Looking after your perineum & care for stitches after birth
The Perineum is the area located between the vagina and back passage (anus) and has an amazing ability to gently stretch and give to allow the birth of our babies. Below are some methods of prevention for perineal trauma. Some points are evidence base, some are common sense, some are just comforting for the woman at the time and some just work!
Good nutrition and health equals strong elastic tissue and rapid healing after the baby is born. Focus on a well balance diet throughout your pregnancy. Eat a large variety and lots of fresh seasonal foods.
Sore, irritated, swollen perineal tissue is not likely to be as pliable, can tear easily and heals poorly. We advise to avoid perfumed soaps and sprays and sometimes panty liners can cause irritation. Comfortable cotton underwear is encouraged and prompt follow-up on yeast or other infections.
Perineal massage; anecdotally, midwives and women all over the world believe that perineal massage has helped avoid tearing and episiotomy during childbirth. The concept of stretching of the perineum by placing two thumbs into the vagina and gradually stretching the perineum open and out is thought to be beneficial. Some midwives recommend evening primrose, olive oil or unscented almond oil for this. Unfortunately, it is physically challenging in later stages of pregnancy and is generally taught as a couple’s activity. Evidence on perineal massage is shown to be effective for women having their first baby and if commenced after 34 weeks gestation (Yates, 2010).
A dilating balloon device is currently being promoted to increase vaginal elasticity antenatally. Experts are challenged to see the benefits of dilating a woman’s vagina to 10cm without actually being in labour and giving birth. The vaginal/perineal tissue does this particularly well when there is gradual dilation in labour, with sufficient expulsive urge, support and encouragement.
Management from your care provider of the second stage (the pushing part) of labour is critical to preserving the integrity of the perineum. We should observe the rest time between contractions and wait for the physiological urge to push occur. There is a significant trend towards poorer perineal outcomes when directed forceful pushing is used, with evidence that pushing on command and expulsive pushing (holding your breath, chin down on chest etc) contributes to pelvic floor damage, fetal distress, exhaustion and perineal tears.
A meta-analysis of randomised controlled trials showed that spontaneous vaginal birth reduced the incidence of perineal trauma (Yates, 2010). The absence of fear and embracing of trust of your body and the birthing process can help reduce the likelihood of tears.
Choosing a care giver who allows you to adopt your birth position instinctively is important with the avoidance of Lithotomy (legs up in stirrups) which is the worst position for pain and tearing. The avoidance of forceps or vaccum deliveries and epidural or local anaesthesia that will numb the area all play a part in preventing trauma.
Placing warm packs over the perineum to help relieve the burning sensation during crowning can be most comforting.
A trusting relationship with your birthing carer will allow you to work with your body and your baby during the process. Humour can help women to relax and a close interaction between midwife and the woman throughout with gentle coaxing and quiet, peaceful talking to encourage slow birth of the head after crowning. The most effective preventative for perineal trauma in our experience is the trusting relationship between mother and midwife developed through pregnancy. Discussion occurs about what happens in the second stage and how the midwife will provide encouragement and support to get through this overwhelming experience.
Below are our recommendations in dealing with perineal soreness, care after birth and how to care for stiches.
- With all normal births try to minimize movement for the first week to aid healing
- Apply ice to your perineum if there is swelling for the first 24 hours
- If you had stitches or an episiotomy focus on a well-balanced diet of fresh seasonal foods
- Avoid constipation by increasing your fruit, fluids and fibre after birth
- Have salt baths for the first few days after birth in a very clean bath (½ fill the bath, ½ cup salt, sit for ½ an hour), but do not submerge your breasts or baby in the salt water.
- use salt washes after using the toilet to keep the area clean and minimise the chance of infection
- Take arnica tablets or pillules regularly (follow instructions on the packet)
- Allow 4-6 weeks for the area to heal completely and consider use of a lubricant when you are ready to resume sexual activity
MAMA Says: MAMA believes a loose open jaw may help to have a loose open vagina. The space held for the woman in the birth room may also greatly help reduce the chance of perineal tears.
For more information, visit http://www.ranzcog.edu.au/publications/o-g_pdfs/O&G-Winter-2010/Perineal_tears_Yates.pdf
Exercise in the antenatal and postnatal period
Exercise in pregnancy is essential. Exercise will help you remain active, mobile and prevent you gaining excessive weight in your pregnancy. Unless you have complications, it should be possible to enjoy some level of physical activity throughout most of your pregnancy. You may need to modify your existing exercise program or choose a suitable new one if you were not a regular exerciser pre pregnancy.
Some of the benefits of exercising regularly throughout your pregnancy include:
- Optimises your chances of a quick, easy birth
- Increases your energy
- Improves the strength of your back muscles which can help manage back pain and strain as your belly grows
- Improves posture
- Releases endorphins helping you feel good during your pregnancy
- Stress relief
- Improved sleep and management of insomnia
- Preparation for the physical demands of labour
- Can help you get your baby into the right position for birth
- Faster recovery after labour
- Faster return to pre-pregnancy fitness and healthy weight
- Increased ability to cope with the physical demands of motherhood
Women should discuss their exercise plans with their midwife or doctor. Depending on your previous exercise program, you may be able to continue this during pregnancy; however you should check this first to receive clearance.
If you have been cleared to exercise, it is recommended that you:
- Engage in at least 30 minutes of moderate-intensity physical activity on most days of the week
- Combine Strength and Aerobic exercise
- Let your body be your guide and back off if you feel faint, weak, or unwell
- Increase your water consumption on your exercise days
- Avoid over heating during exercise and back the intensity off if you feel this coming on
- Don’t forget the pelvic floor
Suggested exercise activities during pregnancy
Activities that are generally safe during pregnancy, even for beginners, include:
- Cycling – outdoors or on a stationary bicycle
- Exercise in water (aquaerobics)
- Dancing (especially Belly Dancing)
- Pregnancy exercise classes
There are some exercises that involve positions and movements that may be uncomfortable or harmful for pregnant women. General cautions include:
- Contact sports or activities that carry a risk of falling (such as trampolining, rollerblading, downhill snow skiing, horse riding and basketball)
- Competition sports – depending on the stage of pregnancy, the level of competition and your level of fitness
- After about the fourth month of pregnancy, exercises that involve lying on your back – the weight of the baby can slow the return of blood to the heart. Try to modify these exercises by lying on the side.
- In the later stages of pregnancy, activities that involve jumping, frequent changes of direction and excessive stretching.
Resuming gentle exercise can be started within the first few weeks after birth, if you feel up to it. As a rule, your post birth recovery takes 4-6 weeks so after this timeframe you should be ready to resume your regular exercise routine. Remember the Relaxin hormone remains in your system for some months after birth so take care with vigorous exercise and stretching. Like in pregnancy, stay well hydrated, particularly if you are breastfeeding and gently increase your duration slowly as your fitness levels improve.
MAMA Says: Many women find themselves feeling heavy and extremely uncomfortable in late pregnancy. You don’t have to feel this way and the key is regular exercise.
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Diastasis of the Rectus Abdominus Muscle (DRAM)
This is the separation of the connective tissue in between the two strap like muscles that run down your abdomen (Gilleard & Brown, 1996). This often occurs during pregnancy as a result of the baby growing. The separation of this muscle usually happens to some degree in the pregnancy but for some women it may be quite severe. Left untreated post birth this can lead to posture problems, back pain or pelvic floor dysfunction.
A DRAM is measured by health professionals in finger widths after birth. Usually it self resolves at around four weeks after the baby’s birth. If it does not, you may need to do some exercises to strengthen your abdominal muscles. It is best to see a Physiotherapist or healthcare practitioner who specialises in DRAM to receive appropriate treatment and follow up. Exercising too hard or with the wrong type of exercises (such as sit ups) can further extend the DRAM therefore appropriate follow up is essential.
MAMA Says: After you have had your baby ask your midwife how many finger widths your DRAM is. See our specialised Women's Health Physiotherapist for exercises to help your DRAM come back together!
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Vaginal Bleeding after birth
Are you in Melbourne and would like to see or speak to a midwife about bleeding in pregnancy or the postnatal period? Call us now on 9376 7474; a Midwife is available any time!
It is normal to have bleeding after your baby’s birth, whether your baby was born vaginally or by caesarean. More often the blood loss is heavier after a vaginal birth. An average amount of blood when a women gives birth is between 200-300ml. Your body prepares in pregnancy to lose a significant amount of blood immediately after the birth, with a large increase in the blood volume. Lochia is the name given to postnatal bleeding.
Lochia is very similar to the bleeding you experience during your menstrual period; however, it is much heavier. It typically begins in the hours immediately following birth and usually continues for two or three weeks. However, in some women lochia can last for up to six weeks. In the first day or two it will be like a heavy period and it will get progressively lighter.
Symptoms of Lochia
Lochia usually begins as a bright red discharge from the vagina. This blood typically continues to be bright red in colour for between four and ten days. After ten days, your lochia will become a pink colour, eventually changing to a clear-yellowish-white colour. This blood flow may be constant and even, or it may be expelled in intermittent gushes. Lochia may also be accompanied by numerous small blood clots, about the size of a grape (Myles, 1999).
Dealing with Lochia
- Rest as much as you can and avoid excess standing and walking (this will exacerbate the blood flow)
- Use heavy duty super pads to soak up the blood
- Do not use tampons for at least six weeks after pregnancy. Tampons can introduce bacteria in to the vagina and uterus, causing infection
Typically, lochia is not the result of any health complication and will end on its own when your body is ready. However, some women do experience problems with their postnatal bleeding. If you experience any of the following signs, call your health care provider or visit your nearest hospital emergency department -
- Bright red discharge for more than seven days after birth
- Discharge that smells bad
- Fever and chills
- Abnormally heavy bleeding
- Large clots continuing more than seven days after birth
Postnatal haemorrhaging is a more severe type of post-pregnancy bleeding. If you lose more than 500 ml, you are classified to have had a postnatal haemorrhage. Postnatal haemorrhaging can be a very dangerous condition and is associated with various complications including heavy blood loss and even maternal death (Myles, 1999). It usually begins in the 24 hours immediately following childbirth (primary postnatal haemorrhage); however, it can occur anytime during the six weeks following delivery (secondary postnatal haemorrhage).
What causes Postnatal Haemorrhage The most common cause of postnatal haemorrhage occurs when the uterus does not contract after birth. This allows the uterus to continue bleeding and can result in massive blood loss. Other causes include:
- Failure to deliver all of your placenta and membranes
- Forced removal of the placenta
- Trauma to the uterus, cervix or vagina during delivery
Symptoms of Postnatal Haemorrhage
Every woman is at risk for developing postpartum haemorrhage. However, there are certain factors that will increase your risk although some may have a heightened risk. It is extremely important that every new mother knows how to recognize the symptoms of postnatal haemorrhage. Quick treatment is essential in order to prevent excessive blood loss. Symptoms include:
- Massive blood loss
- Passing large clots
- Dizziness, light-headedness, or fatigue
Treating Postnatal Haemorrhage
Postnatal haemorrhage is usually taken very seriously. If you are suffering from this type of bleeding, you will likely be treated in hospital with uterine massage, anti-bleeding drugs, surgery if needed, blood transfusion if needed and in some rare cases hysterectomy if they bleeding cannot be stopped.
MAMA says: Continue an iron rich diet after the baby is born! Consider an iron supplement if your iron levels are low post delivery.
For more information, call our MAMA centre and speak to a midwife.
Are you based in Melbourne and would like to see someone for postnatal depression? You can see one of our Midwives*, Psychologists* or Counsellors who can help you through this difficult time. Phone 9376 7474 to book, or send an appointment enquiry at the top of this page. *Medicare rebates are available.
Postnatal depression (PND) can be a devastating and debilitating illness that can persist and affect not just a new mother but everyone around her (PANDA, 2011). PND can be mild, moderate or severe and symptoms can begin suddenly after birth or appear gradually in the weeks or months during the first year after birth. PND can occur after miscarriage or stillbirth, normal or traumatic delivery, or caesarean delivery. PND happens not only after a first baby. It can occur after a third or fifth baby. Sometimes it happens after a first baby only. Sometimes it happens with a third baby, but not with the first two. Sometimes it happens after each pregnancy. A woman who has had PND has an increased chance of recurrence with a subsequent pregnancy (PANDA, 2011).
Symptoms of Postnatal Depression
Like with other forms of depression, the severity of PND depends on the number of symptoms, their intensity and the extent to which they interfere with activities of daily living. The combination and severity of symptoms will be different for every woman, resulting in many different appearances of PND.
- Sleep disturbance unrelated to baby's sleep needs
- Appetite disturbance
- Crying or not being able to cry
- Inability to cope
- Negative, morbid or obsessive thoughts
- Fear of being alone or fear of being with others
- Memory difficulties and loss of concentration
- Feeling guilty and inadequate
- Loss of confidence and self-esteem
- Thoughts of harm to self, baby or suicide (PANDA, 2011).
PND is a multi-factorial condition with biological, psychological and social factors all playing varying levels of involvement. This is why all women who suffer from PND will have their own unique symptoms and experience.
It is essential to seek professional advice should any of the above symptoms exist in your life after you baby is born. Seeking professional help as early as possible will allow a prompt treatment plan to be developed.
MAMA says: The best person to detect any form of PND is your partner. Keep communication channels open after delivery and talk through your feelings and any worries you may have.
Partners suffer from PND too; be aware of each other’s mood around this time and seek help if you need to!
For more information, visithttp://www.panda.org.au/, or for help call PANDA on 1300726306 or your MAMA midwife.
Physical care after a Caesarean section
You will be encouraged to get out of bed and mobilise within the first 24 hours after surgery. This will help start the healing process and get you used to moving around with your incision.
- If staples were used for your incision they will most likely be removed around day 5-7 after birth
- If stitches were used, they will be dissolvable ones
- After your dressing has been taken down there may be steri strips left on the wound. These will start to peel off over the next few days and this is when it is time to remove them completely
- You can shower normally and wash your body with soap. That soap will run over the wound; that is ok. Just avoid rubbing soap into your wound over the first week or so
- You should look at your wound every day over the first few weeks. The wound edges should be together and there should be no gapping of the incision. There should not be redness, ooze or heat coming from the wound and surrounding skin
- Make sure you watch for fever or pain, which can be a sign of infection
- Wear underpants in the first few days that are a big high cut style to come up and over your wound
Things to avoid
- Avoid taking baths until your incision is healed and you are no longer bleeding (up to 6 weeks)
- Public pools and hot tubs
- Lifting anything heavier than your baby
- Repeatedly using stairs
- Exercise until your health care provider says it’s safe
- Driving within the first 4-6 weeks
Reasons to seek medical advice
- Severe headache that begins right after birth and does not let up in intensity
- Sudden onset of pain in the abdominal area, such as tenderness or burning
- Foul smell from vaginal discharge
- Sudden onset of pain in the incision area that can include a pus discharge
- Swollen, red, painful area in the leg
- Burning urination or blood in the urine
- Appearance of rash or hives
Wound care after Caesarean birth
The days following the birth of your baby, can be challenging in many ways. This time can be even more challenging for a mum who has undergone a caesarean delivery. After all births, women must take time to allow their body to rest and heal.
MAMA says: Focus on a well-balanced diet of fresh seasonal foods postnatally to aid in wound healing and avoid constipation.
Vitamin K injection for the Newborn
After birth, all hospitals in Victoria have a policy for babies to be offered vitamin K, either orally or by intramuscular injection. This has been an option in most areas for over thirty years and it is thought by the medical profession to be an important prophylactic measure in preventing newborn Vitamin K deficiency. The medical information regarding this is that it is perceived all babies are born with low levels of vitamin K. Babies need vitamin K to prevent haemorrhagic disease (HDN), which can cause serious complications.
Breast milk is known to carry ‘low’ levels of vitamin K, which are not high enough to prevent HDN.
The babies most at risk from HDN are those who have traumatic births (clinically, this might include babies who are delivered by forceps, ventouse or emergency caesarean section, or babies who show bruising). The risk of a baby who is not given vitamin K, and has low risk factors, developing HDN is between 1 in 10,000 and 1 in 25,000 (Wickham, 2001). Babies who are at high risk of HDN can have a chance as high of 1 in 120.
Babies, who are born vaginally without undue trauma, are at the very lowest risk of developing HDN.However, there is still a risk that a baby who is born vaginally will develop HDN.
Some studies have found a possible link between intramuscular vitamin K and childhood cancer. This is not conclusive evidence (Wickham, 2001), and The National Health and Medical Research Council has looked carefully at these studies and other evidence, and has concluded that vitamin K is not associated with childhood cancer, whether it is given by injection or by mouth.
MAMA Says: In general, babies are born with pretty much everything they need. However, as we are unsure as to why some babies born without ‘risk factors’ still develop HDN, giving vitamin K to your newborn baby is a simple way of preventing a very serious disease.
For more information:
- Visit http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Vitamin_K_and_newborn_babies?open
- Vitamin K – An Alternative Perspective, by Midwife Sara Wickham, AIMS Journal, Summer 2001, Vol 13 No 2
- Visit https://www.nhmrc.gov.au/guidelines/publications/ch38
Hepatitis B Vaccine for the Newborn
Before or soon after you have your baby, your doctor or midwife will discuss Hepatitis B immunisation with you and will ask you to make a decision about whether you want your baby immunised. Hepatitis B is a serious disease that can be contracted throughout life. It is caused by a virus that affects the liver and can lead to liver cancer of liver failure later in life.
The Hepatitis B vaccine is an intramuscular injection given to babies after birth either within the first few hours or after a day or so. The baby will need three more doses of the hepatitis B vaccine to be fully immunised. These will be given at two, four and six months of age in combination with other routine childhood immunisations.
Common side effects of the Hepatitis B vaccine are
- Mild fever
- Joint pain
- Decreased interest in feeding in the first few days of life (www.health.vic.gov.au).
Whilst these common and perhaps transient side effects may be of little concern in an older child they are liable to be of much greater significance in a newborn baby who is already facing many challenges at this deeply important point in its life.
Challenges to the newborn include
- Adaptation to extra uterine life – profound physical changes in all systems respiratory, circulatory, neurological, sensory, digestive/alimentary
- Organisation of suck to enable feeding
- Overcoming effects of pharmacological substances used in labour, birth and postnatally
- Recovery from the traumatic effect of birth e.g. head moulding and other birth injury
All women are screened for Hepatitis B antenatally so that babes of positive mothers can receive both Immunoglobulin and vaccination at birth. This has been shown to be extremely effective in managing the risk of vertical (mother to baby) transmission.
The risk factors (for contracting the disease) are IV drug use, unsafe sexual practices and certain ethnic groups who have “high” endemnicity so may have a slightly elevated risk of transmission. These being Aboriginal, Torres Strait Islander and particular Asian groups (www.health.vic.gov.au).
The World Health Organisation (WHO) classifies Australia as a "low" risk for Hepatitis B with low endemnicity of <2%, transmission rates in infancy are "rare" and "infrequent" in childhood. The WHO recommendation is for universal Hepatitis B immunisation for “high” risk groups and the recommended program is for the full course of vaccination commencing after birth with the other three doses to follow.
If you are in the low risk group and would like to have your baby vaccinated against Hepatitis B consider delaying at a minimum of 24 hours post birth when your baby has stabilised or after a few days. Alternatively, if you have no risk factors and are not putting your baby into childcare within the first couple of months, consider delaying the first dose of the vaccine until your baby is two months old or later.
MAMA Says: A vaccination post birth is a big event for a newborn baby’s immune system. Research your risk factors and make an informed choice on if and when the best time for your baby to be vaccinated may be.
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Looking after yourself in the postnatal period
If you have had a tear of any sort, we recommend applying manuka honey to the tear. Manuka honey comes in different grades and has antiseptic and healing properties.
We may recommend you to apply ice to your perineum if there is swelling.
- Regularly use calendula or salt washes after using the toilet to keep the area clean and to aid healing
- Take arnica tablets or pillules regularly (see packet for usage instructions).
- If your perineum is causing a lot of discomfort, you can safely take paracetamol (panadol) and diclofenac (voltaren). Panadol and Voltaren work well in combination, and are both safe for breastfeeding.
- If you did not have stitches, we will discuss trying to minimize movement for the first week to aid healing.
- Newborns are usually nocturnal, that is, that they are mostly awake during the night. This is because your hormones for breastmilk production peak at this time, and your baby can sense this.
- Try to sleep during the day when your baby sleeps, knowing that it is normal for your baby to be awake at night time.
Food & Drink
- Try to eat regular nutritious meals after the birth of you baby. Breastfeeding uses up a lot of energy and it is important to replace this with a balanced diet.
- Your water requirements also increase when breastfeeding. The recommended intake is 3 Litres per day. Try to get in to the habit of having a glass or bottle of water next to you when you breastfeed your baby.
Pelvic Floor Exercises
Pelvic floor exercises are essential after pregnancy and birth, as there is always a degree of pelvic floor muscle weakness. One in four women who have had babies have problems with incontinence.
Only attempt to start these exercises when you feel up to it.