Women's Health

Postpartum perineum pain: What's normal and when to visit the doctor

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The beautiful experience of new motherhood can be somewhat dampened by the pelvic pain that many women experience after childbirth.

It's that bittersweet feeling of finally having your newborn in your arms, but flinching at the pangs of perineum pains that pop up every time you move a certain way.

In women, the perineum is the area of skin between the vagina and the anus. It's probably not an area you'd ever given much thought to, but now you've had a baby, it's the area you can't stop thinking about!

Be it as a result of childbirth, or complications that follow, postpartum perineum pain is common and quite normal.

Patience does need to be exercised during the healing process, but it's also important to know where 'normal' ends and when it's time to seek medical advice to avoid long-term complications.

Causes of perineum pain after birth

Pushing a 3.5kg baby out of your vagina is no small feat. And the nine months of pregnancy prior causes some of the most rapid bodily changes you'll ever experience.

It's no wonder, then, that childbirth can cause perineal injuries and pelvic pain issues down there. Here are the most common reasons you might experience perineum pain.

Perineal tears during childbirth

Despite the fact that our vaginas are built for this, unpredictable occurrences such as birthing a large baby (over 8 pounds or 3.6 kg), a baby exiting face up, a quick delivery (that doesn't allow the vaginal skin time to stretch and thin), or the need to use forceps for assistance, can all increase the risk of perineal injury.

The reality is that about 85% of women experience some form of perineal trauma during childbirth, especially if it's their first child. It's just that nobody talks about it!

If you do tear, there a four different grades of tearing you may experience:

  • First-degree tear: This is the least severe of the tears. It only affects the skin around the vagina and perineal area.
  • Second-degree tear: The most common type of tear. It extends deeper through the skin into the muscles of the vagina and perineum.
  • Third-degree tear: Extends from the vagina to the anus. It damages the skin and muscles of the perineal area as well as part of the anal sphincter muscle (the muscles that help you control your bowel movements).
  • Fourth-degree tear: This is the most severe but thankfully least common type of tear. It extends from the vagina all the away through to the anal sphincter and to the rectum (the end of the large intestine).

After the birth, your doctor will examine you to determine if you have a tear and whether you require stitches.

Anything from a second-degree to a fourth-degree tear usually will. Your doctor will take care of this straight after the birth (with adequate pain relief, of course).

Episiotomy

If your baby needs to be born quickly, you're at risk of a serious perineal tear, or you require a forceps or vacuum-assisted birth, an episiotomy may be carried out.

This is a cut made by your doctor into the perineum and vaginal wall to make more room for the baby to be born.

This procedure is only made with your consent, and just like most natural tears, you'll have stitches afterwards.

Pelvic floor dysfunction

Pregnancy and childbirth is truly an extreme sport for your poor pelvic floor muscles. The pelvic floor is the group of muscles that support the organs in your pelvis, including your bladder, rectum and uterus.

They also play a key role in your bowel movements. That's why pelvic floor exercises become such a big focus when you're pregnant.

Pelvic floor dysfunction occurs when your pelvic floor muscles don't contract and relax normally. This can be as a result of them being weakened or torn during pregnancy and childbirth.

If you end up with pelvic floor dysfunction, perineal pain is common. You might also feel constipated, have painful and frequent urination, experience lower back pain, or have chronic pain in your pelvic area, genitals or rectum.

Serious cases of pelvic floor dysfunction can result in pelvic organ prolapse. This is when one or more of the pelvic organs, such as the bladder or uterus, bulge out of the vagina.

It can be quite embarrassing for some women to talk about with their doctor, but rest assured, it's something they've dealt with many times, so there's no need to feel embarrassed. The most important thing is that you get the medical care you need.

Haemorrhoids

This is another one of those 'embarrassing' conditions that many people prefer not to talk about.

Haemorrhoids are swollen blood vessels located in and around the anus that can range in size from a small raisin to a large grape.

Pressure from an enlarging uterus during pregnancy plus increased blood flow to the pelvic area can cause the veins in the rectal wall to swell, bulge and itch. Pushing during childbirth also adds to the pressure.

Up to a quarter of  pregnant women experience postpartum haemorrhoids, so it's more common that you might think. Symptoms include pain, rectal itching and bleeding after having a bowel movement.

While haemorrhoids are generally not harmful, they can be downright uncomfortable. If you're experiencing any of these symptoms, it's important to see your doctor for an examination, and to rule out anything more serious.

The Sitz Bath is your secret saviour after birth.

Pudendal nerve entrapment

This condition isn't just reserved for pregnant women, but it can certainly happen after childbirth.

The pudendal nerve is one of the main nerves of the pelvis. Entrapment of the pudendal nerve can occur when the surrounding tissue or muscle starts to compress the nerve.

With all the pressure changes that occur in the pelvic region during pregnancy, this can become an issue for some women.

Symptoms of pudendal nerve entrapment include pelvic pain, including the perineum, vulva or rectum. The pain can vary, from a burning sensation or an ache, to a more shooting or electric-shock type of pain. You may also experience bladder or bowel irritation, or sexual problems.

This one will need medical attention as well as self-care, so it's best to discuss it with your doctor.

Complications of perineum pain

No matter the cause of your perineum pain, complications can follow. Here are some common issues you may experience.

Painful urination

Urine can burn a torn perineum that's in the process of healing. That's why it's important to keep the area clean after using the bathroom.

We recommend Kin's Peri Bottle. It's ergonomically designed to delicately clean your vagina without painful pressure.

The upside-down, angled spout directs water to stinging areas and means you can avoid the dreaded hand-in-toilet situation. You can even squirt the water onto your vagina as you urinate to help ease any discomfort.

Kins peri bottle
Wiping is a no-no when healing so spritz instead with Kin's Peri Bottle.

Infections

If you've experienced a perineal tear, it's important that you care for it and clean the area regularly to avoid infection.

Infections of the perineum after a tear can cause redness, swelling, pain, a discharge of pus and a foul odour.

If you suspect you have an infection, it's important you consult your doctor to have it treated.

Difficulty sitting

A torn and swollen perineum as well as haemorrhoids can make sitting a painful experience.

To help ease the pressure on the rectum, sit on a pillow or waffle cushion. Sitting on a rocking chair or recliner may also be more comfortable than sitting on a regular chair.  

Incontinence

Women with pelvic floor dysfunction after birth can experience some loss of bladder and/or bowel control when coughing, sneezing or laughing. This means urine or poop can leak out at inconvenient times.

Pelvic floor exercises can help improve the muscle tone of the pelvic floor and rectify the incontinence.

However, in some cases, corrective surgery may be needed. It's best to consult with your doctor and a women's health physiotherapist if the problem persists.

Constipation

Pelvic floor weakness, postpartum pain medications, stress hormones and dehydration (from childbirth and breastfeeding) can all contribute to constipation in the days after delivery.

Many women fear tearing their stitches or feeling pain with a bowel movement. This is a completely normal and common fear, but you can rest assure that pooping won't tear your stitches so long as you don't strain too hard.

It's important to listen to your body's cues and poop when you feel the need, because the longer you wait, the harder it becomes to go without pain.

To help with the process, be sure to drink plenty of water and eat fibre-rich foods. Exercise a little (with the OK from your doctor), and if needed, try a stool softener or laxative.

If a week has passed and you still haven't pooped, give your doctor a call.

Postpartum depression

This a serious mood disorder that research has found is linked to postpartum pain.

While it's completely normal to have some degree of 'baby blues' – a mix of anxiety, loneliness and lethargy that new mothers commonly feel – if the negative feelings linger, it could become postpartum depression.

Left untreated, postpartum depression can take a serious toll on both you and your baby, so it's important you see your doctor to discuss your symptoms. Support is always there for new mums who ask for it.

Pain during sex

If you've had a tear or an episiotomy, pain during sex is very common in the first few months. If penetration is painful, hold off until you feel ready.

Rather, choose other ways to be close to your partner until the tear has healed. Other causes of painful sex can be vaginal dryness or weak (but overactive) pelvic floor muscles.

If it's dryness, a water-based lubricant can help. To tone a weak pelvic floor, practice pelvic floor exercises each day.

This involves squeezing the muscles around your vagina and anus as if to stop yourself from going to the toilet. If pain persists, consult your doctor.

Best ways to soothe perineum pain at home

When your downstairs area is sore, tender and swollen, all you want is some soothing relief. We hear you, sister! Here are some of the best at-home remedies to help get you through the worst of it.

  • Ice packs – An ice pack wrapped in a soft towel can provide some much needed coolness and numbing in the area. You can also try Kin's Soothing Padsicles, which double as a pad and ice pack all in one.

  • Sitz Bath – This is a shallow mini-tub that fits neatly over the toilet seat and allows you to soak the perineal area for cleansing and pain relief. Add some Sitz Salts to the water to create an instant soothing spa.

  • Witch Hazel This solution has proven healing properties to relieve discomfort from perineal tears and haemorrhoids. Try Kin's Healing Foam with Witch Hazel. It's travel friendly and can be used with the Soothing Padsicles or added to the Peri Bottle wash.

Kin's Healing Foam contains Witch Hazel

  • Perineal massage  – If you've had a perineal tear or an episiotomy, the scar tissue around the area can become tight and attach to the layers of skin below. This can cause pain during sex or physical activity. By massaging the perineal area, you can reduce your scar tissue. However, massage should only be done once you've had your postnatal check and any stitches and scarring have fully healed. If perineal pain persists, it's time to see your doctor.

  • Keep the area clean with warm water – Use a squirt bottle like the Peri Bottle while you urinate to dilute any stinging urine and to keep perineal tears clean as they heal.

  • Avoid constipation – As mentioned above, be sure to drink lots of water and eat fibre-rich foods to encourage regular, soft bowel movements. Fibre supplements or stool softeners may be needed until the perineum pain subsides.

  • Take pain relief medication – Over the counter pain relief such as paracetamol or ibuprofen can help take the edge of your perineal pain. If you have an extensive tear, prescription pain medication from your doctor may be needed.

  • Rest Finding time to rest when you have newborn is difficult, but do your best not to take on unnecessary chores and to prioritise sleep, especially in the first 1-2 weeks. Resting will eliminate gravity from adding extra pressure on your pelvic floor.

When will perineum pain stop?

How much perineum pain and how long it lasts will depend on the person as well as what's causing the pain. Extensive tearing and swelling usually takes longer to heal.

For women with an uncomplicated vaginal birth, perineum soreness can subside within a few days to a few weeks. A typical episiotomy or second-degree tear that requires stitches can heal as quickly as 2-3 weeks, whereas a third or fourth-degree tear can cause pain and discomfort for a month or longer.

When to seek medical treatment

By virtue of the fact that you've birthed a tiny human, you're already a hero. But that heroism doesn't mean you should push through unnecessary perineal pain.

If you have severe pain, persistent pain, or swelling in the perineal region that isn't going away or is getting worse, you should consult your doctor for a physical examination. They may need to refer to a specialist or for physical therapy to work on your pelvic muscles.

Finally, if you have signs of an infection such as fever, foul-smelling discharge from the vagina or the site of your stitches, it's essential that you seek medical treatment.

References

  1. Vaginal Tears During Childbirth, Cleveland Clinic, 2020.
  2. Smith LA, et al. Incidence of and risk factors for perineal trauma: a prospective observational study, BMC Pregnancy Childbirth, 2013.
  3. Perineal tears during childbirth, Royal College of Obstetricians & Gynaecologists, 2021.
  4. O'Keefe Osborn, C. What Causes Perineum Pain?, Healthline, 2018.
  5. Pelvic organ prolapse, Office on Women's Health, 2019.
  6. Haemorrhoids during pregnancy, Healthdirect Australia - pregnancybirth&baby, 2021.
  7. Obstetrics & Gynecology: Obstetrics Division - Common Conditions: Constipation, University of Rochester Medical Center.
  8. Pudendal Neuralgia, Women's Health & Research Institute of Australia.
  9. Episiotomy and perineal tears, NHS, 2020.
  10. Pelvic floor, Better Health Channel, 2021.
  11. Lim, G. et al. Obstetric pain correlates with postpartum depression symptoms: a pilot prospective observational study, BMC Pregnancy and Childbirth, 2020.
  12. Ries, J. Does Pain After Childbirth Increase Postpartum Depression Risk?, Healthline, 2018.
  13. Bradley, S. Everything You Need to Know About Postpartum Poop, verywellfamily, 2021.
  14. Massage for perineal, episiotomy and caesarean scars, Guy’s and St Thomas’ NHS Foundation Trust, 2020.
  15. Pietrangelo, A. How to Treat Perineal Pain and Swelling During and After Pregnancy, healthline, 2016.
  16. Marple, K. Postpartum perineal pain. babycenter,
  17. Episiotomy, John Hopkins Medicine, 2022