Physical Therapy for Perineal Tears

A perineal tear during childbirth is common during vaginal delivery, involving stretching or tearing of the perineum, the area between the vagina and anus. Perineal tears can lead to pelvic floor dysfunction, urinary or fecal incontinence, and painful sex. The risk of suffering a perineal tear is heightened if you are a first-time mom, had prolonged pushing during labor, delivered a large baby, used forceps during delivery, or if mom is of an older maternal age. Pelvic floor therapy with a physical therapist is one of the most effective and efficient ways to treat perineal pain after childbirth and restore function and strength to the pelvic floor muscles.

Perineal Tears & Childbirth

A perineal tear involves stretching or tearing of the perineum, which is the area between the vagina and the anus, during a vaginal birth. Up to 85% of women experience some kind of perineal injury during vaginal childbirth.  A 2020 review found that of those women experiencing perineal trauma during childbirth, up to 55% continued to experience pain three months postpartum.

Factors that can increase the risk of a perineal tear include:

• First time moms giving birth vaginally

• Prolonged pushing during labor

• A larger baby (over 8.8 pounds)

• The delivery position of the baby

• Use of forceps during delivery

• Episiotomy, an incision made in the perineum to assist with delivery

• Holding breath while pushing, which tightens the pelvic floor muscles rather than lengthening them to stretch

• Older maternal age

Perineal tears are categorized into four types of tears based on severity. First and second-degree perineal tears are less severe, more common, and are limited to the tissues of the vagina, whereas third-and-fourth degree tears are more rare but cause more severe damage to the tissues and muscles of the vagina and anus.

• 1st degree perineal tear: injury to the perineal skin and vaginal epithelium only

• 2nd degree perineal tear: injury that extends into fascia and muscles of the perineum

• 3rd degree perineal tear: injury of the muscles and fascia of the perineum and external anal sphincter complex (EAS complex)

• 4th degree perineal tear: injury to the perineal fascia and muscles and both the external and internal anal sphincters and anal epithelium

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After experiencing a perineal tear, a woman may experience pain, swelling, redness, and bleeding in the perineal area; discomfort moving and during daily tasks; dyspareunia (pain during intercourse); pelvic organ prolapse; and urinary or fecal incontinence. After a perineal tear occurs, the body’s natural response is to form scar tissue where tissues have torn, which can impede normal pelvic floor muscles strength, flexibility, and function.  If a severe tear occurs, the doctor may stich the tear at the time of delivery.

Healing after a Perineal Tear

After a vaginal delivery and perineal tear, it is essential to avoid activities that place excess pressure on the healing tissues, such as straining and heavy lifting, and support the healing process of the perineum. During the first week post-tear, the perineum may be red, swollen, and tender. Women are advised to rest and use ice and gentle compression on the vaginal area. Gentle exercises like walking or ankle pumps can help promote circulation and healing and gentle diaphragmatic breathing can also help pelvic floor muscles relax and lengthen, rather than tighten in response to pain.

During the second, third-, and fourth-week post-birth and tear, women are advised to continue rest, ice, and compression on the vaginal area as well as diaphragmatic breathing and gentle low-impact aerobic exercise such as a daily walk to enhance circulation for tissue healing.

After week four and beyond, continue to engage in rest, ice, and compression and aerobic exercise. However, if pain continues to persist, consult with a physical therapist and begin pelvic floor therapy to strengthen and relax the pelvic floor and address any lingering symptoms. A physical therapist can also teach patients how to do perineal scar massage to reduce pain in the perineal area.

Physical Therapy for Perineal Tears

Pelvic floor therapy is one of the most effective and efficient ways to treat perineal pain after childbirth and restore function and strength to the pelvic floor muscles. Using pelvic floor therapy, the physical therapist can also reduce symptoms of painful intercourse or pain from vaginal scarring.

Pelvic floor therapy involves a variety of treatments, including:

• Pain management using ice and heat

• Perineal scar massage

• Myofascial release and manual therapy, which can include internal and external mobilization of soft tissues that are restricted or painful in the pelvic floor

• Bladder retraining

• Retraining of the core and hip muscles

• Neuromuscular re-education

• Targeted strengthening of weak pelvic floor muscles, beginning with diaphragmatic breathing and Kegel exercises

• Targeted relaxation techniques for weak pelvic floor muscles

• Sensory, motor, sympathetic, and parasympathetic nerve re-training

• Customized home exercise plan

A 2017 study assessed the effects of pelvic floor training after a birth on perineal trauma, involving 466 women who were 32 weeks pregnant with a singleton pregnancy and anticipated a normal birth. The experimental group performed pelvic floor training that involved daily perineal massage and pelvic floor exercises from 32 weeks until birth. The control group received standard care that did not involve perineal or pelvic floor interventions.

Researchers found that women in the experiment group (perineal massage and pelvic floor training) had a 31.6% reduction in episiotomy (50.6% had to have an episiotomy), a higher likelihood of an intact perineum (17.6%), fewer third and fourth-degree perineal tears (5.18% and 0.52% respectively), and had less postpartum perineal pain (24.6%). In the control group, 82.2% of women had to have an episiotomy, only 6.9% had an intact perineum after birth, 13.2% experienced a third-degree perineal tear, 2.5% experienced a fourth-degree tear, and 36.3% had postpartum perineal pain. Researchers concluded that the pelvic floor exercise and perineal massage program was effective in preventing episiotomies and perineal tears in women during childbirth.

Here are a few tips to help prevent perineal tearing during childbirth:

• Stay hydrated. This allows your pelvic floor tissues to be more pliable and thus less likely to tighten and tear.

• Work with your provider and discuss ways that you can push during labor that reduce the risk of tearing. Lying on the back, which is a common birthing position, can in fact increase the risk of perineal tearing as it does not allow pelvic bones to adequately move and can stiffen pelvic floor muscles. Discuss other birthing positions that allow the pelvis to move more freely.

• Avoid holding your breath when pushing, which can tighten the pelvic floor muscles. Engage in diaphragmatic breathing as much as possible to relax and lengthen the pelvic floor muscles.

• Work with a physical therapist before birth to strengthen the pelvic floor and learn effective birthing positions and pushing technique to reduce the risk of perineal tearing.

Have you recently given birth and are experiencing perineal pain? Work with a pelvic floor physical therapist to address pain and improve your pelvic floor function and strength!