In this blog for women preparing for, or after, childbirth, Jennifer Hanratty looks at what research tells us about what might help for perineal pain, and shares her own experience as a new mum.
I had a plan. I had a well-researched and referenced plan. I wasn’t going to be induced. I was going to have a peaceful hypnobirth in water. No episiotomy for me. No intervention required thank you. I got this…
…until 14 days after my estimated due date, feeling bullied and vulnerable I tearfully agreed to have labour induced. The pessary did the trick and all was calmly proceeding until a last minute scramble out of the lovely midwife-led suite, away from the unused birthing pool, up in the lift to the labour ward. My husband, to his eternal credit, tried to object when an episiotomy was suggested. In that moment all I wanted was for everyone to leave me alone and if an episiotomy would get rid of this lovely team of medics quicker then so be it. So my journey into motherhood began with a bruised, torn, cut and stitched perineum.
The perineum and childbirth
If you are unfamiliar with the perineum it is the diamond shaped bit of skin and muscle in between the vagina and the anus. It’s the bit that will (brace yourselves ladies) often tear and occasionally be cut (an episiotomy) during a vaginal birth to allow baby to emerge into the world. There are varying degrees of damage ranging from bruising and small tears that heal on their own through to serious 4th degree tears that require surgical repair, thankfully these are rare.
Many women who give birth vaginally will suffer some form of perineal pain in the postpartum (after birth) period, even those lucky few with no tear. In the days after birth with so much going on with your body and the small person that came out of it, we will want to manage that pain.
But what forms of pain relief work best? Which are easiest on our amazing and exhausted postpartum bodies? Which can be taken safely while breastfeeding? Can different forms of pain relief be safely combined? These are the questions I had when approaching a series of three Cochrane systematic reviews on managing perineal pain, using aspirin (Molakatalla et al, 2017), paracetamol (Chou et al, 2013), or non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (Wuytack et al, 2016).
Painkillers for perineal pain: effective and safe?
The findings of these were that paracetamol probably provides adequate pain relief and probably reduced the need for additional pain relief 4-8 hours later. Both aspirin and NSAIDs may provide adequate pain relief and may reduce need for additional pain relief four hours later when compared to placebo, but trials were low quality and poorly reported. Crucially, those who were breastfeeding were excluded from trials of aspirin and NSAIDs. This evidence therefore doesn’t apply to the roughly 81% of women who initiate breastfeeding within the first hour of birth (McAndrew et al., 2012). We don’t know if aspirin or NSAIDs are safe or effective for the majority of women and their babies.
No trials in any of the three reviews reported neonatal outcomes and none reported on safety for breastfeeding mothers, impacts on breastfeeding, post-partum depression, prolonged perineal pain or acceptability of the drugs. That’s a lot of important questions that remain unanswered. We need to know what is safe for breastfeeding mothers to remove any barriers to successfully initiating and maintaining breastfeeding. Have you tried breastfeeding round the clock when you can’t get comfortable sitting down? Or even simply sitting up to lift baby in and out of their safe sleeping space (UNICEF) in or beside your bed? It’s not easy.
Alternatives to drugs to relieve perineal pain
My other question is what non-drug options are there for pain relief? Well, cooling the area with ice-packs, cooled gel pads or sitting in an ice bath (shudder) may relieve perineal pain (East et al, 2012). I almost hugged my midwife when she produced a bowl of gauze pads soaked in water and witch hazel from the fridge, oh the relief.
A safe alternative to taking the drugs is doing nothing more than getting a comfortable position. My go to daytime position was reclined on the sofa with feet up on a footstool or a big gym ball to relieve the pressure on the area. A comfy position is especially important for cluster feeding when baby wants to be latched on for hours in the evenings. Mastering laid back feeding (video here) and side lying feeding is also a godsend to get more rest. Although side lying feeding can end up replacing the pain in your perineum with pain in the neck and shoulders, so try to take a moment to get yourself comfy before latching baby.
Another vital part of a new Mum’s toolkit for dealing with perineal pain is to have someone at home who can bring you water, snacks and the remote control so you don’t have to move once you get situated. Toddlers are good at this and it helps them feel involved. Change maternity pads frequently to reduce risk of infection. Supporting the area while going to the loo can give you confidence if you’re worried about stitches tearing. Stay in your PJs or a comfy nightdress for the first few days to minimise irritation to the area. Don’t be getting dressed for the midwife or health visitor, they’ll understand you’ve got bigger priorities.
If you do need pain relief check what is safe for you and your baby in the post-partum period before taking it https://www.breastfeedingnetwork.org.uk/wp-content/dibm/analgesics.pdf. Information for GPs on safety of medications while breastfeeding and other very useful resources for HCPs to support women in their feeding choices can be found here https://gpifn.org.uk/ .
Preventing perineal pain
If you’re currently expecting (or indeed supporting women in labour) then really prevention is better than cure in this case. A number of methods have been identified as effective for reducing the risk of perineal trauma and episiotomy, during vagina birth.
Perineal massage reduces risk and degree of tear and episiotomy, with a clear benefit for first time mothers in particular (Beckmann & Stock, 2013). Perineal massage, undertaken by the woman or her partner, for as little as once or twice a week from 35 weeks can be effective.
Perineal support during second stage labour (the pushing part) with a warm compress is effective (Aasheim et al, 2011) and frankly sounds quite pleasant to me. Perineal massage during second stage labour can also reduce 3rd and 4th degree tearing, but not quite so appealing as a nice warm compress. Episiotomy is routinely practiced and may not actually be necessary (I really wish I’d listen to my husband). Routine episiotomy is not recommended and a selective episiotomy policy will result in fewer women with severe perineal/vaginal trauma (Jiang et al, 2017). Finally, birthing in an upright position, like on hands and knees, may help reduce perineal trauma compared to lying on your back (Gupta et al, 2012).
We deserve better…
I felt like applauding (ok I admit I clapped at my laptop) when reading Chou et al’s conclusion that “Perineal pain following childbirth …suffers from lack of research and clinical attention while remaining a major focus for mothers and their families.” They are absolutely right. This is really important. It really hurts. It really can interfere with a person’s wellbeing, at a time when they are already vulnerable, exhausted and often overwhelmed. We deserve better than poorly conducted, badly reported trials that are irrelevant to most of us.
Jennifer Hanratty has nothing to disclose. Views are Jennifer’s own.
References may be found here.