Physical Therapy for Episiotomy and Perineal Tears
A perineal tear or an episiotomy during childbirth can lead to pelvic floor dysfunction, urinary or fecal incontinence, and painful sex. An episiotomy is a surgical incision of the perineum to make more space for the baby, while a perineal tear involves natural stretching or tearing of the perineum, the area between the vagina and anus, during birth. Physical therapy is an effective treatment for perineal tearing or an episiotomy, using pelvic floor rehabilitation to restore function and strength to the pelvic floor muscles and address pain and incontinence. Mangiarelli Rehabilitation physical therapist Jen explains what an episiotomy is and how physical therapy can help you heal after an episiotomy or perineal tear.
What is an Episiotomy or a Perineal Tear?
A perineal tear involves stretching and tearing of the perineum, the area between the vagina and the anus, during vaginal birth. Nearly 85% of women experience some perineal stretching and tearing during childbirth. There are four degrees of perineal tears. The first degree involves injury to the perineal skin and vaginal epithelium only, while the second-degree tear is an injury that extends into the fascia and muscles of the perineum. The risk of a first- or second-degree tear is heightened by a forceps delivery, a baby over 8.8 pounds, a prolonged second stage of labor, and the older age of the mother.
A third-degree tear involves injury through the muscles and fascia of the perineum as well as the anal sphincter complex. A fourth-degree tear is an injury to the perineal fascia and muscles, the external and internal anal sphincters, and the anal epithelium. Third- or fourth-degree tears are less common and are associated with the low-squatting birth position and vacuum extraction. These types of tears can require stitching to properly heal. If you do incur a tear of this level during your first delivery, this can increase the risk of a third- or fourth-degree tear during a second delivery.
An episiotomy, on the other hand, is a surgical incision in the perineum made by the doctor with the intent to provide more space for the baby to exit the birth canal. An episiotomy is a second-degree perineal tear. Episiotomies used to be a routine part of giving birth, but now the procedure is only performed in special circumstances: if the baby’s heart slows or speeds up significantly during birth indicating distress or lack of oxygen, or if the baby’s shoulder gets stuck in the birth canal (shoulder dystocia).
Whether an episiotomy is performed, or perineal tearing occurs naturally during birth, there is a significant risk of scar tissue developing in the perineal area. After laceration and repair, scar tissue and adhesions can form within the perineum and pelvic floor muscles. While this is a normal part of the healing process, the scar tissue can impede normal pelvic floor muscle strength, flexibility, and function. This can lead to urinary or fecal incontinence, painful or urgent bowel movements, painful sex, and pain and weakness in the pelvic floor. It can also cause a hypersensitivity of the nerves of the perineal and vaginal area.
Common symptoms after an episiotomy or perineal tearing include pain, swelling, redness, and bleeding in the perineal area; discomfort moving around and during daily tasks; dyspareunia (pain with sexual intercourse); pelvic organ prolapse; and urinary or fecal incontinence.
Physical Therapy for an Episiotomy or Perineal Tear
Physical therapy is an effective treatment for perineal tearing or an episiotomy, using pelvic floor rehabilitation to restore function and strength to the pelvic floor muscles. Pelvic floor rehabilitation helps to address issues of pain during sex, pelvic floor pain and weakness, and urinary and fecal incontinence through a variety of treatments. According to a study published in 2017, women who participated in a pelvic floor training program had lower rates of both episiotomies and perineal tearing during the birth process. The program involved pelvic floor exercises and perineal massaging.
Pelvic floor rehabilitation can include pain management using ice or heat; scar massage, myofascial release, and manual therapy to areas that are restricted or painful in the pelvic floor; retraining of the core and hip muscles; neuromuscular reeducation; targeted strengthening of the pelvic floor, starting with diaphragmatic breathing and Kegel exercises; and sensory, motor, sympathetic, and parasympathetic nerve re-training.
To minimize pain during the first week of healing, you can sit on ice, elevate your feet to reduce pressure on the perineum, and begin gentle diaphragmatic breathing. You can then move on to walking to enhance circulation for tissue healing with a low impact on the perineum during week two of healing. During week three post-delivery, you can begin physical therapy for pelvic floor rehabilitation to restore function and strength to the pelvic floor, minimize perineal pain, and address lingering symptoms.
Mangiarelli Rehabilitation physical therapist Jen explains what an episiotomy is and how physical therapy can help you heal after an episiotomy or perineal tear.
