I suspect we underrate the negative impact of episiotomy scars.

My last post was about scar tissue after surgery and how it can cause real problems, both in the short and long term. I used the examples of an orthopaedic surgery scar and a Caesarean scar. Both of these are considered major surgery, and when you really stop to think about it, it makes sense that they require some rehabilitation. (As an aside, nutrition has a big impact on healing of scars, and should be a major focus in the first three months after any surgery).

But what about perineal scars from childbirth injury? These include scars from episiotomy, OASIS (obstetric anal sphincter injuries), and all types of tears to the vagina and perineum, whether first-, second-, third- or fourth-degree. Won’t these types of scars benefit from rehabilitation too? Of course they will – in fact, I think we need to be much more proactive about this.

When the obstetrician gives you your six-week postnatal “clearance”, this is just the beginning. In fact, many women see their GP and have no perineal or vaginal examination at their six-week check-up. If they do have an examination, the aim is to ensure healing is adequate and there are no signs of infection. This quick check is not designed to confirm your tissue is back to its fighting best!

Many women I see, when they see their doctor for their six-week check, have not started having penetrative intercourse again yet. This is perfectly natural; not everyone feels ready by this point. However, when they are given the “all-clear” by the doctor, it comes as a rude shock when they first try to have intercourse two, four or six weeks later – to find that it’s horribly painful and not at all what they were expecting.

For some women, this initial pain with penetrative intercourse eases up quickly; for others it is mild or not significant in the first place. However, for a significant number of women, this pain is severe, persistent and very disruptive of their intimate relationships.

Pain with sex after childbirth is quite common, and in a way should come as no surprise. Think about this: you break your ankle and it is immobilised for six weeks in a cast or moonboot. Finally the day comes when it can be taken off. With joy and enthusiasm you throw your weight onto it – in fact, you don’t just try to walk, but jump off a high step and throw yourself into an exuberant set of dance moves. OUCH! It’s excruciatingly painful, isn’t it? Of course it is. Your body is not designed to go from zero to a hundred in the blink of an eye after a significant injury.

Well, an episiotomy or perineal tear is a significant injury to your vulva. While it might be mild and you get away with token, short-lived discomfort, you may be like many women I see for whom it is actually quite a hard road back to enjoyable, pain-free intercourse. I often describe penetrative sex to women as being what a marathon run is to an ankle sprain. You wouldn’t jump straight into a marathon once your ankle sprain heals! But for some reason, women expect (or society expects us!) to be straight up for sex after the perineum heals postpartum. As I mentioned, some women have no ongoing problems. But if you find that the low-level discomfort (or strong pain) doesn’t get better and better each time you try, you need to get going with some perineal rehab!

The longer you leave this, the harder it is. A number of women I have seen with post-partum vulval pain and painful sex were so sensitive in the area of the scar they could barely stand light touch, let alone entry of their partner’s penis. This is more likely to occur the longer you leave it, and may involve sensitisation of the nervous system (where the brain, spinal cord and nerves become hypersensitive to touch and normal sensations become interpreted as pain: this is called central sensitisation). The pelvic floor muscles become both tight/overactive and weak – not a good combination!

A good way to start to help this is some nice perineal massage daily with olive oil, coconut, apricot kernel oil or jojoba oil. You can do this yourself, and if you like, progress to allow your partner to do it. (You may need to have an agreement that nothing sexual proceeds from this, unless you yourself wish to initiate it.) If this does the trick, that’s fine. However, often more specific therapeutic input is required. A physiotherapist trained in connective tissue mobilisation and myofascial release can help your vulva and vagina restore its natural movement, flexibility and sensation. This requires specific training, and it’s worth enquiring of your physiotherapist whether they have this specific set of skills. With the right type of therapy, you can get back your good health in this area, get rid of pain, and restore the quality to your sexual experience. Contact me to get help for this.

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