Postpartum Perineal Care

The perineal area needs extra care to heal after childbirth, including cool sitz baths to reduce swelling and speed healing.

The perineum is the anatomic area between the urethra, the tube that carries urine from the bladder, and the anus. In women, the perineum includes the vaginal opening. This area undergoes a lot of stress and change during pregnancy and delivery, and it needs special care afterward.

Some women have a surgical cut called an episiotomy when they deliver a baby. It is sometimes done to speed up a delivery. An episiotomy is a clean cut, rather than a tear, so it may heal better. Sometimes the skin tears anyway and needs suturing.

Some women perform perineal massage during their pregnancy to try to prevent some of the pain and other problems after delivery. This method has not been shown to lessen or prevent any of the symptoms experienced after delivery.

Injury to the vagina and the perineum during delivery may cause swelling, bruising, or a collection of blood under the skin called a hematoma. Any of these injuries can cause severe pain.

• Small hematomas usually go away without treatment. Painful, large hematomas may need drainage of the blood that collects in them. If a lot of tissue swelling occurs around the urethra, urinating may be difficult. If this happens, a small tube called a catheter can be put into the bladder until urination is possible.
• Lacerations are tears in the tissues. They may be repaired by suturing or sewing, but small ones will heal with normal care.
• As the episiotomy heals, it forms a scar. Women who have episiotomies should be careful to avoid opening the wound while it heals.
• After the baby is born, a discharge called lochia (pronounced LOE-kee-uh) will drain from the vagina. At first, this lochia will look red, because blood is mixed with it. As the woman heals, the lochia will become white or even clear, like mucus.

After delivering the baby, the perineum must be kept clean. Lochia may drain for up to four weeks, so pads should be changed frequently.

• Do not use tampons after delivery. Tampons may cause an infection.
• Take a bath or a shower once or twice daily. A sitz bath can be used after every bowel movement. A sitz bath involves sitting in shallow water, only deep enough to cover the hips and buttocks.
• Urinating can be painful after delivery. Squirting warm water over the perineum during urination may ease the pain. When finished urinating, gently pat the perineum dry.
• Cold sitz baths help reduce swelling and discomfort after delivery. Sit in a lukewarm or room temperature bath, and then gradually add ice cubes to the water. This prevents the uncomfortable, sudden sensation of ice water on the skin. Soak for 20 minutes at a time, up to three to four times a day. After the first two to three days, warm sitz baths will improve blood flow to the perineum. Check with your physician before adding medications such as epsom salts to the bath. An alternative may be ice placed in a sealed plastic bag.
• Hemorrhoids are enlarged veins in the wall of the anus. They frequently occur during pregnancy and often go away without treatment after delivery. Hemorrhoids may bleed after bowel movements. If the hemorrhoids are painful, steroid suppositories may lessen the discomfort.
• Stay well hydrated by drinking plenty of water. Straining with bowel movements will stretch the episiotomy scar and perineum and can cause pain. Avoid constipation by eating fiber-rich foods such as fresh fruits and vegetables. If you do get constipated, you can gently push up on your perineum as you bear down gently.
• Using an inflatable “doughnut” cushion when sitting or lying down may help reduce pull on the episiotomy scar.
• Kegel exercises strengthen and tone pelvic muscles and lessen perineal pain. Kegel exercises are small movements of the vaginal muscles similar to the movement you make if you are trying to stop urinating.
• If you are not allergic to acetaminophen (Tylenol) or ibuprofen (Motrin), you can take them to help control your pain. Both drugs are safe for a mother who is breastfeeding. Ibuprofen in particular is very helpful for episiotomy pain and postpartum uterine pain.
• Avoid sexual intercourse until you have no more perineal pain. Most health care providers recommend pelvic rest until four weeks after delivery, but there are no clear guidelines. If you need to use a lubricant for sex, make sure it is water-soluble.

If you have recently delivered a baby, call your doctor if any of the following symptoms occur:

• Bad-smelling discharge from your vagina
• Burning pain with urination
• Passing urine more frequently than usual
• Urge to pass urine frequently, but only going a small amount
• Vaginal bleeding, like spotting
• Severe pain in your perineum, pelvis, or lower abdomen
• High fever when you are not sick otherwise
• Passing gas or stool through the vagina
• Passing sutures or sponges
• Blistering or herpes outbreaks

If you have recently delivered a baby, go to the hospital if any of the following symptoms occur:

• High fever
• Nausea and vomiting
• Severe abdominal or pelvic pain
• Heavy vaginal bleeding (soaking through more than one pad every hour)

See your doctor for a check-up about four to six weeks after delivery. Expect to receive a full physical examination, including pelvic, rectal, and breast examinations. Call your doctor sooner if you have any questions or concerns.

For problems after childbirth, your doctor will give you a thorough physical examination, including a pelvic examination and a rectal examination.

• Blood or urine tests may be done. A sample of abnormal discharge may be sent to a laboratory for cultures or other studies.
• If an infection occurs from the episiotomy stitches, the stitches may be removed so the infection can drain.
• If a blood collection is present, such as a hematoma, it may be opened and allowed to drain.
• If the rectal exam shows infected or clotted hemorrhoids, they will be opened and allowed to drain.
• Depending on the type of infection, antibiotics may or may not be given. Not all infections need antibiotics to get better.
• If the physical exam is painful or leaves you with pain, you should ask for medicine to relieve the pain.

Most changes that happen to the woman during and after delivery are normal and natural. After delivery of a baby, many women initially are not able to move around as easily or comfortably as before the delivery. Women gradually get back to their prepregnancy state, but the healing process takes several weeks.