Most women experience some sort of perineal trauma during and after childbirth, especially during the birth of their first child. The trauma can vary from excessive stretching, bruising and grazing to more severe tearing which can extend deeper through the muscle layers of the vagina, even into the anus.
This article will discuss the childbirth-related causes of perineal pain, its symptoms and how to relieve the pain.
What is the perineum?
The perineum is the soft area between the vaginal opening and the anus. It’s made up of skin, connective tissues and muscles; and provides anchorage and support for the pelvic floor as well as the bladder, uterus and the anus.
What is perineum pain?
Although perineal pain can affect both men and women, it is most experienced in women after childbirth.
Why is the perineum important during delivery?
During childbirth, the perineum needs to relax and slowly stretch to allow the baby’s head to pass through the vagina. Stretching during crowning can increase the length of the perineum by 50% vertically and 170% horizontally.1
The perineum can tear during the birthing process, or it may be an episiotomy is clinically required. An episiotomy is an incision made into the perineal tissue in order to facilitate a more rapid delivery. As healing takes place, perineal pain can be experienced. For many women, this pain and discomfort will only last a few weeks post-birth and they will heal quickly. However, for some women, this can lead to stress incontinence (leaking urine when coughing, sneezing and laughing), painful sex and in a small number of women, pelvic prolapse. If pain is ongoing and causing distress, it’s important to trust your instincts and speak to your healthcare provider.
What can cause pain in the perineum?
There are several childbirth causes attached to pain in the perineum. From natural tears on the vaginal lining to tears deep into the vaginal muscles, reaching the anus.
Other procedures and diagnoses such as episiotomy, pudendal nerve entrapment, pelvic floor dysfunction and haemorrhoids can all be a result of childbirth and cause perineal pain. So, let’s discuss these injuries in more detail.
Perineal tears during childbirth
Women’s experience of pain does not necessarily reflect the severity or extent of the trauma sustained. For each woman and each birth, this experience will be different ranging from a burning sensation to difficulty in walking, with pain lasting a few days to months.
First and Second Degree Tears
1st degree tears are small scars or grazes affecting only the skin. They usually heal quickly and without treatment.
2nd degree tears involve both skin and perineal muscle. These types of tears usually require stitches and a slightly longer recovery time.
How painful are perineal stitches?
You may feel discomfort and pain after experiencing a perineal tear, with soreness usually lasting 2 to 3 weeks. The area is likely to feel tender and may have a throbbing sensation. Perineal stitches take 1 to 2 weeks to dissolve so you don’t have to get them removed by a doctor.
It’s important to note that many vaginal tears will be 1st or 2nd degree tears, and they should heal without any problems and within a short time period.
Good hygiene is important so it may be helpful to use a perineal wash bottle to keep the area clean. Wash or shower at least once a day and change sanitary pads regularly.
Women may experience pain, swelling and discomfort afterwards, but treatments like cold therapy, a numbing pain relief spray, or a sitz bath should bring soothing relief, and recovery is typically straightforward.Third and Fourth Degree Tears
A small subset of women, around 3%-5% having a vaginal birth, will have more severe 3rd and 4th degree tears, commonly known as obstetric anal sphincter injuries (OASIS).
A 3rd degree tear means the tear has extended through the skin and into the muscles that surrounds the anus, known as the anal sphincter complex.
4th degree tears are the most severe tears and the least common.
3rd and 4th degree tears require a more involved surgical repair and recovery time will be longer. After 3rd and 4th degree tears are repaired and given time to heal, most women make a good recovery. 60 to 80% of women report having no symptoms a year after birth.
It should be noted, 3rd and 4th degree tears are a leading risk factor for loss of bowel control, as well as pelvic floor dysfunction and prolapse, so it’s important to keep up with all postpartum visits to ensure a healthy recovery and protect your future wellbeing. Your later self will thank you.
Do you feel it when you tear during birth?
Because your perineum is under so much pressure during childbirth, you may not actually notice if you tear. If you do tear, a healthcare professional will know and make sure you receive the care you need.
How to prevent tearing during birth
Perineal massage is recommended prior to giving birth to prevent a tear. You should do a perineal massage from 35 weeks pregnant onwards. Massaging this area is thought to make it more flexible so that it can stretch more easily during labour.
The pudendal nerve is one of the primary nerves of the pelvis travelling to the perineum, rectum, lower buttocks and vaginal area.
Pudendal neuralgia is pain originating from the pudendal nerve. Pudendal nerve damage can occur following birth due to stretching and compression of this nerve, typically during the pushing phase of labour as the baby's head stretches the muscles of the pelvic floor. This can result in long-term pelvic pain.
The primary symptom of nerve entrapment is constant or intermittent pain in your pelvic region, including the perineum, vulva and rectum.
The onset of pain can be gradual or sudden with a burning or prickling sensation.
If you suspect you have Pudendal Neuralgia, it is important to seek medical advice on how to manage pain. Take steps to avoid becoming constipated or straining to use the toilet, eating foods high in fibre, such as fruit and vegetables, wholemeal bread, bran, and drink plenty of water.
An Episiotomy is a surgical cut made in the perineum and vaginal walls to make the vaginal opening slightly wider for the baby’s head to come through more easily. An episiotomy can help speed up delivery if the baby needs to be born quickly or to prevent larger tears that may happen during delivery.
Healing time can take up to a month including time for stitches to dissolve. It is important to give your body time to recover and heal. Having a close support network including family and friends is useful to help with daily physical tasks and providing emotional support.
Pelvic floor dysfunction
Pelvic floor dysfunction occurs when the pelvic muscles lose their integrity and normal coordination. This can occur at various points during childbearing, as hormonal and physiological changes during pregnancy put additional pressure on the pelvic floor.
Weight gained during pregnancy and pushing during delivery can weaken and stretch the muscles. This is completely normal, the body’s way of adapting and allowing the baby to pass out of the vagina. This does not only cause pain in the perineum, but it also results in pain in the lower back, bladder incontinence and pain and discomfort during intercourse.
Pelvic floor exercises are recommended throughout pregnancy to improve muscle tone, which can help to prevent damage and discomfort. If injury has been sustained, these can also help to relieve pain and improve function.
Haemorrhoids are swollen blood vessels in the anus which can be caused by excessive pushing during childbirth. They can put pressure on the perineum, resulting in pain that travels to the rectum. The perineal pain can get worse during or right after a bowel movement.
Haemorrhoids are typically self-resolving and very rarely need surgical intervention. Self-managing symptoms can alleviate discomfort – such as a high fibre diet, increasing fluid intake, water immersion, and localised cooling methods.
The pain can be relieved using haemorrhoid wipes to soothe and clean the area. Using a cream or soaking the area in a sitz bath after bowel movements can also provide some relief.
How to ease pain in your perineum
Whether your perineal pain is caused by natural tears or pelvic floor dysfunction, rest assured that it can be relieved using a few different methods. Test which one works best for you or consult a doctor if you’re getting severe pain with fever, as this may be a sign of an infection.
You can relieve pain in your perineum by:
- Taking regular baths – warm baths can relax your muscles providing temporary pain relief. If you don’t want to take a full bath, we recommend investing in a sitz .
- Using cold packs on your perineal area – Lansinoh’s post-birth relief pad can provide relief from perineal, haemorrhoidal and C-section pain.
- Using a post-birth water bottle for gentle cleansing of the perineal area
- Pain relief sprays – make sure to invest in an organic spray suitable for sensitive skin.
- Over the counter pain killers – provide short-term relief for severe pain.
- Pelvic floor physical therapy to manage chronic pelvic .
Overall, there are many possible causes for pain in the perineum and the good news is that they can be relieved by the measures listed above. Minor injuries or natural tears can heal on their own. More painful symptoms such as pelvic floor dysfunction and Haemorrhoids, can be treated by healthcare professionals with the appropriate care in place. Self-care is also important such as doing pelvic floor strengthening exercises regularly, relaxation techniques and eating a healthy diet can often improve everyday life.
However, if you feel the pain is worsening or if you are concerned and notice any other symptoms alongside the pain, such as fever, an unpleasant odour or discharge from the wound, or bleeding, contact your health care provider/professional immediately. The more honest and open you are when describing your symptoms, the sooner the right treatment can be recommended.
 BECKMANN MM and STOCK OM (2013) Antenatal perineal massage for reducing perineal trauma. Cochrane Database Syst Rev 2013, Issue 4. Art. No.: CD005123. Available at: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005123.pub3/full