Episiotomy rates continue to decline in the US today, but prior to the American College of Obstetricians and Gynecologist’s 2006 Official Statement on Restricting Use of Episiotomy, episiotomies were common practice. ACOG’s statement included this admission, “The best available data do not support the liberal or routine use of episiotomy. Nonetheless, there is a place for episiotomy for maternal or fetal indications such as avoiding severe maternal lacerations or facilitating or expediting difficult deliveries.” Frankman et al (2009) in the American Journal of Obstetrics and Gynecology reported “the rate of episiotomy with all vaginal deliveries decreased from 60.9% in 1979 to 24.5% in 2004.”
This is progress in the right direction, but despite the improved practice of avoiding episiotomies, there is still a generation of women, past and present, who are severely affected by perineal trauma during childbirth. A 2005 study in the Journal of the American Medical Association showed midwives, who generally perform fewer interventions, have episiotomy rates in the U.S. are at or below 3 percent. Read statistics and personal stories about episiotomies.
Regardless of whether you had an episiotomy or a tear, long-term pain that results from it can be preventable. Back pain, pelvic pain, and sexual dysfunction result from C-section or episiotomy scars. And although the standard of care after birth in many European countries includes physical therapy in the post-partum, there is no such “standard of care” in the US. This needs to change. If every new mom received PT, I believe we would see a large decrease in postpartum and long-term pelvic pain. See this post on how prenatal perineal massage helped a mom birth easier
If You Don’t Ask, You (Often) Don’t Get
If you have had an episiotomy or tearing during childbirth, or if you have had a C-section, you will most likely have to ask to receive women’s health physical therapy. In other words, you have to be your own patient advocate. Until health care delivery improves in the US, the default setting (unlike in other countries) is “doctor knows best.” This is not always true.
The ideal doctor-patient relationship, says Haidet, is like a meeting of two “experts,” says Dr. Paul Haidet, staff physician at the DeBakey VA Medical Center, in Houston. “The doctor comes to the meeting with medical expertise. The patient is entering with contextual knowledge, what these symptoms mean in the broader context of my life, and what kinds of therapies that broader context is going to support,” Haidet reported in a recent article with Web MD.
Being your own best advocate means your physician should listen to your concerns, while you should also take care to listen to what your body is trying to tell you.
In the case of episiotomy or perineal pain from tearing during childbirth, you may notice pelvic pain, bladder leakage, sexual dysfunction (which can include painful intercourse), back pain, or pain with exercise.
If you notice any of these issues, this is a red flag and you should see your physician to discuss the problem. Conservative treatment should include seeing a women’s health physical therapist, who can evaluate and treat pelvic pain and scar adhesions.
The “How To” of Perineal Massage
The following links may help you identify and manage pain and scarring from birth trauma. You can use the perineal massage links as a guide for massaging your perineal scar. The massage can also used during the last few weeks of pregnancy to prepare the perineum for childbirth by teaching conscious relaxation, control of the pelvic floor, and to provide stretch to the surrounding tissues.
- Perineal Massage during pregnancy
- Oxford University Hospital Antenatal Perineal Massage
- Mater Mother’s Hospital, Australia – What is Perineal Massage
- Postpartum perineal massage is found, along with many other resources and tips in Kathe Wallace’s book – Reviving Your Sex Life After Childbirth
- Postpartum perineal massage – by Isa Herrara
- Internal Pelvic Floor Self-Massage Guide by Amy Stein
The link below illustrates how to massage a C-section scar. It may be more difficult to self-massage the perineum, but it is not impossible. You can also have your partner help if the area is difficult to reach. Although this video shows C-section massage, you can apply the three-layer technique to the pelvic floor as well.
Guidelines for Scar Massage
- Be gentle. In the perineal area, there may be pain and discomfort associated with the scar. Discontinue the massage and seek your physician and/or physical therapist’s recommendations before resuming.
- Wash your hands well and keep your fingernails short.
- All massage should be performed slowly, holding the tension in the area until you feel a release.
- Follow the instructions included in the Perineal and Scar Massage links.
Seeking a women’s health physical therapist in your area, in conjunction with your physician, can provide the best outcome for your pelvic pain.
For pelvic health professionals – Pelvic health handouts and more resources can be found at The Pelvic Health Handout Project, curated by physical therapist and pelvic guru founder, Tracy Sher.
This post is not a substitute for medical care or advice. You should always consult with your physician and physical therapist before starting this or any integrative medicine program.