A guide for episiotomy and perineal scar tissue massage

The perineum is between the vaginal opening and the anus. It is the area covering the superficial pelvic floor muscles, nerves, and blood vessels. 

Perineal tearing/trauma refers to the spontaneous tearing of the perineum during vaginal delivery, as the head and shoulders are born. An ‘episiotomy’ is when your health care provider does a preventive cut in the perineum to allow more room for baby to pass through or in an effort to prevent further tearing. 

There are four grades of perineal tears: 

• First degree: injury to perineal skin and/or vaginal mucosa
• Second degree: injury to perineum involving perineal muscles, but not involving the anal sphincter*
• Third degree: injury to perineum involving the anal sphincter complex. This is then further subdivided into: 
• 3A: where <50% of the external anal sphincter is torn 
• 3B: where >50% of the external anal sphincter (EAS) is torn
• 3C: where the external and internal anal sphincters (EAS and IAS) are torn
• Fourth degree: injury to perineum involving the anal sphincter complex (EAS and IAS) and anorectal mucosa**.

*Anal sphincter: a group of muscles at the end of the rectum that surrounds the anus and controls the release of faeces, thereby controlling incontinence.
**Anorectal mucosa, also known as rectal mucosa: anus/ rectum moist inner lining.

 

It is important to know that overall, perineal tears are quite common and most heal well without complications. Third or fourth degree tears are less common, for Australian women this is a frequency of around 3% in all vaginal births and 5% for first vaginal births. 

Risk factors for a third and fourth degree tear:

• First vaginal delivery
• Women of south Asian ethnicity
• <20 years of age 
• Shortened perineal length (<2.5cm)
• High baby birth weight >4kg
• Instrumental vaginal delivery (e.g. forceps, vacuum) 
• Persistent Occiput posterior (OP) position (the back of baby's skull or the occipital bone) is in the back (or posterior) of mums pelvis
• Shoulder dystocia (baby’s shoulder gets stuck)
• Prolonged second stage (pushing stage) of labour (> 60 minutes)
• Absence of epidural pain relief 
• Oxytocin use (induced labour or oxytocin drip to increase contractions)
• Midline episiotomy (as opposed to medio-lateral) 
• Delivery in stirrups (lithotomy) or deep squatting position
  
  
  

Why do perineal scar massage? 

When scar tissue heals it can often be sensitive and tight, which may give you some discomfort or pain, including during activities like intercourse. Even if your scar isn’t painful, scar tissue often lacks mobility, so providing it with some gentle stretching can help it to regain some of its elasticity. 

 

When to start scar tissue massage?

Perineal massage should only be started once your care provider has given you the “all clear” to have sex or to start massage (normally after 6 weeks). You need to ensure that your scar tissue has closed and healed well prior to starting. 

How to do it? 

• Normally this is best done after a shower and lying on your back in bed
• Wash your hands and get some good quality water based lubricating gel or vaginal moisturiser. 
• Choose your select dilator from the BIEN Silicone Dilator range. Size 3 (the first dilator in the medium set) is often a good place to start.
• Insert your chosen dilator into the vagina taking deep breaths as you do. Initially this might provide quite a strong stretch to the vaginal opening, if this is the case leave the dilator in the vagina for 2-5 minutes and focus on deep breathing and relaxation. 
• Once you are comfortable you can then progress to applying some pressure at the base of the vaginal opening and drawing a U shape, starting at the bottom of the vagina. 
• You can then twist the dilator in a clockwise and anticlockwise direction, putting as little or as much pressure as tolerable into the base of the vaginal opening. 
• Whilst completing this your pain levels shouldn’t be over a 4/10 – where 10 is the worst pain imaginable and 0 is no pain at all. 
• Spend 2-5 minutes every other day doing these techniques and gradually increasing in dilator size until the largest size doesn’t provide you any pain or discomfort.
• Prior to returning to sexual intercourse, you may wish to get your partner to use the dilators on you, to ensure you feel safe and comfortable with somebody else having control over the pressure and movement of the dilator. If this doesn’t provide you with any discomfort, then you can comfortably transition to intercourse – using lots of lubrication and foreplay. See here for our guide on returning to sex after a baby. 

If your symptoms persist or if you experience any burning, stinging, or spotting after sex postnatally, please consult your local pelvic floor physiotherapist or GP. 

NOTE: This is general advice only and should not replace medical advice. If you have any concerns or are unsure if you have any contraindications to perineal massage, please speak to your health care provider.