What is the Perineum?
The perineum is the area of your undercarriage from the back of the vagina to the anus. This area needs to stretch enormously during vaginal childbirth, and sometimes it may tear. A grade 1 tear, (often referred to as a graze) does not need stitches.
A grade 2 tear affects the vaginal skin and the muscles at the entrance to the vagina. The episiotomy cut that is made so the baby’s head can be birthed more easily, or to allow for forceps, is considered the same level of severity as a grade 2 tear. Stitches are placed at the entrance of the vagina to help this kind of tear or cut to heal better. This sort of repair is normally done while you are still in the delivery suite.
A grade 3 or 4 OASI (obstetric anal sphincter injury) is a more significant tear that extends backwards into the anal sphincter muscle, which ordinarily keeps the back passage closed. You will be taken to theatre for this repair, and the stitches will be tighter and more numerous. An OASI occurs in 5% of first-time births.
See this document from Queensland Health for more detail.
How Should I Care for My Perineal Stitches?
It is important to care for the perineum after a tear and repair. Proper care for perineal stitches includes:
1. Proper wound care
Keep the area clean and dry to prevent infection. Use a mild soap and water for cleaning after every bowel motion. There is no evidence that sitz (salt) baths help any better than plain water, but they don’t do any harm either.
If you get into the bath, make sure it is clean, as you don’t want to increase the risk of infection. You’ll want to immerse the whole perineal area with water that is 5-6 cms deep.
Alternatively, you could use a shower nozzle but the pressure must be very low, and you should avoid direct contact with the nozzle.
A peri bottle could be used to spray the perineum but the water will likely make a mess on the floor and will dribble down your legs, so you will need to stand in the shower and lean over. Don’t squat to clean the perineum for the first few weeks, as squatting may place too much pressure on the stitches when they are new.
Make sure the water is no warmer than body temperature, and don’t use ice, as both extremes of heat and cold will damage the skin more. Also don’t rub the area with a towel to dry off, as this could cause more inflammation. You will want to just dab with a clean cotton (not microfiber) washcloth. You may need to bathe 3 times per day for a few minutes each time.
Have your community midwife/nurse, GP, or pelvic health physiotherapist check the wound if you have any concerns about ooze, odour, appearance, or pain.
3. Pain management
Pain relief medication such as ibuprofen can help manage pain. This medicine is considered safe even if you are breastfeeding.
4. Watch how you wipe
After passing a bowel movement, you will want to wipe gently. Dry toilet paper can cause microscopic scratches in the perineal skin. A non-alcoholic baby wipe may be gentler. If you don’t want to use wipes for their environmental impact, you could try a smear of plain sorbolene cream on a wad of 3-4 squares of toilet paper. This removes stool residue more effectively than dry paper. Remember to wipe from front to back so the cream doesn’t get in your stitches.
5. Use stool softeners
Stool softeners can help prevent straining during bowel movements. Straining can further damage the area by aggravating haemorrhoids or opening up an anal fissure. Sometimes these last 2 conditions can be caused by the same injury that caused the anal sphincter tear. If you aren’t improving, you may need your healthcare provider to check whether you have a haemorrhoid or fissure in addition to the anal sphincter tear.
Sometimes poor pelvic floor muscle relaxation can impede the passage of stool, and a cycle of incomplete emptying, straining, poor healing, and pain can develop. Some new mums need advice from a pelvic health physiotherapist regarding the best pushing technique to clear the bowel.
Don’t hold on to your bowel movements because you are scared to pass them. This will only make things worse, as the stool will be bigger and firmer when it eventually comes out! Your pelvic health physio can show you how to improve the stool consistency, and how to push effectively, without straining.
6. Pelvic floor exercises
Kegel exercises can help strengthen the bowel muscles and improve bowel control. You should probably wait a few days after the repair before starting them, and build up strength and endurance slowly. But remember, an incorrectly done Kegel is potentially more harmful than no Kegel at all, so it is wise to have your technique checked by your pelvic health physiotherapist!
7. Consult with a specialist
Follow-up with a colorectal surgeon or specialist trained in treating obstetric anal sphincter injuries. If you are symptomatic 6-12 months down the track, an endoanal ultrasound can check if the repair was successful. Our local colorectal specialist is Dr Jodie Ellis Clark.
8. Avoid heavy lifting and strenuous activity
This can put pressure on the injury and slow the healing process. At the very least you should allow yourself a 30-minute early afternoon rest. Sleep when your baby sleeps and make the housework somebody else’s responsibility. You should have the vagina and pelvic floor checked by your pelvic health physiotherapist before you go back to exercise, as too-soon a return can cause problems like prolapse and pain.
9. Have a Pelvic Floor Assessment before you return to sexual activity
It can be scary contemplating sexual intercourse for the first time after delivery if you had perineal stitches. It can take much longer than 6 weeks to feel like you are ready. On top of sleep deprivation, leaking breasts, a body that doesn’t look like it used to, a dry vagina from breastfeeding or the mini-pill, and altered relationship dynamics, it’s surprising that any of us ever get back to it!
A pelvic floor assessment may be useful to give you the confidence to have sex again, or to know whether there is any reason you should wait. Up to 30% women still have pain in the perineum at 12 months postpartum and this may make a return to sexual activity difficult, so please see your pelvic health physiotherapist if you are concerned that this may be the case for you.
Also see us if your stitches are hurting with sitting or upright activity, or if you have accompanying symptoms of vaginal heaviness, dragging, or bulging, or loss of urinary or bowel control.
Get Your Postnatal Check Up Today
Taking care of your perineal stitches after birth is important to avoid any issues like infection and speed up the healing process of your pelvic floor. If you’re looking for help with any postpartum conditions from pelvic floor assessments to recovery, we have postnatal physiotherapy services available to provide support and guide you through. Book in with us and we’ll help you get started.