Episiotomy Scar Caused by Perineal Tear How to Recover

A perineal tear scar refers to the scar tissue that forms after a tear occurs in the perineum during childbirth. The scar may vary in size and appearance depending on the severity of the tear and the healing process.

Perineal tears and episiotomies are common during vaginal deliveries with as many as 85% of women who deliver vaginally experiencing either one, or both. In the weeks and months after birth, perineal tears and episiotomy incisions normally heal and form a scar as torn tissues close and new blood vessels are formed.

How you care for these tears and incisions, however, can directly influence your recovery time and prevent long-term side effects like pain during sex or incontinence. 

In this article, we’ll discuss caring for an episiotomy scar caused by perineal tearing and what you can do to help yourself recover. 

Perineal Tears

Regardless of whether an episiotomy is performed, women giving birth vaginally can also experience scar tissue from a healed perineal tear. Also known as vaginal tears or perineal lacerations, these tears during childbirth are categorized into four types by obstetricians and midwives, depending on the severity of the laceration. 

First Degree Perineal Tear

A first-degree perineal tear is considered the mildest in that only the skin of the vaginal wall is torn, but not the underlying muscles, so sutures are not required and healing of the wound usually only takes a few weeks. 

Second Degree Perineal Tear

Second-degree tears are deemed more painful due to the tear extending through the skin & muscles of the perineum and into the vagina. Sutures are often required, but healing also happens within a few weeks.  

Third Degree Perineal Tear

Third-degree perineal tears spread from the vagina to the sphincter muscles, sutures are required, and it can take up to three months for the incision to heal completely. 

Fourth Degree Perineal Tear

Fourth-degree perineal tears extend from the vagina through the sphincter muscles and into the rectal lining. Healing of the incision can take up to three months during which women often experience temporary incontinence and pain during bowel movements. 

Although up to 85% of women who give birth vaginally will experience perineal tears, it can be comforting to understand that only two-thirds of tears typically require sutures, and only 0.5- 2.5% of women are known to experience severe third or fourth-degree tears.

What is an Episiotomy Caused by Perineal Tear? 

The perineum is the area of the body between the anus and the vagina. Its primary role is to protect the pelvic floor muscles, as well as the nerves & blood vessels to the genitals, bowel, and urinary tract.

During childbirth, however, the perineal skin and muscles are stretched to their limit as the baby’s head enters the vaginal canal, and this is typically when perineal tears occur, particularly for first-time mothers.   

When a midwife or birthing professional notices that the perineal muscles and vaginal skin have torn, or will not stretch any further, they will typically perform an episiotomy (incision) to allow the baby’s head through with more ease. 

Sutures to close an episiotomy incision are normally administered within an hour of delivery and although the incisions usually heal within a few months, women’s health experts recommend caring for the developing scar tissue for much longer to avoid any long-term complications. 

Can Episiotomy or Perineal Scars Cause Complications?

After an episiotomy or perineal tear, most women can expect to feel some swelling and pain in the perineum for the first few days, but this should subside as the wound heals. 

As the fibers of scar tissue form, however, they are typically weaker with more limited movement and less oxygen circulation than normal skin tissue. This lack of skin and muscle elasticity around an episiotomy or perineal scar can result in side effects, such as; pain during sex or when passing a stool, urinary or fecal incontinence, pelvic organ prolapse, and ongoing infections. 

It is therefore recommended that regardless of their severity, all episiotomy and perineal scars are adequately cared for to improve blood flow and elasticity in the months after childbirth to avoid long-term pain or complications. 

How to Care for Episiotomy and Perineal Scars

When it comes to caring for episiotomy or perineal scars, of utmost importance is to follow the hygiene and wound care instructions given to you by your obstetrician or midwife for the first few weeks, particularly when using the bathroom or changing bandages. 

To reduce the risk of long-term side effects or complications from an episiotomy or perineal scars, follow the steps for each phase of recovery outlined below. 

Week 1 

It is normal for the perineum to be red, swollen, and painful during the first week after a perineal tear or episiotomy, and during this time, it is extremely helpful to apply the RICE method – Rest, Ice, Compress & Elevate. 

Rest as much as you can by sleeping when your baby sleeps to allow your immune system the time it needs to heal your wound. Regularly apply ice wrapped in a towel or a cold compress to the perineum to help reduce pain and swelling.

And elevate your feet above your heart a few times a day, by lying down with the feet resting on top of a cushion, to improve blood circulation and alleviate pressure on the perineum.  

Calming breathing exercises, which can be performed while feeding your baby, are also helpful to improve relaxation and blood circulation to your healing wound.

While lying down with your feet elevated, circling the ankles both clockwise and anti-clockwise 15-30 times per day can also help to encourage nerve mobility in the initial healing phase. Once you feel ready, try walking slowly for 5-10 minutes per day. 

Lastly, although the body will naturally begin the healing process as early as the first week, it is important to look out for any signs of infection on the perineal wound, such as; discharge or pus from the tear, an unusual odor, or pain that grows in intensity instead of subsiding. 

Week 2-4 

During the second to fourth week after birth, skin tissues around the perineal tear or incision begin to close and new blood vessels are formed. Continuing the regular application of the RICE method will help to alleviate pain, redness, and swelling. 

Calm, conscious breathing exercises while feeding your baby will promote blood circulation to the newly forming skin tissue. And increasing your gentle daily walk to 15-20 minutes is a great way to get moving and improve circulation without putting too much pressure on the perineum.  

Week 4 – At least 1 Year

Approximately four weeks after birth, the skin and muscle tissue of the perineum begins to form a scar. Application of the RICE method should be continued regularly to reduce inflammation, pain, or swelling, gentle walking can be increased to 30-45 minutes per day, and calming, conscious breathing while you feed your baby will continue to improve blood circulation in the perineum. 

Strength and elasticity are still lacking in the newly formed skin at the beginning of this phase, but both can be significantly improved with regular perineal scar massage. The practice of regular perineal scar massage will also help eliminate any side effects like painful sex or long-term complications such as incontinence.  

How to Do Episiotomy and Perineal Scar Massage 

To perform perineal scar massage after a perineal tear or episiotomy, follow the steps below, or seek the guidance of a pelvic health physical therapist to ensure you are performing them correctly. It is also important to check with your doctor to make sure your perineal wound is healed and ready to be massaged before proceeding as follows: 

• Always wash your hands before performing a perineal massage
• Have some water-based lubrication on hand to make your massage more comfortable
• Lie on your back with your knees wide and your head and lower legs supported by pillows
• Use a mirror to orientate yourself and find the area that you will massage

Side to Side Perineal Massage

With clean hands and well-lubricated fingers or thumbs, massage the scar and perineum area from the center and outward (left & right) with moderate pressure for 3-5 minutes every other day. 

Up and Down Perineal Massage

Similar to the side-to-side perineal massage, massage the scar and perineum area from its center, but this time massage in an up-and-down direction with moderate pressure for 3-5 minutes every other day. 

Sweeping Perineal Massage

Using a clean and well-lubricated thumb, start at the lower end of the vaginal entrance and sweep it upward to the left, then upward to the right, massaging in a ‘U’ shape along the vaginal wall with moderate pressure for 3-5 minutes every other day. 

Scar Rolling Perineal Massage

With a clean and well-lubricated thumb and index finger, place the thumb inside your vagina and your index finger on the scar outside of the vagina. As if you are rolling something between the thumb and finger, gently massage the scar for 3-5 minutes every other day. 

Vaginal Dilators & Pelvic Wands for Perineal Scars 

After 6-8 weeks, healing has usually progressed to the point that perineal massage is no longer uncomfortable and can be performed daily for five to ten minutes. At this point, a vaginal dilator and/or pelvic wand can be used to further reduce the risk of long-term complications associated with perineal or episiotomy scar tissue. 

These pelvic health tools are also particularly helpful to massage the raised bumps that some women experience with episiotomy and perineal scars. 

Vaginal dilators are silicone tube-shaped medical devices that are used to gently stretch the vaginal and perineal muscles, as well as massage scar tissue, after a genital trauma or vaginal condition that resulted in injury, pain, or vaginal dryness. A gently vibrating pelvic wand, like these from Intimate Rose, is helpful to relax and massage the perineum while continuing to improve blood circulation and the elasticity of new scar tissue.  

How to Prevent Perineal Tears & Episiotomies During Childbirth

To prevent perineal tearing or an episiotomy during birth, female health experts recommend preparing your vaginal and perineal muscles for labor a few weeks in advance with a regular perineal massage. Before labor beings, it is also suggested that you speak with your midwife or birthing provider about the ideal birthing position, as well as when & how to push, to avoid perineal tears. 

For a concise guide on how to prevent perineal tearing during childbirth, click here. 

When to See Your Doctor

While it is normal to experience some pain while urinating or passing a stool in the first one to three weeks after a perineal tear or episiotomy, contact your doctor if it does not subside by the fifth week.

Once you have been cleared to return to sexual activities after a perineal tear or episiotomy, speak with your doctor if you experience any pain during sex. It is also important to schedule an appointment with your doctor if you are suffering from ongoing urinary or fecal incontinence after the first few weeks.   

Conclusion

Although perineal tears and episiotomies are common during vaginal childbirth, and normally heal well, the scars and scar tissue that develops afterward can often cause unwanted side effects.

To help with the healing process, post-partum perineal care is vital in the weeks after childbirth. And using vaginal dilators and/or vibrating pelvic wands to massage the perineal scar and scar tissue for up to one or two years afterward will prevent long-term complications like incontinence, pelvic organ prolapse, or painful sex. 

References

What To Expect – Vaginal & Perineal Tears During Childbirth - https://www.whattoexpect.com/first-year/perineal-tears/

Intimate Rose – Childbirth and Your Perineum - https://www.intimaterose.com/blogs/kegel-exercise/childbirth-and-your-perineum

Johns Hopkins Medicine – Episiotomy - https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/episiotomy

Birth Injury Health Center - Episiotomy Complications and Side Effects - https://www.birthinjuryhelpcenter.org/episiotomy-complications.html

Cleveland Clinic – Skin - https://my.clevelandclinic.org/health/articles/10978-skin

Cleveland Clinic – Healing After an Episiotomy - https://my.clevelandclinic.org/health/treatments/22904-episiotomy

Obstetrics & Gynecology Online Library - Effectiveness of antenatal perineal massage in reducing perineal trauma and post-partum morbidities - https://obgyn.onlinelibrary.wiley.com/doi/abs/10.1111/jog.13640