Scarring After Episiotomy and What To Do About It

episiotomy and perineal tear scarring after childbirth

Episiotomy rates have been decreasing in the US since the 1990s. And in 2006, the American Congress of Obstetricians and Gynecologists advised episiotomies to be avoided if possible due to the risk of increased pain, lacerations, and anal incontinence.


What is an episiotomy vs a perineal tear?

A perineal tear is common among first-time mothers, occurring anywhere from 30-85% of vaginal deliveries. Mothers who have given birth are less likely to tear than first-time mothers. During natural childbirth, tearing occurs along the perineum or the area between the vagina and the anus.

It was once common practice to do episiotomies for all pregnancies. An episiotomy is a surgical incision along the area of the perineum to make room for the infant’s head. The idea was to avoid severe trauma to the perineum and avoid tearing into the vaginal and pelvic floor muscles which cause urinary or fecal incontinence.

Perineal tears are classified into four degrees:

  • First degree – affects only the skin, heals quickly, and typically heals on its own
  • Second degree – impacts the perineal muscles and skin, usually requires stitches
  • Third degree – concerns the anal sphincter, muscles, and skin, and requires surgical repair
  • Fourth degree – also affects the anal sphincter and deeper into the bowels, requires surgical repair

What are some risk factors for perineal scarring?

A major risk factor of perineal tearing or episiotomy is developing scar tissue and adhesions in the area of your vagina and anus. Because limited mobility of your pelvic floor causes tissues to stick to each other, it can lead to:

  • Pelvic floor disorders
  • Bowel dysfunction
  • Overactive bladder
  • Bladder incontinence
  • Painful sex
  • Pelvic pain
  • Prolapse

What can physical therapy do about my pelvic floor scarring?

Pelvic floor physical therapy can offer rehabilitation specifically targeting your pelvic floor muscles. They can evaluate for strength, range of motion, pain, and function. Treatment includes:

  • Pain management with cold and heat therapy
  • Scar massage
  • Myofascial release
  • Manual therapy
  • Strengthening core/floor
  • Breathing exercises

Perineal massage is used to stretch your perineum to reduce your risk and severity of perineal tearing. And it reduces your risk of perineal incision by:

  • Stimulating nerve endings
  • Enhancing blood circulation
  • Improving elasticity
  • Increasing ductility
  • Broadening vaginal opening

Studies have shown that prenatal perineal massage can reduce your risk of tearing during vaginal birth and reduce your need for an episiotomy. This is especially true to avoid third and fourth degree tears. You also reduce your risk of developing perineal pain beyond three months from vaginal delivery.


How can I prevent tearing during vaginal delivery?

The following list of instructions for self-perineal massage is typically what you’d hear from most experts:

  1. Clean your hand and trim your nails.
  2. Use unscented oils or personal lubricants.
  3. Lie down on your back with pillow support or stand with support in the shower.
  4. Use a mirror to see where to massage, if needed.
  5. Insert your thumb into your vagina, start gently with progressively increased pressure toward your anus, then in a U-shape, sweep and stretch from the back and up along the sides of your vagina.

Your physical therapist can provide feedback to help you determine the most comfortable and effective method.


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