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Obstetric Anal Sphincter Injury (OASI) bundle

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Obstetric Anal Sphincter Injury (OASI) bundle

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Reducing the rate of 3rd and 4th degree tears during childbirth

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Painful sex after childbirth (Dyspareunia)

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Painful sex after childbirth (Dyspareunia)

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How is dyspareunia treated?

Treatment options vary widely based on the underlying cause(s) of the pain being experienced. Any infection, whether vaginal, pelvic, or urinary should be properly treated. Low-dose vaginal estrogen is very useful in treating vaginal menopausal symptoms (see leaflet on low-dose vaginal estrogen therapy). The vaginal estrogen can be combined with water-based lubricants to provide adequate lubrication as well as advise about foreplay.

For vulvodynia and vestibulitis, the underlying cause must be determined. Dermatologic (skin) conditions leading to scarring and inflammation can often be treated with steroid or hormonal creams. Vulva lichen sclerosus is a common example of a skin condition that can be treated easily with steroid creams. Local cream applications, vaginal dilators and, in some instances, laser therapy, can help alleviate vulvar skin symptoms. Trigger point injections may also provide some relief as can biofeedback and physical therapy. Your doctor can also prescribe medications that help reduce nerve irritation and pain as well. When to use multiple treatments is a decision made by the individual healthcare provider.

For bladder pain leading to dyspareunia, treatment generally begins with eliminating irritants such as caffeine and cigarettes from the diet (see leaflet on interstitial cystitis) and physical therapy. There are also a variety of medications that can be used, although not everyone responds to the same regimen. Instillations of a medication 'cocktail' in the bladder is also used as an adjunct to therapy. If the underlying issue is the urethra, treatment may be medication or surgery depending on if the underlying cause is infection or a physical defect with the urethra itself.

Musculoskeletal issues with pelvic floor muscle spasm (levator spasm) may be treated with meditative techniques, physical therapy (including massage, heat, biofeedback with a therapist trained in pelvic floor problems), counseling, trigger point injections of anesthetic and/or steroids into the trouble spots or Botox injection to relax the muscle, as well as using vaginal dilators. Pain that is resistant to multiple treatments may be a different neurologic type of pain which requires a nerve block.

Dyspareunia caused by pelvic pain due to endometriosis or adenomyosis can be initially suppressed with continuous hormone therapy as fluctuations in hormones can exacerbate pain. Examples of such hormonal treatment are taking the contraceptive pill continuously or the Mirena coil system. Hormone blocking injections are also an option but have some side effects which your doctor will explain to you. If still unsuccessful, removal of the ovaries (if endometriosis is the cause) or the uterus (if adenomyosis is the cause) may be the last resort. Removal is generally a last resort in the absence of other pathology. Your doctor may refer you to another specialist if he/she believes the pain is related to your bowel or other area.

If found, local causes in the vagina, e.g. vaginal cyst, can be removed. Removal of vulva/vaginal scar tissue or a vaginal mesh sling if causing pain can be done by specialist doctors with experience in these procedures. In women with spasm of the muscles at the entrance to the vagina (perineal muscles) e.g. following childbirth trauma, sexual assault or rape, Botox injection into the muscle has been found to be very useful as it relaxes the muscle and makes intercourse less painful. Sexual discomfort due to pelvic organ prolapse (descent of the pelvic floor leading to a bulge in the vagina) should be evaluated by a urogynecology specialist and either corrected surgically or supported with a vaginal insert called a pessary (see leaflets on pelvic organ prolapse and vaginal pessary for pelvic organ prolapse).

Finally, it is important to stress that dyspareunia can be a chronic and frustrating condition that may require multiple visits, and treatment involving various specialists in order to adequately manage it. Your doctor will advise you about this.

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Dyspareunia (Painful Sex) - Your Pelvic Floor

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How is dyspareunia treated? Treatment options vary widely based on the underlying cause(s) of the pain being experienced. Any infection, whether vaginal, pelvic, or urinary should be properly treated. Low-dose vaginal estrogen is very useful in treating vaginal menopausal symptoms (see leaflet on low-dose vaginal estrogen therapy).

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Pelvic health before and after having a baby

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Pelvic health before and after having a baby

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Welcome to the latest in our series of antenatal podcasts at Hillingdon Hospitals.

Today I'm am talking to Juilia Chiccolini and Samantha Vincent from our pelvic health team, who are going to talk to me about perineal care, pelvic floor exercises and bowel and bladder care.

Firstly, Giulia, could you please tell us what the perineum is and why it is so important to discuss it?

Guilia

- What the perineum is

- What happens to it during birth (it can tear)

- How you can avoid damage (massage)

- Kind of tears to expect

And what about after birth? How can mothers care for their perineum after birth?

Guilia

1. Advice to help to reduce and control pain in hospital and at home

2. Advice about washing

3. When to return to sex

4. In our previous podcast related to perineal massage, you mentioned that antenatal perineal massage is slightly different from scar massage. Could you please fill us in with more information?

5. if you experience any abnormal symptoms, get access to specialist healthcare professional by contacting....

And we have all heard about pelvic floor exercises, Samantha, can you tell us what they are and why they are important?

Sam

- what pelvic floor exercises are, why they are important

- pelvic floor exercise and how to do them

Lucy - should we all be doing our pelvic floor exercises or is this just for women before and after birth?

Guilia - yes we should!

Sam, a lot of women want to return to exercise as soon as possible postnatally, can you tell us the guidance about returning to exercise?

Sam

- guidance about returning to exercise

- circumstances when a mother should NOT return to exercise in these timeframes

- breastfeeding impact on exercising?

Lucy - Is there any additional advice for mother's who may be higher level athletes or consider themselves an advanced exerciser?

Sam -

Sam, can you tell us what you recommend as standard as bladder and bowel care?

1. Are there any bladder signs we should particularly look out for after birth which might mean that it hasn't returned to working normally and what can the mother do?

2. Constipation is something which can be tricky both ante and postnatally, have you got any top tips for avoiding constipation in these periods?

Finally, are there any parting messages which you would like to say before we go?

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Pelvic health before and after having a baby - The Hillingdon Hospitals' Podcast

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Welcome to the latest in our series of antenatal podcasts at Hillingdon Hospitals. Today I'm am talking to Juilia Chiccolini and Samantha Vincent from our pelvic health team, who are going to talk to me about perineal care, pelvic floor exercises and bowel and bladder care.

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* Use the heading column to find the information you need

* Scroll down the column to see information related to that heading

* Click on the links to view the information

* Scroll right to find other headings

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Constipation and problems with bowel function

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Constipation and problems with bowel function

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thh.perinatalpelvichealthservice@nhs.net

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Giulia - Specialist Pelvic Health Midwife

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Giulia - Specialist Pelvic Health Midwife

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This class will cover:

Exercising safely in pregnancy

The role of the pelvic floor muscles and how to exercise them

Bladder and bowel symptoms you may experience

Perineal tears and how to reduce them

What to expect after birth

Getting back to yourself and sex

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POSTER Pelvic Health Awareness and Education Event

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Repair of first- and second-degree tears, care of stitches and what to expect when healing.

What is a first-degree tear?

These are small tears, or grazes, affecting only the skin.

They can occur around the labia, clitoris or inside the vagina.

These tears can be referred to as lacerations, superficial abrasions or actual tearing.

First-degree tears usually heal quickly and without treatment. They are very unlikely to cause long-term problems, but they can be very sore.

What is a second-degree tear?

These are tears affecting the muscle of the perineum and the skin. These usually require stitches.

The repair is normally done using local anesthetic in the room where you had your baby.

Second-degree tears are unlikely to cause long-term problems, but they can be very sore.

Caring for your stitches

Hygiene

Good hygiene is important if you have had a first- or second-degree tear. Use only water to keep the area clean.

Wash or shower at least once a day and change your sanitary pads regularly.

Wash your hands both before and after you go to the toilet or change your sanitary pads.

This will reduce the risk of infection.

Diet and water

It is important to eat well and drink plenty of water to help avoid constipation.

You should drink at least 2 litres of water every day and eat a healthy balanced diet (for instance: fruit, vegetables, cereals, wholemeal bread and pasta).

Opening your bowels

If you have stitches, opening your bowels should not open them.

It can be helpful to put your feet on a footstool, to raise your knees above your hips while sitting on the toilet

Try to relax and rest your elbows on your knees. Do not strain as this weakens your pelvic floor. Bulge out your tummy by taking big abdominal breaths, which will help expel your stool without straining.

Most importantly, take your time and do not rush.

What should I expect when healing?

Stitches

If you have stitches, they will eventually all dissolve. When you have contact with a healthcare professional, ask them to examine your stitches.

Pain and discomfort

After having any tear, it is normal to feel pain or soreness after giving birth, particularly when walking or sitting. The skin part of the wound usually heals within a few weeks of birth, and after that you should feel much less raw and tender.

If you have stitches, they can irritate as healing takes place, but this is normal.

Placing an ice pack wrapped in a towel on your perineum may help. Do not place ice directly onto your skin as this may cause damage.

Passing urine can cause stinging depending on where your tear is.

Pouring body temperature water over the area when urinating can help.

Your pelvic floor

It is important to do pelvic floor exercises as soon as you can after birth. This strengthens the muscles around the vagina and the anus and helps healing.

Read more about pelvic floor exercises

Will I have any follow-on appointments?

You will usually be offered an appointment with a healthcare professional 6 weeks after you have your baby, to make sure that you are recovering well.

At that appointment, you will be able to discuss any concerns and ask any questions you may have about the birth of your baby and any of your symptoms or concerns about future pregnancies.

When should I contact a healthcare professional?

If your stitches become painful.

If your stitches become smelly.

If your wound does not heal.

If you have been diagnosed with a first- or second-degree tear, but you are having problems controlling your bowels, for instance you struggle to make it to the toilet or control wind.

If you have any concerns.

Further information

Caring for yourself after childbirth

Including what you changes you can expect, and when to be concerned:
https://www.nhs.uk/conditions/pregnancy-and-baby/you-after-birth/

Sex and contraception after childbirth

https://www.nhs.uk/conditions/pregnancy-and-baby/sex-contraception-after-birth/

Caring for yourself after an episiotomy or tear after childbirth

https://www.nct.org.uk/labour-birth/you-after-birth/episiotomy-care-and-recovery

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Repair of first- and second-degree tears, care of stitches and what to expect when healing.

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A tear happens spontaneously as the baby stretches the vagina during birth.

An episiotomy is a cut made by a healthcare professional into the perineum and vaginal wall to make more space for your baby to be born. It is possible for an episiotomy to extend and become a deeper tear.

Episiotomies are only done with your consent.

If you have had an episiotomy, you will need stitches to repair it. This is normally done using local anesthetic in the room where you had your baby.

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A tear happens spontaneously as the baby stretches the vagina during birth. An episiotomy is a cut made by a healthcare professional into the perineum and vaginal wall to make more space for your baby to be born. It is possible for an episiotomy to extend and become a deeper tear.

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Bladder and vaginal problems during and after pregnancy

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Bladder and vaginal problems during and after pregnancy

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0:00 / 2:07•Watch full video

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Bladder and vaginal problems during and after pregnancy

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Pelvic floor exercises during and after pregnancy

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Pelvic floor exercises during and after pregnancy

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Pelvic floor exercises during and after pregnancy

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My name is Luce. I'm a writer. A partner. A mum. And I had a difficult birth which left me thunderstruck, confused, sad, broken, and well, pretty angry. I'm probably older than you. My children are now very different creatures, tall and long with difficult questions about the state of the world, films they're too young to watch, and football. Mostly football. They are no longer squishy babies or toddlers clambering into my bed. The years were over in the blink of an eye, just as everyone warned me. But those cliches don't tell the whole truth. Because if I close my eyes tight, take a deep breath, I still remember their smell, their serene velvet faces, their outsized hands clenched into pink fists as they look up from their crib into the world. Their sleep noises and intricate, edible toes. The echo of toddler giggles, small feet lurching towards me, an object in each hand, demanding more Iggle Piggle.

Other memories cling tightly too, like tears that don't want to leave your cheek, or spill out when you are trying to have a straightforward conversation about what happened to you in the labour room. They are a visceral collage: light, colour, sensations, smells, many not very nice. They catch me unawares when I am minding my own business and see a pregnant woman. Maybe she is like I was, bright-eyed and enthusiastic, absolutely no idea what birth can be like, poorly prepared at school for the reality of her anatomy, slightly unclear on the mechanics of birth? I don't want to scare her by saying it might be horrible. But I want her to know this: if it doesn't work, if things are not perfect, if she needs stitching back together in more ways than one, there are people who have her back. People like me, further down the road, once broken and stunned about what happened, but who have had treatment, time, kindness, and validation, and are here to help her feel less alone. I think this is what MASIC truly offers.

My reaction to birth trauma was unconventional. I wrote a book - a gory, funny, moving book - about the truth of it for me, what I saw and heard and felt as I gave birth and then coped with injuries, continence issues, depression and trauma. I needed to speak out because I traumatic births are often undiscussed. Unprocessed. Unheard. I certainly couldn't find many places that captured my weird, conflicting thoughts. Like: 'Yes, I love my baby, but I also want to disappear', or 'I don't know if I feel a "rush of love" - I don't even know what that means', or 'If this is 'the baby blues', someone needs to change the name STAT because this feeling ripples through my gut and makes me feel young and stupid and old and broken and happy and useless all at the same time'.

Also, I had noticed the magic trick: talking about birth, even tricky, injuring birth, can empower. Mention birth and others share their stories - friends, relatives, strangers telling you about their delivery 60 years ago, brand new mums asking in whispers when stitches start to feel less sore. Emails from people who've read my book often open with,'I've never told anyone this before...' They talk of shame, fear, feeling silly. That's the magic of MASIC and any place like this where you get to talk or listen. Recognition is important - we don't talk enough about births that aren't picture perfect, as if they should be hidden in shame. Like MASIC, I'm here to say it isn't shameful. And don't worry - you have found your people.

Another thing about sharing: among the crying, laughter, wincing and weeping, there's often one poor soul, slightly quieter than the rest, eyes glassy, listening in, who hasn't found the time or space to work out quite what they think, or what to say, about what has happened to her. If that's you, we see you too.

Like my book, this website is a place for all of you - the entertainers, the shellshocked, new mums and old hands - to share, process, or even just start to think about what is happening, and why googling 'birth trauma' or 'MASIC' late at night is a good thing. You are not alone.

Whether you are coping on the outside and smashing motherhood every day, or hiding in the shadows wondering when you'll get back to being you again, or feeling okay but still burst into tears when you think too hard about contractions or have nightmares about the birthing pool - this site, this community, these resources are for you. You've got this. We've got you. Hang in there. Things can change. The time really does whizz by. Treasure having somewhere you can come and reach out.

I'm so thrilled MASIC asked me to be involved. If we can talk about things, properly, and kindly, even if just with each other at first, there are ways to move on.

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My name is Luce. I'm a writer. A partner. A mum. And I had a difficult birth which left me thunderstruck, confused, sad, broken, and well, pretty angry. I'm probably older than you. My children are now very different creatures, tall and long with difficult questions about the state of the world, films they're too young to watch, and football.

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It's possible to become pregnant again very soon after the birth of a baby, even if you're breastfeeding and even if your periods have not returned.

You usually release an egg (ovulate) about 2 weeks before your period starts, so it's possible to get pregnant before you have a period.

Find out about your options

It's important to plan contraception in advance. If you have your baby in hospital, you'll probably discuss contraception with a midwife before you go home.

You'll also be asked about contraception at your postnatal check, which happens 6 to 8 weeks after the birth. But you can discuss it at any time (including while you're still pregnant) with a:

health visitor

midwife

GP

doctor or nurse at a contraception or sexual health clinic

pharmacist

Not all methods of contraception are safe for all women. For example, you should not use some methods if you have certain medical conditions, such as high blood pressure (hypertension).

You can discuss with your doctor or nurse which methods are suitable for you.

Contraception choices immediately after birth

At any time after the birth of your baby, as long as you have no medical risks, you can use:

Or, you can choose to have an IUD (intrauterine device) (more than 99% effective), or an IUS (intrauterine system) (more than 99% effective) inserted within 48 hours of the birth.

If an IUD or IUS is not inserted within 48 hours, you'll usually be advised to wait until 4 weeks after the birth.

3 weeks after birth

If you're not breastfeeding and your healthcare professional has checked you have no medical risk factors for a blood clot in a vein, you can start to use the:

But if you're breastfeeding, have certain health conditions, or a risk of blood clots, you'll usually be advised to delay using the combined pill, ring or patch until at least 6 weeks after the birth.

4 weeks after birth

If you did not have an IUD or IUS inserted within 48 hours of the birth, you can have one inserted later. But you'll usually be advised to wait at least 4 weeks after the birth.

6 weeks after birth

If you're breastfeeding or you've developed certain medical conditions during pregnancy or delivery, you'll need to wait until at least 6 weeks before you can use the:

combined pill

vaginal ring

contraceptive patch

You can usually start using a diaphragm or cap (92% to 96% effective if used correctly) around 6 weeks after giving birth.

If you used a diaphragm or cap before becoming pregnant, see a GP or a doctor or nurse at a contraception clinic after the birth, to make sure it still fits correctly.

This is because childbirth and other factors, such as gaining or losing weight, can mean you need a different size.

Find contraception services near you.

Page last reviewed: 29 June 2020
Next review due: 29 June 2023

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When can I use contraception after having a baby?

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Find out when you can start each method of contraception after having a baby, how effective they are, and which methods are safe to use if you're breastfeeding.

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Need advice or support?
MASIC charity run a 24 hour helpline for birth injury support 0808 1640 8333

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Most women who have experienced wound breakdown, experience no further problems.

Once the wound is healed, it will not break down again with exercise or sex.

However, if you experience any problems, or are concerned, you should see your healthcare professional.

Granulation tissue

With any perineal wound, 'over- healing' can sometimes occur. This leads to raised red patches of tissue called 'granulation tissue'.

This can be uncomfortable or continue to cause bleeding.

It can sometimes be confused with new infection, but it is not solved by antibiotics.

Granulation tissue will usually settle on its own and does not require any treatment.

Granulation tissue can sometimes be treated in a perineal or gynaecology clinic with a painless procedure using silver nitrate.

Rarely, it will persist and may need to be surgically removed.

If you need treatment, your healthcare professional will explain what is suitable for you.

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Overview of perineal wound breakdown and what to expect.

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Including perineal massage

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Advice for after a 3rd or 4th degree tear

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Advice for after a 3rd or 4th degree tear

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Caring for the perineum 3rd and 4th degree tears PF EXERCISES

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from "Red flags for episiotomy in a midwife-led birth: Using co-production with midwives to capture clinical experience" 

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Reduce perineal tears Video- English, Urdu, Bengali, Spanish, Pashto, Arabic, Punjabi

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Reduce perineal tears Video- English, Urdu, Bengali, Spanish, Pashto, Arabic, Punjabi

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Reducing your risk of perineal tears | RCOG

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The following animation explains what an OASI is, the four components of the OASI Care Bundle and how women can reduce their risk of sustaining an OASI in childbirth.