A guide for episiotomy and perineal scar tissue massage
The perineum is between the vaginal opening and the anus. It is the area covering the superficial pelvic floor muscles, nerves, and blood vessels.
Perineal tearing/trauma refers to the spontaneous tearing of the perineum during vaginal delivery, as the head and shoulders are born. An ‘episiotomy’ is when your health care provider does a preventive cut in the perineum to allow more room for baby to pass through or in an effort to prevent further tearing.
There are four grades of perineal tears:
First degree: injury to perineal skin and/or vaginal mucosa
Second degree: injury to perineum involving perineal muscles, but not involving the anal sphincter*
Third degree: injury to perineum involving the anal sphincter complex. This is then further subdivided into:
3A: where <50% of the external anal sphincter is torn
3B: where >50% of the external anal sphincter (EAS) is torn
3C: where the external and internal anal sphincters (EAS and IAS) are torn
Fourth degree: injury to perineum involving the anal sphincter complex (EAS and IAS) and anorectal mucosa**.
*Anal sphincter: a group of muscles at the end of the rectum that surrounds the anus and controls the release of faeces, thereby controlling incontinence.
**Anorectal mucosa, also known as rectal mucosa: anus/ rectum moist inner lining.
It is important to know that overall, perineal tears are quite common and most heal well without complications. Third or fourth degree tears are less common, for Australian women this is a frequency of around 3% in all vaginal births and 5% for first vaginal births.
Risk factors for a third and fourth degree tear:
First vaginal delivery
Women of south Asian ethnicity
<20 years of age
Shortened perineal length (<2.5cm)
High baby birth weight >4kg
Instrumental vaginal delivery (e.g. forceps, vacuum)
Persistent Occiput posterior (OP) position (the back of baby's skull or the occipital bone) is in the back (or posterior) of mums pelvis
Shoulder dystocia (baby’s shoulder gets stuck)
Prolonged second stage (pushing stage) of labour (> 60 minutes)
Absence of epidural pain relief
Oxytocin use (induced labour or oxytocin drip to increase contractions)
Midline episiotomy (as opposed to medio-lateral)
Delivery in stirrups (lithotomy) or deep squatting position
Why do perineal scar massage?
When scar tissue heals it can often be sensitive and tight, which may give you some discomfort or pain, including during activities like intercourse. Even if your scar isn’t painful, scar tissue often lacks mobility, so providing it with some gentle stretching can help it to regain some of its elasticity.
When to start scar tissue massage?
Perineal massage should only be started once your care provider has given you the “all clear” to have sex or to start massage (normally after 6 weeks). You need to ensure that your scar tissue has closed and healed well prior to starting.
How to do it?
This will depend on what degree of tearing you had, how mobile the scar tissue is and how irritable your scar feels. In order to determine these factors we recommend you booking in to see one of our expert pelvic floor physios.
!! If your symptoms persist or if you experience any burning, stinging, or spotting after sex postnatally, please consult one of our pelvic floor physiotherapists.
NOTE: This is general advice only and should not replace medical advice. If you have any concerns or are unsure if you have any contraindications to perineal massage, please speak to your health care provider.
