Perineal injury care and support

We recognise that every person will have different names for their pelvic body parts, however throughout this website we will be using anatomical names. We encourage you to use your own preferred body part names with any healthcare professional you come into contact with during your pregnancy and postnatal journey, so let your preferences be known.

Your vulva

Quite often many women and birthing people will refer to their vulva as the vagina, however this is anatomically incorrect. The vulva is what you see from the outside and the vagina is the muscular structure inside. Every vulva is different, have a look at the diagram and see if you can identify there on yourself. Sometimes your vulva may look different during pregnancy due to increased pressure and weight of baby(s). It is useful to get to know your vulva to be able to identify any changes from what is normal for you, and you can also look to see if you are doing pelvic floor exercises.

Where is your perineum?

Your vagina is a passage through which your baby passes during vaginal birth. Above your vagina is your urethra, the small hole you wee from. Either side are your labia, the larger labia are on the outside, and the smaller labia on the inside. Below your vagina is your anus, which is a ring of muscle which helps to control when you need a poo (open your bowels). Your anus has two sphincter muscles, an internal ring which sits inside an external ring, like a circle inside a circle, between your vagina and your anus is your perineum.

What happens to my perineum during birth?

The perineum is an area that comes under a lot of pressure during birth. Near the end of your labour, your baby’s head will come through your cervix (the opening to your womb) and move down through your vagina. The pressure of your baby’s head encourages the muscles of your vagina and perineum to stretch and open. It is this relaxing and stretching of your vaginal and perineal muscles that allow your baby to be born. Sometimes if these muscles are not able to relax and stretch, they can be injured. Your midwife or doctor will recommend examination of your vagina and anus after birth to check for any injuries to your vagina, perineum and anal sphincter muscles.

If you have an injury, your midwife or doctor will locate the injury to see if it is anterior or posterior. An anterior injury is any injury to the top part of your vagina, this can include your labia and around your clitoris or urethra (where you wee from). A posterior injury is any injury to the lower part of your vagina; this can include your perineal and anal sphincter muscles.

Your midwife or doctor will also grade how severe it is, this ranges from first degree to fourth degree.

A tear happens spontaneously as the baby stretches the vagina during a vaginal birth, but an episiotomy is a surgical cut made by your midwife or doctor into the vaginal wall and through the perineal muscles to make more space for baby to be born. Episiotomies are only done with your consent. If you have an episiotomy, you will need stitches after birth to repair it. For more information on episiotomies and reasons why you might need or have one, please visit the episiotomy section.

First degree tears

A first degree tear is trauma to the skin. This can happen around your labia, clitoris, inside the vagina or to your perineum. They are sometimes called grazes, lacerations, or superficial abrasions. These types of tears usually heal quickly and without the need for any treatment. They are unlikely to cause any long-term problems, but they can initially be quite sore.

Second degree tears

A second degree tear is trauma to your skin and involving part of the muscles. These tears usually need stitches and like with 1^st degree tears, they are unlikely to cause long-term problems but can be sore.

Third degree tears

A third degree tear is trauma to your perineal and anal sphincter muscles. There are different grades to a third degree tear, they can be 3a, 3b or 3c tears. The 3a and 3b tears involve your external anal sphincter muscle. Whereas 3c involves both external and internal anal sphincter muscles.

Fourth degree tears

A fourth degree tear is a trauma to your perineal muscles, external and internal anal sphincters, and the lining of your back passage (rectum).

Third and fourth degree tears are also known as Obstetric Anal Sphincter Injuries (OASI).

For more information, visit the Royal College of Gynaecology website here. 

The statistics

As many as nine in ten women and birthing people experience some sort of tear, graze, or episiotomy during a vaginal birth. Tears can occur to parts of the vulva including the labia, inside the vagina, into the perineal muscles and the anal sphincter muscles.

Around 70 per cent of perineal tears will need stitches to repair them.

An episiotomy is a medically indicated cut done by your midwife or doctor.

One in seven women and birthing people will have an episiotomy during a vaginal birth.

Some tears go into the anal sphincter muscles, these are called Obstetric Anal Sphincter Injuries (OASI).

The number of women and birthing people who experience an OASI during the first vaginal birth is approximately six in every 100.

Less than two in every 100 women and birthing people will an experience an OASI if they’ve had a vaginal birth before.

The risk factors

If you are pregnant with your first baby, you are more likely to have a minor tear, an episiotomy, or a tear involving your anal sphincter muscles during a vaginal birth. There are some known risk factors that will increase your changes of any of these happening. They include:

• South Asian ethnicity
• Baby being over 4kg
• If your baby’s shoulders get stuck during your vaginal birth
• If your baby is born facing up towards the front of your pelvic (around 10% of babies are born this way when they should be facing downwards to the back of your pelvis)
• A pushing stage that is longer than expected
• Having a very fast pushing stage
• Use of forceps or suction cup during your vaginal birth
• Being over 35 years old

These risk factors do not predict that tears or need for an episiotomy will happen, but there are techniques to minimise perineal injuries that are advised for all.

For more information, visit the Royal College of Gynaecology website here. 

An episiotomy is a medically indicated cut performed by a doctor or midwife.  An episiotomy will not harm your baby and around one in seven women and birthing people experience an episiotomy during vaginal birth. 

A doctor or midwife will recommend an episiotomy in the following situations: 

They are concerned that your baby’s heartrate is abnormal

Midwives and doctors analyse your baby’s heartrate during labour and birth to assess your baby’s response to labour. For some babies, an abnormal heartrate shows they are struggling to cope with the stress of birth. An episiotomy can shorten the amount of time you are pushing for and help your baby to be born sooner.

They think that you have been pushing for too long

Pushing for a few hours can be normal, but generally pushing for more than two hours, or being in the pushing stage of labour for more than four hours is considered too long. Pushing for this length of time can increase the risk of tears that involve your anal sphincter muscles, and pelvic floor concerns such as a prolapse and leaking wee and/or poo (urinary and/or faecal incontinence). 

They are recommending using an instrument such as forceps or a suction cup

This is because using forceps or a suction cup without an episiotomy increases your risk of having a tear which involves your anal sphincter muscles, and these tears have worse outcomes compared to an episiotomy.

If they think you might have a tear which involves your anal sphincter muscles

These tears can have worse outcomes compared to tears which only involve your perineal muscles. These tears are hard to predict. Some of the signs your midwife or doctor will look out for are:  

• If they feel your perineal muscles during vaginal birth and they don’t feel as stretchy as they would like. 
• If your perineum is looking pale during vaginal birth  
• If you have been pushing for a long time and they think it might be because your perineal muscles aren’t stretching as they would like
• If they think your baby’s position or size may cause a tear to your anal sphincter muscles. This may be because your baby’s face is facing the front of your pelvis, or the weight of your baby is predicted to be over 4kg. 
• You have previously had a tear which involved your anal sphincter muscles, and they think it might happen again. 

The evidence and knowledge which supports offering an episiotomy to prevent a tear into your anal sphincter muscles is conflicting. This means midwives and doctors cannot predict which women and birthing people will benefit from having an episiotomy. If your midwife or doctor recommends an episiotomy, they will talk through the decision with you at the time.

Once your doctor or midwife has explained their recommendation for an episiotomy, you can choose whether to consent or not consent. 

How is an episiotomy done?

Step 1:

For women and birthing people who consent, your midwife or doctor will make sure you are given medication so you cannot feel anything. If you already have an epidural, this will be used. If you do not have an epidural, an injection of local anaesthetic will be given into your perineal muscles to numb them. You can choose to use gas and air (Entonox) whilst the midwife or doctor does this.

Occasionally the doctor may want to move you to an operating theatre to birth your baby. Here you can be given a spinal anaesthetic. This is similar to an epidural and it will numb your body from your waist down to your toes. After you have been given medication, your doctor or midwife will test that you cannot feel your perineal muscles.

Step 2:

Your doctor or midwife will use specialised surgical scissors to do the episiotomy. These specialised surgical scissors make sure the episiotomy is the correct length and angle away from your anal sphincter muscles. They will do the episiotomy once your baby is low, and your perineal muscles have started to stretch.

Step 3:

Once your baby is born the doctor or midwife will aim to repair the episiotomy as soon as they can. 

There are some risks to having an episiotomy, but we cannot predict which women and birthing people will be affected.

• You may bleed from the episiotomy but repairing it quickly will reduce this risk.
• The episiotomy may tear further and cause a tear involving your anal sphincter muscles. This risk is reduced by using the special surgical scissors known as epi-scissors.
• Other risks are similar to perineal trauma.

More information is available on the Royal College of Obstetricians and Gynaecologists here.

Most women and birthing people who have a tear repaired will recover well, although it can take time.

In the first few days and weeks, it is common to experience:

• Pain where the injury is.
• Pain which is worse when sitting, standing, or walking around 
• Stinging felt on the wound when weeing (passing urine)  
• Discomfort felt on the wound when pooing (passing a stool) 
• Feeling swollen 
• Some bleeding from the injury 
• Leaking of poo/wind/wee or needing to rush to the toilet to have a wee or poo. 
• Feeling depressed or a low mood because of the impact of their injury on their life 

Most of these experiences should resolve by themselves as your body heals. 

Once the wound has healed after around 2 months after birth, some women and birthing people can experience: 

• Pain where the injury was. 
• Other pain in their pelvis 
• Pain during sex. 
• Worrying about having sex or avoiding having sex because of their injury 
• Difficultly controlling their wind 
• Leaking of poo (faecal incontinence) 
• Leaking of wee (urinary incontinence) 
• Anxiety about leaving the house, or not having easy access to a toilet. 
• Low mood or depression because of the impact of their injury on their life 
• Difficultly bonding with your baby because of the impact of their injury on their life 
• Feeling isolated because of the impact of their injury on their life 
• Changing their lifestyle such as physical activities and social activities because of worries about leaking wee or poo. 
• Worrying about having more children because of the impact of their injury on their life 

If you are experiencing any of these symptoms, please complete an assessment on MyPathway[DA1] .

Women and birthing people who have had complicated tears, large tears or tears which involve their anal sphincter muscles may be more likely to experience these symptoms. However, 60-80% of women and birthing people who experienced a tear into their anal sphincter muscles will not have any symptoms by 12 months after birth.  

How can I reduce my risk of having a perineal tear?

During vaginal birth, it is very common for women and birthing people to experience a graze or tear.  Although this may not always be preventable there are things that can be done during pregnancy and during vaginal birth to minimise or even prevent trauma. 

https://www.rcog.org.uk/for-the-public/perineal-tears-and-episiotomies-in-childbirth/reducing-your-risk-of-perineal-tears/ 

RCOG AN leaflet – will need uploading to the website 

Pelvic Floor Exercises

Pelvic floor exercises are recommended for all women and birthing people.

Pelvic floor exercises assist to train the pelvic floor to contract and relax fully. 

During pregnancy and vaginal birth, the strain on the pelvic floor increases. Pelvic floor exercises will help to strengthen these muscles, and strong muscles help prevent or reduce incontinence and trauma.  

Being able to relax the pelvic floor muscles can help during the pushing stage of labour. 

Muscles that are regularly trained are less likely to be injured. If injury does occur, muscles that are regularly trained are able to recover well. 

Perineal Massage

Research has shown that carrying out perineal massage from around 35 weeks of pregnancy can reduce your risk of having a tear, episiotomy or a tear involving your anal sphincter muscles during vaginal birth, especially if it is your first baby. Perineal massage can also reduce the length of time it takes for you to push your baby out, improve wound healing if you do have a perineal injury and can reduce the amount of perineal pain you feel after birth. 

Massaging your perineum helps this muscle to become softer and stretcher, so when your baby is being born, this muscle can stretch more easily to allow your baby to pass through. 

The following clip shows a quick experiment using your hands to demonstrate just how effective massage can be: 

For more information, you can watch a video which uses a model to show how to do perineal massage. Ideally aim to massage your perineum for up to five minutes, three to four days a week. Although even one to two times a week can make a difference. Either you or your birth partner can massage your perineum.

Don’t perform perineal massage if you have current thrush, active herpes, vaginal infection, the waters around your baby have broken or it is very painful for you. If you are unsure whether perineal massage is suitable for you, ask your midwife or doctor.

Ideally aim to massage your perineum for up to five minutes, three to four days a week. Although even one to two times a week can make a difference. Either you or your birth partner can massage your perineum.  

Helpful tips to get you started:

• Start by deciding the best place to perform perineal massage. You may find being in the bath, or your bedroom most comfortable.
• You may wish to lie down or stand up.
• You may want to dim your lights, put music on, aiming to create a similar environment that you wish to give birth in.
• Make sure your nails are short and wash your hands and perineum before massage.
• You may find a bath helpful as the warmth can help the muscles start to relax.  
• Use lubrication. Using an emollient is best, alternatively any natural oil that you are not allergic to e.g., almond oil and olive oil etc.

How to do perineal massage:

1. Get into a comfortable position. Lying, standing with a leg up, lying on your side or being in the bath can all work.  
2. Use your thumbs up to your second knuckle, or for your birthing partner, use their forefinger and middle finger.  
3. Start with smaller and gentler movements and build up as your muscles warm up and relax. Massage inside the vagina, pushing downwards and outwards in a sweeping motion. Massage from 3 o’clock to 9 o’clock. You will make a J and backwards J shape, or a U-shaped motion.
4. You can hold the stretch, slowly increasing the amount of time and pressure you use as your muscles become softer with repeated massage. You may feel a strong stretch, a tingling sensation, a mild burning type sensation or strong pressure. However, it shouldn’t be painful. It is important that you relax your perineal muscles during massage.

You can use this time to practice any relaxation techniques you plan to use in labour such as deep breathing and visualisation techniques. You could picture your baby’s head stretching your muscles. This will help you learn to relax your muscles when you feel pressure and when you visualise your chosen image.   

It may take a couple of weeks of regular massage before you notice an increase in softness and stretchiness in your perineal muscles.  

Birth positions

It cannot be predicted how you will labour, or the type of birth you might have. However, you can try and encourage a spontaneous vaginal birth (a vaginal birth without forceps or suction cup). Choosing to birth in a birth centre or at home if this is suitable for you can encourage a spontaneous birth. Labouring and birthing in upright positions and avoiding lying on your back can also help. Positions such as standing, kneeling, being on your hands and knees, or lying on your side if you need to rest, are encouraged. If you are able to avoid an induction or epidural analgesia this can also encourage a spontaneous vaginal birth.   

Being upright can help encourage a spontaneous vaginal birth (a vaginal birth without forceps or suction cup) and can help to minimise your risk of a tear which involves your anal sphincter muscles. Choosing an upright position such as kneeling, hands and knees, or lying on your side if you are too tired to be upright, uses gravity to reduce the amount of pressure from your baby’s head on your perineal muscles. Lying on your back or having your legs up in lithotomy poles can work against gravity, increasing the pressure on your perineal muscles and increasing the chance of having a tear which involves your anal sphincter muscles. More information here.

Warm Compress

When you are in the pushing stage of labour, your midwife or doctor can put a warm compress on your perineum when they see it start to stretch. The warmth will help your muscles relax and soften, allowing them to stretch more easily. 

It can often feel comfortable and reassuring to have something warm on your perineum during vaginal birth. If you do not like the feeling of the warm compress, it can be easily removed. 

Warm compress has been shown to reduce your risk of having a tear which involves the muscles of your anal sphincter. 

Hands On

When your baby is being born, your midwife or doctor will offer to have their hands positioned to help control your baby’s birth and support your perineal muscles. One of their hands will use gentle pressure on your baby’s head, helping your baby to be born in a slow and controlled way. One of their hands will be on your perineal muscles to offer additional support to counter act the pressure on these muscles from your baby’s head. They will keep their hand on your perineum for the birth of your baby’s head and shoulders. Your midwife or doctor will help guide you when to push, gently push or breathe, to help control your baby’s birth and minimise the pressure on your perineal muscles. 

Episiotomy

Sometimes, your midwife or doctor will see signs that your perineal muscles aren’t stretching as expected. Maybe the pushing stage of labour is taking longer than expected, maybe your muscles look overstretched. If your midwife or doctor is worried that your muscles are not stretching well, they may offer you an episiotomy, to prevent a tear which involves the muscles of your anal sphincter muscles. 

Checking for injury after a vaginal birth

All women and birthing people who have a vaginal birth are at risk of having a tear. Injuries and tears are not always obvious. This is why after birth, your midwife or doctor will offer to thoroughly examine your vagina and your back passage (rectum and anus) to check for any tears, and accurately assess their size and complexity. Your midwife or doctor cannot exclude all injuries without being able to touch and look inside your vagina and being able to insert one finger into your bottom to perform a rectal examination.

Your midwife or doctor will ask your permission to perform these checks. They will ideally aim to exam your vagina and bottom soon after birth so that any injury can be quickly repaired. You can use any pain killers you used during labour for this examination. It should only take a few minutes. 

What is the OASI Bundle? (S 16) 

The OASI (obstetric anal sphincter injury) care bundle is a partnership between the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives (RCM).

It is a collection of techniques which can help reduce the risk of a woman or birthing person having a tear which involves the anal sphincter muscles. 

These techniques include talking to you during your pregnancy about your risk of OASI (obstetric anal sphincter injury/a tear into your anal sphincter muscles), using a hands-on technique during vaginal birth, using a 60-degree angle for episiotomy, and offering a vaginal and rectal examination after birth to detect any injury in the vagina and the anal sphincter muscles. 

When the OASI bundle was evaluated, the hospitals using it reduced the number of tears involving the anal sphincter muscles by around ten to 20 per cent. More information is on the Royal College of Obstetricians and Gynaecologists website here.

Will I need to have stitches?

After birth, your midwife or doctor will offer to exam your vagina and back passage to assess whether you would benefit from stitches (sutures). If they identify any injury they will classify it as a first, second, third or fourth degree tear.

First degree injuries may not require stitches. Second, third, fourth degree injuries and episiotomies are recommended to have stitches. Suturing involves putting stitches into the injury to bring the muscle and skin together.  

Repairing injuries with stitches improves wound healing and outcomes. If you compare outcomes for those who have had their injuries repaired, and those who didn’t, repairing your injury: 

• Reduces the amount of blood you will lose from your injury.
• Minimises the risk of infection to your injury.
• Helps the muscles which have been injured to repair and improves their function.
• Reduces the risk of long-term pain and pain during sex. 

 Additionally, if repairing your injury is recommended, there are some risks to having stiches:

• Having stiches can be uncomfortable. Your midwife or doctor will make sure you are given pain relief and are comfortable during the procedure.  
• Placing stitches can cause pain and infection, although the risk of both is still lower if you choose to have stitches than if you choose not to.  
• Long term pain is reduced if you choose to have stitches compared to if you choose not to have stiches. Short term pain in the first days and weeks is similar whether you had stitches or choose not to. 

What care will I receive if I have an injury?

If your injury would benefit from being repaired with stiches (sutured), your midwife or doctor will aim to do this as soon as possible after birth to reduce the amount of blood you may lose and reduce your risk of an infection in the wound.  

Most of the time this repair can be done in the room where you gave birth. For tears which involve your anal sphincter muscles or your rectum, these repairs are advised to be done in theatre. These tears have a higher chance of complications. Repairing them in theatre with good lighting, good pain relief, a sterile environment and a skilled doctor can help to optimise healing. 

Your doctor or midwife will ensure you are comfortable during the repair. For most women and birthing people, they can continue to use the pain killers they used during their labour and birth, such as gas and air (Entonox) or epidural. Extra numbing pain relief can also be injected into the injured area. If you have your repair in theatre you will be offered a spinal anaesthetic unless you already have an epidural. A spinal is similar to an epidural and will numb you from your waist down to your toes. You won’t be able to stand or walk for several hours afterwards. If you have an epidural or a spinal, you will be advised to have a catheter inserted. This is a soft tube inserted through the hole you wee from (urethra) and will drain your wee (urine) from your bladder. When the epidural or spinal has worn off and you can stand and walk, the catheter can normally be removed. 

Your midwife or doctor will normally prefer for your legs to be resting in supports (lithotomy poles) for the repair. They will usually cover your legs and tummy in sterile drapes to minimise the risk of infection. All the equipment used for your repair will be sterile. 

The time taken to complete your repair may be as little as ten minutes or up to an hour. Your midwife or doctor should be able to estimate the time it will take after they have assessed your injury. They will use repair techniques that will maximise comfort and wound healing and minimise infection. The stitches your midwife or doctor use will eventually soften and fall out (dissolve) and will not usually need to be taken out. Most stitches dissolve within seven and ten days and are fully dissolved by six weeks. If you have had stitches into your anal sphincter muscles, these are designed to dissolve by around three months after birth.

Once your injury has been repaired, your midwife or doctor will ask to exam your vagina and back passage (rectum and anus) and offer you a suppository of diclofenac to put in your back passage. This suppository helps to reduce swelling and provides pain relief for up to 24 hours. Whilst in hospital you will be provided with pain relief. If you have experienced a tear which involves your anal sphincter muscles or your rectum, you will be provided with a course of antibiotics to reduce the risk of an infection into your wound, and laxatives to help you go for a poo. Most routine medications used will be safe whilst breastfeeding. 

Most women and birthing people find their injuries heal well, and by two months after birth, they feel completely healed. For some, they may have ongoing symptoms or concerns, such as pain, wound healing concerns or maybe cosmetic concerns. Your GP can refer you into the correct services if you feel these are a problem for you.

Follow Up Appointments (S 19) 

In the first few days after birth, your midwife or doctor will regularly offer to check your stitches. Ideally this will be every time you see them. This is a good opportunity to assess healing and look for early signs of any concerns.  

If you have had a first or second degree perineal injury, you won’t require any additional follow up appointments.

If you have had a third or fourth degree tear which involves their anal sphincter muscles, routine follow up appointments are made with a physiotherapist and a specialist clinician to review your recovery. These appointments are usually around two to three months after birth. These appointments provide an opportunity to review your injury, recovery and assess whether you could benefit from any other specialist services. It is also an opportunity for you to ask any questions.

If you had your baby at Birmingham Women’s Hospital you will also be offered an ultrasound scan of your anal sphincter muscles (an endoanal ultrasound). This scan looks at images of the anal sphincter muscles to assess the repair, how they are healing, and identify any problems. If you choose to have another baby in the future, the scan can provide your midwife or doctor with information that can be used to help guide your decision when choosing the most suitable way to give birth next time. It can also provide you with the reassurance that the muscles are healing well internally. 

​​​​​​​What about next time?

For most women and birthing people who have had a perineal injury, it is safe to have another vaginal birth in future. If you are worried about having another vaginal birth, you can choose to have a planned caesarean birth. You can discuss this with your midwife and doctor if you become pregnant again.  

If you have had a tear which involve your anal sphincter muscles, you will be offered an appointment with a specialist to help you decide which type of birth is most suitable for you, either a vaginal birth or a planned caesarean birth. Most women and birthing people have no long-term problems following a tear into their anal sphincter muscles and can safely have a vaginal birth in future pregnancies. For women and birthing people who experience any on-going pelvic health symptoms, a planned caesarean birth can be offered. Your individual circumstances and preferences will always be considered so that you can make a decision that is right for you. 

What can I expect whilst my wound heals?

For most women and birthing people who experience a perineal injury, the healing period lasts around two months after birth. This is how long it takes for soft tissues (skin and muscle) to heal and for your stitches to dissolve. You may experience pain, discomfort, and might find it difficult to control your wee, wind and poo. This will usually improve as your wound heals. If you have any concerns make sure you speak to your midwife or GP.

How should I look after my injury if I have one?

Looking after your wound carefully can help it to heal. Keeping your wound as clean as possible is important to help it to heal and prevent infection. It can be a good idea for you or your birthing partner to look at your wound regularly. If looking yourself, you can use a handheld mirror.

By checking your wound regularly, you will be able to notice small changes that you need to tell your midwife or doctor about. It is also a good idea to ask your midwife or doctor to check your perineum every time they see you.  

Top tips to help care for your wound:

• Clean your wound daily either in the shower or in the bath. If you bathe your wound only take a short ten-minute bath.
• You don’t need any products to help clean your wound, water is enough. If you do use products whilst showering or bathing, make sure they aren’t perfumed as these can dry out the wound.
• Clean your wound after going to the toilet. Use a bidet if you have one, or a jug with body temperature or cool water to pour over the area.
• Change your maternity pad every few hours. Maternity pads are advised as they are more absorbent and softer.
• Make sure you wash your hands before and after changing your maternity pad, going to the toilet, or cleaning your wound.
• Dry the area carefully with a clean paper towel after cleaning. Make sure when you clean and dry your wound, you move from front (your vagina) towards your back (back passage).
• Air your wound when possible by taking off your pants and pad and lying with your legs comfortably open. 

After having any tear, it is normal to feel pain or soreness. The skin part of the wound usually heals within a few weeks after giving birth and your pain reduces. You might find you can feel a stitch, and it feels uncomfortable. As the stitch dissolves and the swelling in the wound reduces, this irritation will also reduce. 

Additional advice to help you heal well:

• Take regular pain relief, this is important. For the first few days, alternate taking paracetamol and ibuprofen. Don’t wait to feel pain, or for the pain to worsen to take pain killers. Once the pain has settled, take pain killers when you feel you need them. Do not take paracetamol or ibuprofen if you are allergic or if these medicines are not suitable for you.
• Ice packs can be very comforting. They can help reduce pain and reduce the swelling and bruising which can sometimes cause pain. Don’t put ice directly on your wound. Wrap in a towel. Use for about ten minutes at a time, but you can use an ice pack several times a day.
• Take regular breaks from being upright. You might find certain activities can increase your pain. Sitting, standing, and walking can put pressure on your pelvic floor muscles, causing swelling and pain around your wound. Lying down or lying on your side can take some of the pressure off.
• Feeding your baby in a variety of positions can help reduce the pressure on your pelvic floor muscles. You will find your own balance to how much activity you are able to do. Do make sure you continue to move regularly.

Perineal Scar Tissue

During wound healing, fibrous tissue forms to repair the wound. This tissue is often referred to as scar tissue. It is firmer and less flexible than your normal skin and can become attached to surrounding layers of muscle and tissue which can cause discomfort after the wound has healed. You may feel uncomfortable during some activities including sex. The amount of scar tissue which forms can depend on the size of your wound, whether your wound healing was affected by infection or your wound opening, and how well your body was able to repair the wound. Massaging scar tissue can help it to break down and become more flexible and this can help to reduce discomfort. 

Do not start massaging your scar until your wound has completely healed. The wound should be completely closed and covered by skin. Most wounds have healed by the time of your six-week check with your GP. You can ask them to check during this appointment that your wound has completely healed. If you are experiencing any discomfort or concerns with your wound, tell your GP at this appointment. You can also speak to your GP about scar massage. Do not massage your scar if you have any infections in the wound or your vagina.  

How can I do perineal scar massage?

Perineal scar massage works best when the area is warm. Warmth helps the area to relax and helps blood flow. You may want to try different positions and use this guide to help you:

1. You can warm your perineal area by taking a bath or using a warm compress.
2. Use lubrication, an emollient if you have one, alternatively oils such as almond or olive oil, or any other oil you are not allergic to.
3. Use your fingers and thumbs, to be able to comfortably reach all of your scar tissue.
4. Massage your scar tissue outside on your perineum, and inside your vagina. Use a variety of directions and pressures. It may be a little uncomfortable but shouldn’t be painful. Adjust your touch to avoid pain. You will be able to feel the areas which need massage and will be able to feel the best pressure to use.
5. You can massage your scar tissue every day, for up to 10 minutes. Stop before this if it is uncomfortable.  

What should I tell my midwife or doctor about?

It is normal for your wound to feel painful in the first days and weeks, but you should tell your midwife or GP if you are experiencing:

• Pain which is worsening 
• Pain during sex 
• Pain after the wound has healed (around two months after birth) 

When your wound is healing, you may notice signs of inflammation such as swelling, pain and redness. This can be normal part of the healing process. However, if you notice an signs of infection, please tell your midwife or GP straight away because you might need antibiotics. If you are already taking antibiotics a doctor may need to change your antibiotics. Signs of infection can be: 

• An offensive (horrible) smell from your wound
• An offensive discharge (smelly or pus like) 
• An increase in pain from your wound  
• An opening in your wound  
• Redness and swelling in and around your wound.
• If you have a fever or temperature or are feeling generally unwell 

Your GP will ask to make an appointment with you and your baby around six to eight weeks after your birth. This can be a good time to tell your GP if you are experiencing any pain, leaking of wee, poo or wind, or feeling anxious, depressed or any symptoms of post-traumatic stress disorders. Your GP can help to arrange referrals to specialist services to help to treat these symptoms. If you have given birth at Birmingham Women’s Hospital and are concerned about your wound, your midwife, GP, or maternity triage may be able to be refer you to the perineal wound review clinic.

Bladder and bowel health:

It can be common to experience leaking of wee, poo or wind after birth. Usually this resolves by itself, and it will help to be doing pelvic floor exercises. However, you should tell your midwife or doctor if you experience: 

• Leaking of poo (faecal incontinence) 
• A strong urge to poo which makes you stop what you’re doing to rush to the toilet. 
• Difficulty controlling your wind. 
• Passing wind or poo through your vagina 

Health habits:

Having a balanced diet including having fruit, vegetables, cereals, wholemeal foods, will help your wound heal. Fibre and plenty of water can also help you to avoid constipation and straining. If you have had a tear into your anal sphincter muscles, you will also have been provided with some gentle laxatives to help you avoid straining in the first days and weeks. Sometimes the laxatives work so well that you may struggle to get to the toilet in time. This should improve and settle over the first few days and weeks. 

You may find that going to the toilet can be uncomfortable. 

When you go for a wee, you can use a jug and pour lukewarm water over the area whilst you wee. This can help reduce any stinging sensation you might feel. Make sure you drink enough water. Staying hydrated can help dilute your wee so it doesn’t sting as much. Avoiding drinking can make your wee concentrated which can increase any stinging sensation. It also irritates your bladder so you may need to wee more. 

Having a poo (opening your bowels) won’t break your stitches but when you go for a poo (have your bowels open) try to avoid straining. Straining can put extra pressure on your stitches and over time it can weaken your pelvic floor muscles. Eat foods that are high in fibre and drink between one and a half, and two litres of water to make sure your poo isn’t too hard to pass. Try to wait until you feel an urge to poo. If you are finding it difficult to poo, when you sit on the toilet, put your feet on a footstool to raise your knees above your hips as this can relax the pelvic floor muscles. Take deep breaths in, allowing your tummy to relax and this will help you to poo without straining. For some people it can feel more comfortable to hold a pad to your perineum when you have you poo.

Pelvic Floor Exercises

You can start doing your pelvic floor exercises straight after birth. Initially you only need to do gentle squeezes. This will help to encourage blood flow to your wound and reduce swelling, which can help the healing process. They will also start to strengthen your pelvic floor muscles helping them to heal. You may feel after birth that your pelvic floor muscles are not very strong. You may also feel that you have difficulties working with your pelvic floor and that you have very little sensation. This usually improves with time and the more you can work your pelvic floor muscles, the quicker recovery will be. For more guidance on how to do pelvic floor exercises and how to progress them, visit the pelvic health section. 

When is the best time to start having sex after birth?

You are the best person to decide when to start having sex and every woman and birthing person is different. If you have had a wound, we would advise to wait until this wound has healed and the skin has come together. Some women and birthing people like to wait until they have seen their GP for their routine post birth check, or until they have seen a specialist if they have had a tear into their anal sphincter muscles.  

It is common to feel a little anxious about having sex, particularly if you have had a perineal injury. When you are ready to have sex, you might want to consider: 

• Using lubrication. Your vagina can be drier after birth due to hormonal changes. Using lubrication can help. 
• Use contraception. It is possible to get pregnant soon after giving birth, even if you’re breastfeeding.
• Gentle perineal massage on your scar tissue can help you feel more comfortable. Only do this once your wound is fully healed and the skin has come together.
• Talking with you partner about sex and any anxieties either of you may have and choosing a time when you both feel relaxed. 

Sex may be a little uncomfortable and feel different at first, but the discomfort should not persist. If it does, please complete an assessment on MyPathway for additional support.

What level of activity should I do after a perineal injury?

Whilst your wound heals, it is advised to try and reduce the amount of pressure through your pelvic floor. Sitting upright, standing and walking can put pressure through your pelvic floor. High impact exercise such as running or heavy lifting also increase the pressure through your pelvic floor. Resting in the first days after birth can allow your body to heal and removes pressure from the pelvic floor helping to reduce swelling. However, gentle movements and walking will help your blood flow and with wound healing. Everyone’s experience will be slightly different, and only you know what gentle activities you can achieve, and what feels like too much. This will change as your wound heals. For more guidance on returning to physical activity after birth please visit pelvic health section.

Post-traumatic stress disorder Some women and birthing people can feel their birth was traumatic for them or their birth partner. This can be linked to feeling out of control, feeling left or uncared for, or feeling isolated from others. For some women and birthing people who experience birth trauma there is a risk of post-traumatic stress disorder. Symptoms can include flashbacks, heightened anxiety, low mood, or isolation. You may find it hard to bond with your baby. Post-traumatic stress disorder can develop immediately after the event, or can occur several weeks, months or years later. If you, or your partner, experience signs of post-traumatic stress disorder, there is help available to you, please contact your midwife or GP as you feel able to.

Form more information, visit the Birth Trauma Association website here.

Links to other websites with further information:

• The RCOG’s OASI bundle
• Your Body’s Journey during Pregnancy and After Birth
• Episiotomy and perineal tears
• Perineal tears and episiotomies in childbirth
• The MASIC Foundation
• Bladder and Bowel Foundation
• Birth Trauma Association
• Squeezy 
• Pelvic Obstetric and Gynaecological Physiotherapists (POGP)