Fear of pelvic floor damage during birth is reasonable, especially given the existence of Mother’s Day cards like this:
Prevention of pelvic floor damage is a worthwhile topic out of the scope of this post. Most care providers have their bag of tricks they use (evidence-based or not) that they believe will reduce tearing and deeper pelvic floor damage. Ask your midwife or doc what they do, and research these methods for yourself.
Routine episiotomy should have gone out with heroine chic, but unfortunately some care providers are still doing it. Ask your midwife or doc what their episiotomy rate is, and under what circumstances they would perform an episiotomy. Decide whether their strategy is acceptable to you.
No matter what you do right, pushing a baby out of your vagina is going to have some consequences: Most of them are not too serious, all of them are annoying. Here’s what I’ve most commonly seen after birth in the short-term and long-term, and how we’ve put our heads together to solve the problem.
Degrees of tearing. Vaginas may tear during birth to varying degrees. It’s important to familiarize yourself with the different variations so you can ask intelligent questions about how to care for your pelvic floor after the baby. Here is an decent resource.
3rd and 4th degree vaginal lacerations (tearing into or through the anal sphincter) are uncommon, especially in home birth. Repair of 3rd and 4th degrees is complex and typically requires an epidural and time in the OR, even if you had an otherwise unmedicated and normal vaginal delivery. Some people may choose general anesthesia for such a repair, which I totally get, but an epidural is less risky as anesthesia goes and if you ask for general you may meet resistance.
In my home birth practice, I mostly see, in order of frequency:
- 1st degree perineal tearing (some skin damage, pretty superficial)
- No perineal tearing at all (very common for second-time birthers but not impossible for first-timers!)
- 2nd degree perineal tearing (Into the muscle tissue but not nicking the sphincter of the anus/rectum)
I almost never suture (stitch) 1st degree tears. Unless they are bleeding actively (like a blood vessel got nicked or something) they just don’t benefit from stitches.
I will frequently suture 2nd degree tears, especially if they gape open. With the 2nd degrees I worry more about bacteria, scar tissue, and a longer healing time.
When I check out the vagina after birth, I usually “think out loud” with the client so they know the extent of their tissue damage. I’d like them to be a part of the “repair-or-not-to-repair” conversation. I will offer a mirror so they can see for themselves. I like to involve the partner in the conversation, too, so they understand how to support you in the postpartum. The question to ask is, “Is the extent of the tissue damage incurred worth the extra tissue damage, swelling, infection risk, discomfort and hassle of the stitches?” Sometimes the answer is yes, and sometimes, no.
How we repair.
First I use some Lidocaine gel to numb the outer tissue, then I inject Lidocaine into the tissue. Depending on the degree of the tear, where it begins in the vagina, where it ends in the perineum, the client’s history, and what mood I’m in, I’ll either do a continuous suture or interrupted sutures.
“Continuous” suture is when we make a knot at one end of the tear, and use that one line of suture throughout the whole tear, finally making another knot at the opposite end. I’m simplifying, but that’s the gist. People will ask me, “How many stitches did I need?” It’s hard to answer that question because I was doing continuous sewing.
“Interrupted” suturing is when you make one loop, tie knot, cut the suture. Move down. Make another loop, tie a knot, cut the suture. Move down. Make another loop, tie a knot, cut the suture. You get the idea. With interrupted sutures, when people ask me how many stitches they needed, I can easily give them a number, because I made several stand-alone stitches.
A note about the “husband stitch.” I literally don’t even know what it is. We didn’t learn how to do it in school, and I have no concept of how I would make the vagina “tighter” while I’m doing a repair, since the goal of the repair is simply to put tissue back where it came from. People swear it’s real and I guess I believe them, but it just sounds like a sick urban legend to me. If you are worried about it – and I wouldn’t blame you! – please talk to your care provider. I’m pretty sure only ancient male OBs even bring it up anymore when they’re trying (and failing) to be funny.
Labial tears and aesthetic considerations. When we talk about tearing, most people immediately think of the perineum and vagina. However, frequently we see labial tears. These can range from “paper cuts” or “road rash” (I did not invent these terms!) on the inner labia to actual tears that need to be sutured on the labia minora.
Suturing the labia minora is a tricky business. The tissue is not as vascularized as the perineum, and it’s more nerve-y and sensitive. This means labial stitches are slower to heal and often more painful over time. Another risk is the dreaded “notch.”
When we have to piece together tiny bits of labial tissue, we hope and pray that the tissue will stay healthy and heal together. However, sometimes one small piece will peel away during healing, leaving a visible space between two bits of labia that used to just be one labium. We call this a “notch”. It’s not a health risk, but some people really grieve the loss of their previously uninterrupted labia.
Please also remember that your care provider is simply trying to restore your pelvic floor to its original condition, not perform reconstructive surgery. Years ago I had a client with a labial tear that needed suturing. I sewed it up and sweat bullets about until the 4 week visit, when we looked at it together. It was gorgeous, if I do say so myself.
She burst into tears and told me how disappointed she was. I was looking at a beautifully healed labium virtually indistinguishable from before the baby. She was devastated. I couldn’t figure out why we weren’t seeing the same thing.
After much investigation I learned that her right and left labia had always been two different sizes. Not a huge difference (I hadn’t even noticed until she pointed it out), but she had felt self-conscious about it since girlhood. She assumed that when I sutured her after birth, I was going to make her labia matching sizes. I am of the opinion that there is no one way that a vulva “should” look, but if you desire labiaplasty, you’ll need to see a specialist.
General healing in the first few weeks.
The vagina is designed to stretch, sometimes tear, and then to heal, so minor vaginal and labial tears will need very little treatment. If you are very uncomfortable or simply want to be pro-active about healing, these are my favorite strategies:
- Rest. At least a week of bedrest. Sleep is always helpful. Don’t exercise until you get the go-ahead from your care provider. I find my clients usually get antsy for exercise at around two weeks. If they didn’t have a really bad tear, I’m ok with gentle exercise at that point. Some people will just need to be sedentary for longer, especially our 3rd and 4th degree people.
- A diet of iron-rich foods, protein and healthy fats to speed healing, high in fiber and water content to prevent constipation. Avoid sugar.
- Ice during the first 24 hours only. Longer will delay healing. If you can avoid ice altogether, it’s ideal, but I know that sometimes ice is the only thing that will bring comfort.
- Warm baths. Plain water is fine. Make someone at your house clean and rinse the tub thoroughly. Fill it up to your belly button with warm water. Sit in it until you get bored or cold. Do this every day, or as often as you can. If you want to get fancy, you can make a big pot of sitz bath herbal tea, and pour some into your bath. (This is my favorite sitz bath blend.) If you have stitches, avoid too much salt in the bath. If you are wanting to sooth a tear that was not sutured, sea salt can be great (more on that, later).
- I have mixed feelings about the sitz bath basin for perineal baths. (It sits in the toilet so you don’t need the bathtub.) Sitting on the toilet distends the pelvic floor and puts strain on the tissue and stitches. If you do use the sitz bath basin, squeeze your pelvic floor while you sit, then relax the muscles. This will reduce distention. Don’t sit on the toilet for much longer than 10-20 minutes.
- For when sitting in chairs, some people love a hemorrhoid pillow. Others find a hard flat surface feels better. Experiment.
- Use your peribottle when you relieve yourself, and afterwards. The peribottle will dilute urine so that labial abrasions don’t sting so much, and it will clean you up bidet-style, after. If you can get your hands on two peribottles, all the better. Don’t use toilet paper, or I guess you can just barely dab dry with toilet paper. A fancy alternative to the peribottle is the Fridet. Some people like to put sitz bath herb tea in their peribottle and that’s lovely, but not a must.
- Herbs I like for healing vulvas: Calendula, comfrey (comfrey can cause tissue to heal too rapidly, so go easy), plantain.
- Some things to keep in mind: Inflammation is part of the healing process. Most tears feel mysteriously worse before they rapidly get better. Don’t be afraid to have your care provider check it out, but 5 days tends to be the peak of the discomfort, in my experience. Also? Stitches themselves contribute to the discomfort. You can talk to your care provider about whether you are actually having wound healing challenges, or whether your wound is healing beautifully but it’s the stitches that are bothering you. Itching is also a “symptom” of healthy healing. Around 2-3 weeks, people think they are getting a yeast infection. Most of the time, it’s just normal healing itchiness. As the stitches dissolve, they will get big and rope-y. They may fall out in small pieces in your undies or the toilet. You may feel a knot on your perineum or in your vagina. Do not be alarmed.
Short-term healing challenges.
Sometimes healing gets complicated. These are the issues we see during the first week or so after birth:
- Stitches occasionally come undone. I’ve seen this happen after both home and hospital birth. It’s usually just human error. There are risks and benefits to using continuous vs. interrupted suture, but one of the biggest benefits to using interrupted stitches is that if you tie a bad knot in one stitch, it doesn’t make the whole wound come undone. If you are at home after baby in the first week and feel that your stitches are not holding together properly, you may be correct, and the sooner you get it fixed, the better.
- You may be a “suture eater.” It’s standard after vaginal birth to use dissolvable suture material, so that you won’t have to have it removed. I find that dissolvable sutures almost magically last about as long as they need to for the wound to heal completely. The length of time it takes is wildly variable, from 2 week to 8 weeks in my experience. However, the rare person will present as a “suture eater.” This means the the sutures will dissolve way too quickly and the wound will fall apart. I don’t know why this happens. It may be that some people possess elevated levels of the enzyme that breaks down the suture material. As with stitches that are poorly knotted, please call your care provider if you think that your wound is opening. They’ll need to re-stitch you with a different material, as soon as possible.
- Infection. You will have increased pain, swelling, beefy redness, increased discharge, possibly increased bleeding, and a weird smell if your vaginal laceration gets infected. You may or may not have a fever. If you think you have an infection, please call your care provider immediately. They need to make sure you don’t have a uterine infection, which left untreated, is deadly. Most OBs will prescribe antibiotics for a perineal infection. That’s an option, but when my clients want to try natural measures, sea salt soaks can work wonders. (See the end of this post for sea salt soak recipe.)
Long-term healing challenges.
The following are challenges I see at the 4-8 week visit:
- Granulomas. Sometimes your tissue heals so enthusiastically that it overheals. There is often a bright red, shiny part of the tissue that is very sensitive to the touch, and causes constant irritation, when everything else around it is just normal. The bright red tissue can be very small or it can present as a large, floppy bit that looks like it doesn’t belong there. Both OBs and midwives will burn it off with silver nitrate. It sounds gruesome, but once the stinging from the silver nitrate subsides, people report immediate relief, and it usually heals quickly. Granulomas can happen whether or not your wound was stitched.
- A little bit of tear that just won’t heal. Sometimes it’s just stubborn. I recommend 4-7 days of sea salt soaks (recipe at the bottom of the post). Or a silver nitrate treatment can help that part of the wound “start over from scratch” and it often heals better and faster the second time around.
- Scar tissue. For mild scar tissue that is merely annoying or aesthetically unpleasing, massage with rosehip seed oil. The fresher the scar tissue, the better the results. If scar tissue is extensive or very painful, ask for a referral to physical therapy. Rarely, surgery will be necessary. Sex can sometimes be impossible with scar tissue, because it is simply too painful, but you might try sex as a therapy, because it massages and brings blood flow to the tissue.
- Vulvo-vaginal atrophy. Inflammation and irritation from birthing and healing, and the hormones inherent in the postpartum and breastfeeding (increase in prolactin and drop in estrogen) can cause a thinning of the vaginal tissue and a flattening of the labia. It’s unpleasant but will resolve with time and cessation of nursing. Like with scar tissue, sex can be painful but in some cases therapeutic as it brings blood flow and lubrication to the area. Some care providers will prescribe estrogen cream but the research is out on whether or not it works and insurance may not cover it. A client of mine once spent $300 out of pocket on her prescription estrogen cream from her OB and it did nothing.
- Vaginal dryness. See above about increased prolactin/reduced estrogen. Get yourself a good lubricant if you want to have intercourse.
- Prolapse of pelvic organs. This is a huge topic. Prolapse of the rectum, uterus, and bladder can happen to varying degrees whether or not you had a vaginal tear. This is because deeper muscles and ligaments are involved in birth than just the vulval tissue. If you are having pain with sex, a constant heavy sensation in your pelvis, or leaking of urine or fecal matter, tell your care provider. Many pelvic floor complaints will clear up with time and weaning of the baby, but some will require physical therapy and rarely, surgery.
- Labial adhesions. I have never seen this with my own eyes but it’s worth mentioning. Rarely, one side of the vagina can heal together with the other side. There will be a “tissue bridge” or a complete occlusion. It will need surgery.
- Vulval varicosities and hemorrhoids deserve their own post. Varicosities will usually clear up after baby but do benefit from support garments. Hemorrhoids tend to be more stubborn.
How to do a sea salt soak.
- Go to the health food store or somewhere where they sell sea salt in bulk. You can buy smaller packaging at a regular grocery store, but it is wasteful and expensive. You will need a few pounds of it. The sea salt should be pure sea salt, no additives. Epsom salts won’t hurt you but may not be as effective.
- You can use the bathtub or the sitz bath basin. Either vessel should be very clean and rinsed well of cleaning product.
- Fill up your tub to your belly button or fill up the sitz bath basin with warm water.
- Add enough sea salt so that it tastes like the ocean or in the very least, your tears. You’ll know if it’s too much salt because some of the salt will simply not dissolve. For a sitz bath basin you will usually need a small handful of salt. For a bathtub you may need several handfuls.
- Soak for 20 minutes or longer if you have time. For very busy parents who don’t have much help with child care, soaks may not be for you. But consider it medicine, and ask for help with the baby and kids.
- Try it for three days. It may sting during the soak but should provide great relief in the long run. If the condition worsens, bail and call your care provider. If the condition gets better, consider continuing the soaks for a week.
- Some people think salt may dissolve sutures more quickly than they ought to, so ask your care provider if you have stitches and want to do a sea-salt soak.