Answered by Isa Herrera, MSPT
Q: Seventeen months ago I gave birth to my daughter via natural childbirth in a hospital. It was a great experience, but I ended up receiving a small pressure episiotomy, without any warning or realization that it had happened (until the next day when I asked my husband if I had torn, since I knew I’d received stitches). I suppose my recovery was ‘normal’: I had pain and some swelling for several months afterward, and sex hurt for a very long time (but I was also breastfeeding). I returned to yoga and walking within six weeks. But now here I am almost a year and a half later, and I still have pain/soreness after a rigorous yoga class, if I go running, or even after a long day chasing my toddler. I am an active person– I used to run marathons and would like to again some day–is it possible to return to these activities and not experience pain? Also, we are trying for another baby. Does having the previous episiotomy mean that I will need another one? If I refuse, do I have a higher likelihood of tearing?
A: Frequently after perineal tears or episiotomy there is a build up of scar tissue in the perineum. To help reduce pain and soreness and to restore function in the pelvic floor muscles and the perineum it is necessary to do gentle scar massage. There are several self-care techniques that will help that I always recommend to my patients. Remember to be gentle with these techniques, check with your midwife or caregiver also to make sure these massages OK for you to do. This massage is not recommended before six weeks post-partum.
Gentle clock stretches at the vaginal opening
1- Imagine your vagina opening is a clock. 12 o’clock is the clitoris, 6 o’clock is the anus, 3 o’clock is the left side and 9 o’clock is the right side.
2- You perform the stretches between 3 o’clock and 9 o’clock, avoiding 12 o’clock where the bladder is.
3- Put you index finger into your vagina up to the first knuckle of the index finger
4- Start at 3 o’clock and press downwards for 30 seconds
5- Avoid pressing too hard. Keep the pain level between 3-5 / 10 (0=no pain and 10 is the worst pain you’ve ever had)
6- Now press at the 4 o’clock position for 30 seconds and continue around the clock until you reach 9 o’clock
7- For better results, note the painful spots on the clock and then focus on these spots for additional 30 second reps
8- Make sure to use some form of lubricant that does not contain alcohol. I like vitamin E, rose oil, olive oil, or organic lubricant when doing the stretches because it makes it easier on the tissues and where the scar is present
1- Old fashioned perineal massage also would work ok, but be careful about pain levels as this type of massage may cause more initial pain since you are using both thumbs to mobilize the tissues.
2- For this technique, place 2 lubricated thumbs into the vagina and gently press downward for 30 seconds to 3 minutes and repeat. Do this technique several times as tolerated, making sure to pay attention to spots that are causing more pain.
After the stretching
1- After the stretching I usually recommend that you apply a cold pack wrapped in a towel or t-shirt for up to 10 minutes to help decrease the inflammation and pain that frequently accompanies this kind of massage.
If you find that your pain persists after doing this massage for more than 2 weeks, consider seeking expert care from a physical therapist who specializes in post-partum perineal conditions. There are other techniques and treatments available if your condition is more serious, especially if you find that your scar area opens up during intercourse, or you are experiencing extreme pain when performing the gentle massage techniques described above.
The second baby
As for trying to have the second baby, once you are pregnant you will need to focus on mobilizing the perineum with massage in order to increase the elasticity of the area. This is done after 34 weeks of pregnancy. You are certainly a candidate for a vaginal birth, but you should make sure to choose a caregiver who shares your vision for a vaginal birth without episiotomy.