. Well, there’s actually a lot of research, which means we actually know a lot about what to do, and what not to do to prevent perineal tearing.
There is very strong evidence that massaging the perineum during pregnancy decreases the change of the perineum tearing during birth, and also that it reduces the chance of ongoing pain in the perineum after birth (makes sense if there has been no tear!). There is also no increase from doing this massage on the risk of instrumental birth, no impact on sex after birth, and no increase in suffering incontinence after birth (it’s important to consider the potential side effects of any treatment – even if it produces a good outcome, like reduced tearing, so it is reassuring that this practice doesn’t seem to have negative physical effects).
You wouldn’t be alone in thinking ‘massaging my what now?!’ But if you are pregnant, and facing a labour and birth, reality is – it’s time to get comfy with your body! Read this hospital guide (http://brochures.mater.org.au/brochures/mater-mothers-hospital/perineal-massage) for a how-to on perineal massage. The main take home points – start massaging only after 35 weeks, once or twice a week. Interestingly, more frequent massage doesn’t increase the chance of not tearing, so no need to go crazy doing it. You should aim to feel a stretch sensation, which may feel a bit like a burning sensation, but don’t overdo it. This is similar to the sensation of stretch you will feel when the baby is being born, so being familiar with this feeling may help you to stay focused when birthing your baby – rushing the birth may increase the chance of tearing (see below).
The World Health Organisation [WHO] (a global organisation charged with improving health outcomes internationally) published their recommendations recently. This is high quality evidence on this topic, because WHO experts will have considered all of the research available when making their recommendations. The main points are:
Perineal massage during birth is beneficial (more on this in a bit);
Warm compress on the perineum during birth reduces the chance of severe tears (third and fourth degree tears);
Mum’s position when giving birth: upright positioning (such as standing, kneeling, leaning) will ensure gravity is on your side, which may make birthing the baby easier and help to avoid episiotomies and/or instrumental births;
A “hands on” approach during birth (where the midwife or obstetrician uses their hands to support the perineum) probably reduces the incidence of small tears
Other articles reviewing the relevant research have agreed with the WHO recommendations above, as well as:
A “hands off” approach (where the midwife or obstetrician has their hands poised ready to help with the birth, but otherwise hands are off the perineum) decreases the likelihood of needing an episiotomy (this may be because the midwife or obstetrician is happy with the progress of the birth if they are not changing to “hands on”);
Slow, physiological birth – this is talking about listening to your body, your urges to push and going with that instead of being coached to push, straining and so on. A slow, controlled birth of the baby allows the perineum time to stretch over the baby’s head and avoid tearing;
Position of mum is crucial – allow your body to guide you into what position feels best, and be aware that upright positioning will ensure gravity is doing some of the work for you;
A lateral (side-lying) position might help slow the birth and control the stretch of the perineum, whilst also taking a lot of pressure off the perineum, reducing the chance of tearing;
Perineal massage during the birth increases the chance of the perineum not tearing during birth
Care after birth
This applies to all mums who have had a vaginal birth: it may surprise you to learn that even when a perineum is intact after birth, it can still be swollen and painful for a few days! Some other causes of perineal pain after birth include vulval varicose veins (yes!) and haemorrhoids. Here are some recommendations for looking after your perineum (and stitches) after birth:
Pain – this will vary for each woman. For mild discomfort after birth, an ice pack can be really effective as reducing this. Medication-wise, you can take paracetamol regularly, plus an anti-inflammatory such as Voltaren or Nurofen (as reducing the swelling will also reduce the pain in the area)
Swelling – you can treat this like you would any tissue injury, and there is an acronym for treating any injury with swelling: RICE. This incorporates rest (so lying down, off the affected area), ice (something cooling like an ice pack or gel cooling pack will reduce swelling), compression (wear comfortable, supportive underwear) and elevation (achieved by rest/lying down and possibly with comfortable pillow or towel under your bum – this helps by aiding the extra fluid from the swelling back into your circulatory system)
Hygiene – particularly if you have a tear that needs to heal, good hygiene practices are essential to healing and avoiding infection. This means showering at least once, if not twice a day; wiping well after toileting, patting your stitches dry with a clean towel after showering, and changing pads frequently, as moisture is a great environment for bacteria to grow
Bowel care – avoid straining and constipation, so pay close attention to your diet (high fibre, lots of fruit and vegetables) and ensure you are drinking lots to avoid constipation. Sometimes a gentle laxative can help ensure the stool is soft and easy to pass
Pelvic floor exercises – following vaginal birth, you can start these whenever you feel comfortable and ready to do so. Click here for a guide on how to do pelvic floor exercises correctly
Some final, handy tips from the midwife!:
Start your pelvic floor exercises in pregnancy – this will help reduce postnatal complications, AND you’ll have a stronger pelvic floor to begin with – meaning recovery is much quicker and better. Women who do pelvic floor exercises in pregnancy are also less likely to report perineal pain after birth. There are some great pelvic floor trainer smartphone apps with inbuilt reminders to help you to do these daily throughout pregnancy
Pads and nappies can double as great ‘ice packs’. Just wet them with water (they’ll absorb the liquid) and freeze, then you can pull them out of the freezer as you need and throw them out once done
Make sure you have some options ready for when you get home after birth – nothing like needing something for pain or discomfort but it's 2am and you have nothing…
Change your pad every time you go to the toilet, even if it’s not full – this is much easier than going off the clock, and ensures a cleaner environment for any tears to heal
If you don’t have a hand held shower, take a plastic cup into the shower with you and pour/rinse over the area. This will wash off any dried blood etc
Likewise, you can use the cup to rinse after going to the toilet (and warm water might reduce any stinging you have during weeing). Just make sure you gently dry the area after
If experiencing pain/stinging during urination, Ural is a great over-the-counter medication you can take to reduce this, and it’s safe for breastfeeding
Have a midwife check your perineum and get them to teach you how to inspect it yourself (if you wish), so you can keep an eye on healing at home
SEEK HELP! If you have ongoing pain, concerns, incontinence or pain during sex – research shows many women don’t disclose these problems because they’re embarrassed or scared. However, trained professionals are really skilled in dealing sensitively with these issues, and we have some really effective treatment options
I hope this has been a helpful read. Please share the love by sending this post to a supermum or supermum-to-be, who might benefit from this article. And I would love to hear your thoughts and experiences in the comments below!
Want more? Click the below links to read related topics!
 Australian Institute of Health and Welfare 2018. Australia’s mothers and babies 2016—in brief. Perinatal statistics series no. 34. Cat. no. PER 97. Canberra: AIHW.
 Jiang H, Qian X, Carroli G, Garner P. Selective versus routine use of episiotomy for vaginal birth. Cochrane Database of Systematic Reviews 2017, Issue 2. Art. No.: CD000081. DOI: 0.1002/14651858.CD000081.pub3.
 Beckmann MM, Stock OM. Antenatal perineal massage for reducing perineal trauma. Cochrane Database of Systematic Reviews 2013, Issue 4. Art. No.: CD005123. DOI: 10.1002/14651858.CD005123.pub3.
 WHO Reproductive Health Library. WHO recommendation on techniques for preventing perineal trauma in second stage of labour (February 2018). The WHO Reproductive Health Library; Geneva: World Health Organization.
 Hastings-Tolsma, M, Vincent, D, Emeis, C & Francisco, T 2007, ‘Getting through birth in one piece: protecting the perineum’, American Journal of Maternal Child Nursing, vol. 32, no. 3, pp. 158-64
 Aasheim V, Nilsen ABV, Reinar LM, Lukasse M. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database of Systematic Reviews 2017, Issue 6. Art. No.: CD006672. DOI: 10.1002/14651858.CD006672.pub3.
 Steen, M (2007). Perineal tears and episiotomy: how do wounds heal? BMJ 15(5): 273-280