Prepare

Birth Tears: Prevention, Repair & Recovery

• Season 2 • Episode 22

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In this episode, Dr Rangi is joined by Melanie Francis, Clinical Midwifery Educator and Head of Operations ANZ for GynZone.

Together, Rangi and Mel take a deep dive into the important - and often daunting - topic of perineal tears. 

  • They explain what perineal tears are, why they happen, and the factors that can increase the risk of tearing during birth. 
  • They also discuss practical strategies that may help reduce the risk, including perineal massage and the use of warm compresses during labour.
  • The conversation also covers the different types and classifications of tears, what recovery looks like, and practical advice for coping and healing after birth.

Join us next week as Rangi and Mel continue the conversation by exploring the important topic of episiotomies.

SPEAKER_00

Welcome to Prepare, the Mercy Perinatal podcast dedicated to helping parents prepare for the journey of pregnancy, childbirth, and early parenthood. Mercy Perinatal would like to begin by acknowledging the Wawundri Woiwarung people, traditional custodians of the land on which we gather today, and also the traditional custodians of the lands in which you're listening from today. We'd like to pay our respects to the elders past, present, and emerging, and we extend that respect to Aboriginal and Torres Strait Islander peoples listening today.

SPEAKER_01

Hi everyone, welcome to Prepare. My name is Dr. Rangi, and I am an obstetrician and gynecologist and perinatal researcher here at Mercy Perinatal. And we are so excited to be joined by the lovely Melanie Francis today. We're going to be talking about a really important topic, which is birth tears. And birth tears are a really common part of vaginal birth, but they're often not talked about openly. But it's a really important topic and a topic where people have lots of questions and concerns. And whilst it can be a bit confronting to hear about them, I think it's important that you feel informed and prepared rather than fearful. So hopefully we're going to help do that for you today. So I'd love to introduce Melanie. Thank you so much for joining us, Mel.

SPEAKER_04

Thank you for having me.

SPEAKER_01

Melanie is a clinical midwifery educator and experienced midwife with a really special interest in perineal trauma and women's health. She spent many years working as a clinical midwife before moving into education, where she now helps clinicians develop the knowledge and skills needed to support women through pregnancy, birth, and postpartum recovery. Thanks so much, Mel. Thank you for having me. Excited to be here. So, Mel, can you tell us a little bit about why you've developed such a strong interest in this particular topic?

SPEAKER_04

Yeah, I think it comes initially from my just my general interest in women's health. And when I first became midwife, I always wanted to make sure I was working to my full scope of practice. And so incorporating perineal repair into that was really important to me. And once I did learn how to suture, I think that's when it became really obvious to me how fundamental it is for us as care providers to be able to inform women of the facts around vaginal birth and also be able to give them the support that they need to be able to reduce their risk of tears and how we can manage their birth so that they have really good outcomes afterwards. So that's sort of where that passion has come from. And then since moving into the space of Gind Zone and being able to support more midwives to be able to not only suture but increase their knowledge on diagnostics and assessment of tears, that's just become even more evident of how important this work is. Yeah, yeah, so important, isn't it?

SPEAKER_01

So by suturing, you're talking about stitching and repairing the Yeah, that's the most common method of repairing a perinal laceration.

SPEAKER_04

Um there is some more research being done around the use of glue, which is ongoing and I think would be really amazing if we have something other than stitches that we could use for tears. But at the moment, particularly with the larger tears, it is the best option to use suture material for those kinds of injuries. Yeah.

SPEAKER_01

We'll talk about that in a little bit more detail. But can we first talk about what how do you describe what happens when a tear is happening during vagina birth?

SPEAKER_04

Yeah, so tears are really, really common. I think it's really important for women to understand that up to 90% of first-time mums will sustain a tear. And although that can sound like a really scary statistic, it doesn't mean that these are life-altering injuries. For the majority of women, these are really superficial and they heal really, really well. The reason they occur is because the skin around the vagina or between the vagina and the rectum stretches and sometimes it just reaches capacity before the baby's head can be born, and that's when that tear can sometimes occur.

SPEAKER_01

Yeah. I think it's really important that you said that it is quite common, but it doesn't necessarily mean it's going to be a terrible injury. Yeah. And there's lots of things that we can do to try and prevent it or minimise the extent of tearing, and also important to try and repair those really well.

SPEAKER_04

Absolutely, absolutely. And those really minor ones, sometimes we don't need to do anything at all. It might just be an ice pack and some panatol, and that's all they need, and within a week they're healed. No long-term effects really occur from them.

SPEAKER_01

Yeah.

SPEAKER_04

Yeah. But there's definitely lots of things that we can do to prevent the risk of those larger tears from happening for sure.

SPEAKER_01

Yeah. So what are some of those things that we know in the evidence has been shown to reduce those risks?

SPEAKER_04

Yeah, so things in the antenatal period that can be really helpful is perineal massage. So that's something that not all women are really familiar with. It's not an easy thing to do having my having my own baby and actually trying it myself when you've got a pregnant baby. Yeah, when you're 36 weeks pregnant, you're trying to put your hands down there, it can actually be quite challenging. But the goal is to just softly massage that perineal space. So, as I said, the perineum is that skin between the entrance of the vagina and the anus that stretches at birth. So if we can try and soften the tissue around that area, it'll allow it to stretch. The idea is that it will stretch a lot easier. Also, I think just having women massage that area and get used to the sensation of that of pressure and stretch actually happening in that area can make it a little less scary when it's actually happening when the baby's head's putting pressure on there too.

SPEAKER_01

That's a good point. Yeah. Yeah.

SPEAKER_04

So that particular method or technique can really reduce the risk of severe tears during childbirth.

SPEAKER_03

Yeah.

SPEAKER_04

Other things can be during the birth itself, can be the use of warm compressors, which are usually supported by the midwife or the doctor who's assisting with the birth. But birth positions is a really, really important factor. So we know that any position that puts pressure on that perineal area is going to cause an increased risk of tearing. So women lying on their side or kneeling can really reduce that risk because if you think of gravity, there's not that ongoing pressure, persistent pressure on that space.

SPEAKER_01

Great. And going back to the perineal massage, when would we recommend people start to do that and how often do they need to do it for there to be a benefit?

SPEAKER_04

Yeah, so anytime from sort of, I would say 36 weeks onwards is fine. There's not really evidence to suggest that doing it any earlier is going to make much of a difference. Okay. But just daily, if the woman's comfortable with, or even just as much as they are comfortable with. So if it's just every second day or once a week, as long as they're happy to have a go. But ideally, based on the evidence, once a day from sort of 36 weeks, just for a five minutes or so, yeah, it can really make a difference.

SPEAKER_01

And do you usually recommend just going into the real practical aspects? Do you recommend they use some lubrication?

SPEAKER_04

Yeah, so lubrication will definitely help. So olive oil, really cheap, you'll probably already have it in your kitchen, can be really helpful. Yeah. You can get other water-based lubricants. Really important that anything with like heavy fragrances or stuff like other emollients and oil. Avoid those. Yeah, avoid those. So yeah, just your really natural stuff is really helpful.

SPEAKER_01

Cool. And as you said, sometimes it can be difficult physically to do that yourself, particularly when you are 36 weeks pregnant and beyond. Is it helpful to sometimes see if your partner can support you if they're comfortable and you're comfortable with that?

SPEAKER_04

Yeah, absolutely. I think most partners are really they want to help. I think they get, you know, during pregnancy, they've got to just sit and just watch their partner go through this experience on their own. And so if they can be involved in any way, they often will do that. And if, you know, obviously as a woman, if you're comfortable having them support you, then that's really important too. But yeah, it can be really, really beneficial for you to both to do it, and that can be sort of a bonding moment as well as a couple and in terms of the preparation of welcoming your baby.

SPEAKER_01

Definitely, definitely. But as you mentioned, there are some people who might find that difficult or the idea of it difficult for whatever reason, and that's okay, isn't it?

SPEAKER_04

Absolutely, absolutely. You've got to do what's right for you. Um, you've got to feel comfortable in your own body and being pregnant is a really big change, you know, physically. So if you're not comfortable, having someone else help you with that, if you just want to do it, try it yourself, that's totally fine. Trying to get into a position that's gonna make it the easiest for you. Generally on your back is probably the easiest, but sometimes even if it's just in the shower, if you can sort of if you're able to reach down, at least the water can sometimes distract you sort of from what else. Or the bath. Yeah, or the bath. Yeah, absolutely.

SPEAKER_01

Yeah. So importantly, there are different types of tears. As you mentioned, some are more mild than others. Yes. How do you usually describe them in terms of defining them for people?

SPEAKER_04

Yeah, so from I guess an obstetric point of view, there's four categories that we generally will talk about in terms of classification. So you've got first degree tears which are really, really superficial. Yeah. They usually just involve the perineal skin or a little bit of the tissue behind the skin. These heal really, really well. Often they don't need anything to be done about them at all unless there's a bleeding problem or maybe an alignment issue. So if the midwife or obstetrician feels that it might not actually heal evenly, they might recommend having something done to support that. First degree tears also encompass labial lacerations and tears that could be around the clitoris or the urethra. These are quite sensitive and tears because of just the amount of nerve sensations. But they heal extremely quickly. And there's usually no long-term issues for women who experience these types of tears.

SPEAKER_01

Yeah, that's really reassuring. And for I think I would agree with you that obviously those tears can be quite painful, but I think also in my experience, many people have healed quite quickly and feel a lot of symptomatic relief in the first couple of days.

SPEAKER_04

Yeah, and there's things that we can do to try and like relieve some of that discomfort as well. So you know, you can take things like panatol and neurophin, but also just when you go to the toilet, just running some water over your vagina as your wean can severely improve that sort of stinging sensation that you can get. So, yeah, really simple things that you can do, and within a matter of days, those symptoms resolve.

SPEAKER_01

I sometimes compare it to patients to if you've got like a cut in your mouth. Yeah. Because the tissue is sort of similar in a way that it can actually heal quite quickly before you even notice it. It's kind of like that, isn't it?

SPEAKER_04

That's a really good comparison. And you can think about how quickly those little wounds can heal in your mouth. It's the same as as the perineal. Yeah. Great.

SPEAKER_01

So that's a good summary of the first degree tears. What about the second degree tears, which are probably the more common?

SPEAKER_04

Yeah, so they're slightly more common than the first degree tears, and they they are the most common out of all of the categories. So these involve the muscles of the perineal bodies. So the superficial muscles of the pelvic floor that help keep all of the female organs up inside our bodies. And there's two superficial muscles that can be torn during this time. Sometimes only one gets torn, so your doctor or your midwife might say, Oh, it's just a small second, or it's just a little bit larger. It depends on sort of how much of those muscles have been torn. Yeah. But again, they heal really well. It's becoming a lot more common for women to choose not to have these injuries repaired. And as much as it's important that we're respecting those choices, it's important for women to understand that even though they will actually heal quite well on their own without any intervention, the muscles themselves will never actually grow back together without support. And that support usually involves stitches. Stitches. Yeah. Yeah. So that's usually the reason why we recommend stitching is so that we can bring those muscles back together because they're going to help support that pelvic floor with its function postnatally. But also one of those muscles in particular is responsible for assisting women to orgasm through penetrative sex. And so when that muscle is not brought back together, some women can complain later on that they're not experiencing orgasm in the same way that they did beforehand.

SPEAKER_01

Yeah, that's really important. So we're really just trying to maintain function. Absolutely. Back to what it was originally.

SPEAKER_04

Yeah, absolutely. And look, sometimes it might just be a matter of trying to stop bleeding. Some of the these tears can can tend to bleed quite a bit. And so, yeah, functionality, bleeding, and also alignment of the tissue as well. So we can do a much better job at restoring the alignment of that tissue and the skin better with suturing than we could if it heals on its own.

SPEAKER_01

Yeah.

SPEAKER_04

But it's not to say that the healing isn't good without it. The healing's just accelerated and optimized. And optimized with sutures. Yeah. With stitches.

SPEAKER_01

And important to note that those stitches are dissolvable.

SPEAKER_04

Yes. Yes.

SPEAKER_01

So you don't need to get them removed or anything.

SPEAKER_04

Correct. You don't you shouldn't need to get them removed. And most hospitals or midwives and obstetricians will use a rapidly absorbable suture. So within two weeks, 50% of that suture material has already lost most of its strength and started to break down. So women shouldn't feel tension around that area because of the stitches after those sort of two weeks. So yeah, very, very Yeah, it's a bit like that. Yeah. It's great.

SPEAKER_01

It's important to note. Yeah. Going on to the next type of tear, third degree tears. Now I think we'll have an episode on this separately, third and fourth degree tears, but just quickly to talk about it, third degree tears are a little bit deeper, aren't they?

SPEAKER_04

Yeah, so they involve part of the sphincter muscle. So there's two sphincter muscles that wrap around the anus, and they're responsible for helping us hold in our farts and our poos. So if you're in a public space and you think now's really not the time to go, these muscles are going to help keep it until you can find a safe space to do your business. So critical muscles. Critical, yeah. So third degree tears will affect the external muscle, one of these muscles. The one on the outside. The one on the outside, yeah. None of us can see, but yeah, is inside our bodies, but on the outside of the anus. And so it evolved that. And sometimes the deeper third degree tears might involve a little bit of the internal sphincter as well. Yeah. It's really important that these are diagnosed correctly. Outcomes can be still quite good if they are diagnosed correctly and they're managed promptly. Yeah. And with the right physio, women have really, really good prognosis in the future.

SPEAKER_01

Yeah. Yeah, I think that's really important to note that you might be scared of a third-degree tear, which is completely fair enough. And we're obviously always trying to minimize those. Yes. And it's one of those outcomes that we take real notice of in terms of the quality of birth and the injury. And we do want to be repairing it quite quickly and well. Yes. And we will, of course, have another topic about this in a separate episode, but the way we repair it is with really good lighting, really good pain relief. And that's often done in the theater so that we can make sure that those muscle layers that you mentioned well are brought together almost perfectly. Yeah. Because we want that bottom muscle to be working really well for you. Absolutely. But if that's done, as you said, most people don't have any symptoms later on, depending on the severity of their tear.

SPEAKER_04

Yeah, absolutely. And it's important to know that these are like the least common tears. So they do happen, and certain populations are sometimes a little bit more susceptible to them. As we'll we'll talk about shortly, there's a lot of things that we can do to try and minimize that. But yeah, they account for a very small percentage of the overall tears that women experience.

SPEAKER_01

Yeah. And then an even smaller percentage is those fourth degree tears, which is of course something we we never want to happen. No. But that is where the tear might go through the outer muscle and the inner muscle around the bottom, but then go through to the bottom or the rectum.

SPEAKER_04

Yeah, that's right. Yeah. So these are quite serious. And again, with the correct diagnosis and management, again, women can have still really good long-term outcomes, but they can take a lot longer to heal. They're a lot more painful to recover from as well. And physio is really, really important for these women. And decision around type of birth if women choose to have more babies is a conversation that's really important to have with their care provider. Yeah, definitely.

SPEAKER_01

Going back to before these tears happened, what are some of the risk factors that we might see in someone's pregnancy for the patient or the health provider to be keeping in mind that might increase your risk of any of these tears?

SPEAKER_04

Yeah, so there's a few factors such as size of baby, how many babies you've had before. So if it's your first baby, there's always that slightly higher risk because your body's never done this before, so none of us are to know how you're gonna go. Ethnicity can play a part. And things like other comorbidities. So women who have, say, for example, gestational diabetes, or if they have other conditions where they potentially might have challenges with healing and even that elasticity of the skin. So if you've got a woman who's 22 years old versus a woman who's 45 years old, their skin's probably got to be a little bit more elastic and stretchy, unfortunately. We can't get away from that, can we? No. So these things can play a part in that overall risk, but it's also important that they're not assessed in isolation. So just because you have potentially a larger baby on board, it does not mean that you're going to have a third or fourth degree tear. You could have a completely intact perineum. But it's important to know that these are potentially a risk factor, and then so management of that, particularly during that labor and birth, are really important to try and reduce that risk of it actually happening.

SPEAKER_01

And other things that can impact is I suppose how long you've been pushing for. Absolutely. And the baby's position when they're coming out, if you've had a previous tear is always something to keep in mind. Yeah. And something that we often talk about is if we need to help out with instruments like a forceps or a vacuum, particularly forceps, absolutely might increase that chance that you might have a tear or an episiotomy, which we'll talk about in the next episode.

SPEAKER_04

Yeah, absolutely. They're really important things to note. And I think it's important to understand, particularly in that antenatal space again, what that sort of means, so that when it comes time to to giving birth, if you know the doctor walks in the room and says, I need to help your baby out with a vacuum, you have a better understanding of what that actually involves. And then yeah, understanding that that might increase your your risk slightly of sustaining your tear.

SPEAKER_01

Really important. We did talk about things that can help, such as perineal massage and warm compressoring labour and the positioning of pushing and when baby's coming out. It's also really important when you're pushing, isn't it, to be guided in that and have someone who's an experienced, what we say, a kusha or someone who's experienced at delivering babies to help you through that to minimise tears.

SPEAKER_04

Yeah, so one thing that can, I guess, help as well is women's own mental health, like mental space. Yeah. And so if they're feeling very calm and in control, then they might not need as much verbal guidance as someone who's struggling to be in that space. And so feeling safe in your birth environment's really, really important. But one thing that's helpful when you've got a midwife and obstetrician at the other end of the bed or at the other end of the, you know, at the bottom of the shower or wherever you're choosing to birth is that they can visually see what's happening. So as a woman birthing, you'll be able to feel what's happening, but they can actually see what's going on. And so you might hear them say, just you know, slow it down a little bit more or just take a breath, you know, stop pushing for the minute. So listening to that instruction is really important because making sure that your baby's head is coming down and birthing really slowly is going to really be a massive factor in whether you or not you tear at the end of the day. Yeah.

SPEAKER_01

And it might push you to be stretching too quickly.

SPEAKER_04

Absolutely. And it might involve, with your consent, the midwife or obstetrician applying a little bit of counter pressure on your baby's head just to help slow them down. And it might be supporting your perineum with their hand, and that's where the warm compress comes in as well. So there's usually a warm cloth. Again, if you're comfortable with that, just holding that up against the perineum to help slow that down. And the warmth of the cloth can actually really help with pain relief as well, and also help with that stretching of that skin and tissue. Really good method, isn't it?

SPEAKER_01

Yeah. Talking about warm compressors, that of course makes sense trying to make the tissue a bit more flexible and make that more comfortable when the head is coming out. What about water birth? How about if someone's giving birth in water and and what kind of effect does that have on the risk of tearing?

SPEAKER_04

Yeah, so it actually doesn't really change the statistics at all. Um the benefit of water birth for a lot of women can be it's a natural pain reliever and it can help women stay calm or calm them down, especially during that sort of transition period towards that late stage of labor when birth's sort of imminent. So those factors, if you've got a woman who's really calm and in a good headspace, that in itself, as we said, is going to help reduce the risk of tear. But the water itself is not going to assist in reducing that risk. With warm compressors, the temperature of the water is really important. So there's a Hannah Darlin study I have a couple years ago that spoke about research on the temperature of water for warm compressors to be the most optimal. And that was between 38 and 44 degrees. And so even when you were using warm compressors, it's important for midwives and doctors to continue to make sure that that water temperature actually is maintained. And then we're not just putting cold water because that's there's no point. It's also not very comfortable. It's not comfortable, no. But with water birth, usually the temperature is around 37 degrees. So it's slightly lower than what we use for warm compressors. It doesn't mean it's harmful, but it's just it's not a I guess a substitute for warm compressors. Okay. But the benefits of water birth also can help reduce that risk of tearing anyway.

SPEAKER_01

Yeah, that makes sense.

SPEAKER_04

Great. What's happened and then how to manage it afterwards. And then once the vaginal assessment has been done, they might also recommend a rectal examination. So this can be a little bit more awkward and a little bit more uncomfortable. But and again, it can only be done with your consent. But it's really, really important to consider because there is one other tear that could occur that doesn't really fall into any of the other categories, and that's a button-hole tear. And it doesn't actually involve any of the sphincter muscles or any of the perineal muscles, really, either. It's sort of in isolation, but it can have really catastrophic effects if it's not diagnosed. Women can experience feces coming through their vagina because it sort of creates a tunnel, I guess, if it's not identified. And so the only way to really diagnose this at all is by doing a rectal examination. It can still be tricky to identify with a vaginal assessment. So that's when that sort of discussion might be had as well. And it's quite common for us to ask every woman, even when we see that the entire perineum or vagina is in completely intact, we might still offer it to you because it's again just to rule out that final details that could have occurred.

SPEAKER_01

Exactly. And by buttonhole, we mean a small hole between the bottom and the vagina that happens higher up than where we can see on the outside of the vaginal opening. Yeah, that's right. Where the baby's head may put some pressure on as it's coming down. Very rare. Very rare. But as you said, something that we we don't want to miss. Yeah. As a consequence, it's going to be quite bad.

SPEAKER_04

That's right.

SPEAKER_01

After we've examined thoroughly, we usually then try and repair things. As you said, we don't have to do it straight away unless there's concerns about pain or bleeding. But it is often nice to get it done quickly so that obviously we can get you just feeling back to normal and recovering and enjoying that time with the baby as quickly as possible. So and often that will be, particularly if you've had any pedural, it will be quite quickly so that we can make sure that that pain relief and the epidural is still working so you don't have any discomfort. Importantly, when we do repair the stitches, if you don't have an epidural, we make sure we put in some local pain relief. And that will usually be in the form of some local anesthetic with an injection. Yes. Or sometimes an injection into the nerves around the pelvic area called a pudendal block, which is a bigger needle. But usually it's at least some local anesthetic. So we we want to make sure that the process is comfortable for you.

SPEAKER_04

Yeah, absolutely. And just going back to sort of the timing of repair, women have a rush of adrenaline running through their bodies after birth, and that adrenaline itself can be a natural anesthetic condition. So it can be helpful to do it quite soon after, just so that we're optimizing all those amazing hormones after birth to sort of help support you as well, so you're not feeling as much discomfort. As you said, Rangi, those are usually the main forms of analgesia that we would give. You can use the gas as well. So if you've used gas during your labour or your birth, or even if you haven't had time to use that, but you want to give it a go, this is your last chance to use it. And even just things like focusing on your baby or having your partner support. I don't think it's very popular or it's not been really established here in Australia, but there's a lot of research being done around virtual reality and how that can be actually like a natural anesthetic almost. So yeah, women are being sent on to beaches or in safari jungles just while they're being suited repaired. Yeah, and it's actually being shown to really reduce their um degree of pain and discomfort during that repair period. So anything to distract you can also be really, really helpful. Yep, and the best distraction is your baby. Yeah, yeah, absolutely. But it's important that if you are experiencing pain during the repair, it's normal to feel touching and some pressure, but actual pain itself, it's important that you're letting your midwife or doctor know about that so that they can give you some more pain relief. That's right, we don't want that.

SPEAKER_01

Absolutely not. Afterwards, we usually do give you some also local pain relief in the bottom as well, don't we? So we do that bottom check, as you mentioned, to check that there's no tears involving the bottom or the bottom muscles before we start stitching. But we also do another bottom check to again make sure that there's no stitches where uh the bottom is involved, but also to give you usually some suppositories of pain relief and that will work really well in that local area, be absorbed from the bottom, and basically just pan it all in and anti-inflammatory is what we give you. But it seems weird that we would give it to you in the bottom, but it works really well in that area, doesn't it?

SPEAKER_04

Yeah, I guess if you think about it, it just has less of a distance to travel to the pain, to the side of the pain. Yeah. You you really need to do that once, usually, and so um going forward you can just take oral um analgesia for to support you after that.

SPEAKER_01

Yeah, just tablets, yeah. I know. And then the reason why I mention it is because sometimes people are a bit confronted and surprised when you might ask them to do a rectal exam for either the first bit before you stitch or afterwards when you're putting the suppositories in. It's just good to be prepared for that. It's completely normal and will help with your recovery.

SPEAKER_04

Absolutely. Yeah, good point.

SPEAKER_01

It's not every day that that happens. So it's not. It's fair enough. We've talked a lot about how we can minimise tears and prepare for them, but we can't take away that risk completely, can we?

SPEAKER_04

No, no, we can't. And it's just part of the nature of birth, unfortunately. And it might be a a poor comparison, but if you compare it even to a C-section, there's a hundred percent chance that there's going to be a cut. Yes. So, you know, there's there's other factors that affect from a vaginal birth perspective, but there's a lot of reassurance around um, you know, for women to to understand that it doesn't, yeah, the tears, if they do sustain it, are often going to be very minimal. Yeah.

SPEAKER_01

Now, if you do have a tear, we've mentioned it briefly, but and it also, of course, depends on what type of tear and the extent of everything else that's going on. But what are some of the things that we can do to support recovery early on?

SPEAKER_04

Yeah, so plenty of rest. I think as a society, we're really bad at doing that. If we talk about building a village, but for some women that can actually be really challenging, depending on what kind of family or friendship that support that they have. But trying to get as much rest as possible is so important in the weeks post. But in that initial period, so rest, keeping pressure off that area if you have had stitches. So especially if it's a bit tender, still, put a pillow under. You can get those inflatable donut rings if they're helpful. But a pillow is often just fine. If you're breastfeeding, try and breastfeed baby on your side, or just tilt your hips a little bit so you're just not having that pressure on that area as much. You can use ice packs as well just to help reduce that pain. Changing a pad regularly so that you're not increasing the risk of infection to that area because you've got to remember it is still a wound that needs to heal, and keeping it clean, so giving it a little clean with just some water, number no soap in that area in those days following when your bleeding's the most heavy. Avoiding like baths and soaking because we just don't, again, want to increase risk of infection, but we also don't want to increase the pace at which those stitches are absorbing and breaking down as well. And then just being mindful of if the pain is increasing or you're feeling like there's swelling or a redness or burning or heat or abnormal discharge in that area, that you're letting your care provider know that this is happening so that they can review it and make sure that it's nothing worse that has happened.

SPEAKER_01

What we worry about in terms of complications with the tears might be an infection. Correct. Which is not common. It's not common at all. But certainly a possibility when you have any wound in your body. Absolutely. And particularly when that wound is in an area that already has a lot of bacteria, which is normal. But there we want to make sure that there's no infection. So, as you said, if you have any of the symptoms, important to let your health provider know. Yeah. And it might be just a case of watching and seeing or some tablet antibiotics. And very rarely, if you're very unwell, you might need some intravenous antibiotics. It's really uncommon that any infection or problems with your tear might need to have another procedure. We usually try not to do that, don't we?

SPEAKER_04

Yeah, yeah, yeah, we do. And like you said, it's really uncommon. And it you will usually stem from initially like an infection that's then just started to affect the healing process of that actual wound. Yeah. So getting onto it early is important. Getting onto it early is important. And often we don't necessarily need to re-stitch the wound or anything, it's just a bit like you said, watch and wait, antibiotics and just yeah, managing those symptoms until that healing starts to progress a little bit further. I thought as well, in terms of sort of those couple of days following bow motions. Yeah, I was about to say, yes.

SPEAKER_01

I think one of the big things that, and and we'll talk about this on a separate episode, but one of the big things that people often fear after they've given birth, particularly vaginally, is that first time they have to open their bowels afterwards.

SPEAKER_04

It's really a confronting experience. Then if you add stitches on top of that, so many women have said to me, What if I tear my stitches? You won't. You won't tear your stitches, but it I know it can definitely feel like you might. So it's important to make sure that you're not constipated. Yeah. And taking medication if you need to to help soften your poo so that you can go without too much straining. So avoid straining at all costs. Just like in pregnancy, we advise to you know reduce your the risk of of constipation because of your pelvic floor. We've got to let that rest. So it's the same in the postpartum period as well. Yeah.

SPEAKER_01

Important. Yep. What about in the long term? Well, now we had a really great episode with um Professor Helena Frawley that people can listen to, where we go into this in detail. But just briefly, after those first few weeks of rest and recovery for these tears and wounds, what else do you think people can do in the long term to make sure their tears and their pelvic floor are best managed?

SPEAKER_04

Yeah, so pelvic floor exercises is generally the answer for that. And pelvic floor exercises are encouraged. We should have been doing them before pregnancy. So long before everybody should do that. Everyone just should do that. Should be taught in high school. Absolutely, absolutely should be taught in high school. Um so if you haven't done it yet and you're pregnant, start doing them now. They're going to not only support your recovery, but they can also actually support you to have an easier labour and birth as well. Because if you've got strong pelvic floor muscles, then your ability to mobilize them and push is going to be a lot better than if you don't. And when I mean strong pelvic floor muscles, I don't mean tight. You want them to be mobile. So you want to be able to relax and contract them evenly. But there's lots of apps and there's lots of, you know, YouTube videos that you can Google to just show you how to do pelvic floor exercises. And I think you said you have a physio episode prior to this, so I'm sure she goes into a lot of detail about them. But yeah, within sort of the first two weeks of giving birth, like start your pelvic floor exercises, but also know that even if you were able to do 20 kegels before birth, and you can only do one now, that's okay. And so don't overdo it. Do what works for you. And what feels comfortable. And what feels comfortable, absolutely. Yeah. But they're going to help your recovery. They're going to help if you're choosing to have more children after your first one in the future, then that's going to make pregnancy and birth easier for you the second, third, and fourth time round as well.

SPEAKER_01

And reduce some of those other complications that we want to avoid, like problems with keeping your farts and your poos in and your wee.

SPEAKER_04

Yeah, absolutely. That's it. Strengthening the pelvic floor.

SPEAKER_01

Yeah. One other question that commonly comes up, and you know, not everyone is always thinking about this or may take longer to think about it, but it's an important point is when can people resume sexual intercourse after they've had a tear?

SPEAKER_04

When you're ready. It's a good answer. I know we have this sort of six-week rule, and that's usually because women will generally fit stop bleeding by six weeks. In terms of any tears that have needed to be repaired, the healing should have completed by that time. But I think it's important that women understand that there's no golden rule around sexual intercourse. It's really up to how you feel and what's comfortable for you. And knowing that it might take a bit of time. I remember Physio said to me after my first baby, it's just like your first time all over again. You just gotta sometimes rip the band-aid off. And then after the first time, you realise it's not so bad. It's not so bad. Yeah. But if you are having any sexual function issues, I think historically we've been told as women or that you've had a baby, so you could probably expect to feel that. But it's important you understand it's not normal. Um, and you know, we can do things to help women recover from any ongoing or issues that maybe uh have carried out a little longer post-birth than what they should have. Yeah, that's that's really important. Yeah. We don't want you to be feeling like that. No, you don't have to suffer in silence. Yeah. Great.

SPEAKER_01

We did talk about not trying to soak too much in baths, but we have previously recommended things like cis baths and things like that. What are your thoughts on that?

SPEAKER_04

There's not a whole lot of strong evidence around sort of whether they're helpful or not. I think in terms of if it's pain that you're really worried about, then that can sometimes be helpful. And again, it can be quite soothing to sit in a bath. It's more probably whether you put things in the bath, or I know some women will put witch hazel on their pads to help with pain and and healing and that kind of thing. It's important to know that that can actually cause more problems. So just avoiding anything to apply directly over that area, that perineal area after birth is really important to avoid for the first couple of weeks.

SPEAKER_01

That's really important. There's actually no evidence that there's m any benefit with those things and it can cause harm.

SPEAKER_04

Yep. Yeah. Yeah. It doesn't necessarily mean that it will definitely cause harm, but it's not going to be of really any benefit. Yeah. Yeah.

SPEAKER_01

I think it's really important to know that just because you've had a tear once doesn't necessarily mean you'll have another one.

SPEAKER_04

You've actually got less of a chance of having another one the second or third time round than you do the first time. So that's can be really reassuring, especially if you've had only a small tear the first time. You will likely maybe only have that again or or nothing at all. Yeah.

SPEAKER_01

Because that tissue has stretched already. Yeah. Is the theory.

SPEAKER_04

Absolutely. Absolutely.

SPEAKER_01

There are obviously other factors that go into that, as you said, like size of baby and length of labour, which of course is hard to predict the second time, but in general, less likely. Yes, yeah. And when people have a tear in their perineal area, it can be quite confronting. And sometimes it can affect the way you might feel about your body and particularly that area, whether it comes to your confidence or even, as we mentioned, your sexual function and your intimacy. What are some things that you would say about that and advice you might give people?

SPEAKER_04

I'm gonna quote my boss here. And she will always tell her women to take a vulfi before birth. So a selfie essentially of your vulva. Oh wow!

unknown

That's great!

SPEAKER_04

Cause it's a vulfi. Now that could also be quite confronting, I think, for a lot of women, and again, this is just this is just growing up as a woman, as you know, as a young girl and a woman. We're not encouraged to explore our bodies or even look down there. So the first time you ever look down there might actually be when you're pregnant or after you've given birth. But if you can look down there before you give birth and you can see what your normal is, because I think it's really important women know that your anatomy is going to be very different to your friend's anatomy or the woman birthing next to you. That's right. So if you can know what your normal is, especially after birth, whether you've torn or not, you can have a look again and say, well, yep, it all looks the same. Or if you have torn, hey, they did a really good job. Or perhaps something doesn't look right. And so if you you're able to do that, then you could report that and we can address that. So yeah, have it doing it's a really great idea. I love it. It's a really great idea. And even um, you know, even if again with your partner, if you're comfortable with your partner sort of, I mean, I'm sure they've probably probably know your body better than you know yourself, your own sometimes. But I've even had to ask partners before when I've done a repair for a woman, does that look right? Just double checking. I mean, they can usually tell us so and they're usually very inquisitive and keen to, again, keen to be a part of anything that they can be. But that I guess is probably the most helpful, and it sort of reduces that overall fear about what's happened to your body as well, because we know that pregnancy is a completely transformative experience, physically and emotionally, that continues to evolve after you've given birth as well. Yes, and so it's important that you're feeling comfortable in your own skin, and that can take a little bit of time, um, but just be kind to yourselves, and if you are concerned in any way, it's important that you seek help.

SPEAKER_01

Yeah, really good advice.

SPEAKER_04

Thanks, Mel. Yeah, take a ball fit.

SPEAKER_01

Yeah, I've never heard that, but that's fantastic. I'm gonna use that from now on. Fantastic. Thank you. No worries, thank you. Thanks so much, Mel. That was really great. Um, I think we covered some really important topics about what exactly tears are, how we manage them, and hopefully that gives people information and makes them less fearful and concerned about it. And information is is power when it comes to this.

SPEAKER_04

It definitely is. As scary as some of the information can sometimes be, I think going into birth prepared will definitely help with your feelings around your birth afterwards as well. Fantastic.

SPEAKER_01

Thanks so much, Melanie. Thank you.

SPEAKER_00

We'll see you next time. See you next time. Every pregnancy is unique. The information provided in today's podcast is for educational and general purposes only. It is not intended to be substitute for professional medical advice. It is important that you always seek the guidance of qualified health professionals with any questions you may have regarding your health, pregnancy, or any medical conditions.