Pregnancy

You know that thong of tissue that keeps your tongue anchored to the floor of your mouth? It’s your frenum. And the translucent cartilage between your nostrils is your septum. And the flesh that stretches like a hammock between your vagina and your rectum is your perineum, and you and it are going to have a special relationship in the childbearing year.

You will want to be on good terms with this most tender of tissues. You will want to get to know it well. You will want to become, in fact, your perineum’s pal.

Will your perineum be sore after delivery? You know we’d be lying if we said anything but yes. Giving birth is a beautiful, painful miracle! In the postpartum days you will be distracted by the perfection of your little angel, but if your baby enters the world through your vagina, she or he will have temporarily worn your perineum like a too-tight halo, and you will know it.

But before we begin to treat our perineal pal as though it were a site for trauma only, let’s see if there are other ways to think of this special link between coming and going.

Some women become aware of their perineum for the first time in their lives during pregnancy, so it may also be the first time they become aware of its power and flexibility.

Tracey Germa of Peterborough, Ontario, says pregnancy changed her attitude toward her perineum. “I had always known about it as a source of pleasure. But the engorgement and pressure it supported during pregnancy reminded me of its strength, and of what it would have to do during birth.”

Roseanne Hickey is a clinical nurse specialist with the Perinatal Progam at the Sunnybrook and Women’s College Health Sciences Centre in Toronto. She says that hormonal and physical changes through the childbearing year affect the perineum in several ways.

“During late pregnancy,” says Hickey, “blood flow to the perineal area is slowed because of the pressure of the enlarging uterus.” Slowed blood flow to the area causes the swollen sensation some women report. Further, Hickey has seen in her practice that during pregnancy there may be edema - swelling created by retained fluid - in the vulva, just as there may be in the face, hands, legs and feet. The pregnancy hormone progesterone contributes to fluid retention, as does the slowed blood flow.

And then there is the birth itself. Says Hickey: “During labour, especially the second stage (pushing and delivery) pressure from the baby’s head causes reduced blood flow, engorgement, inflammation and swelling. A half-hour or more of pushing will result in some degree of swelling of the perineum, the vagina and even the urethra.”

And what about mothers who deliver by Caesarean section and don’t do any pushing, but still discover that sitting down after having a baby is not so nice? “Even if a woman does not deliver vaginally, the perineum will have helped cradle the baby throughout the pressure of pregnancy. A C-section is considered major abdominal surgery and the bedrest required for recovery will also reduce blood flow to the perineal area,” explains Hickey.

Remember that all this reduced blood flow means swelling, which contributes to postpartum discomfort in the perineum. This swelling generally passes naturally in the weeks after delivery, aided by drinking fluids and resting with the feet and legs elevated. As with any swollen body part, relief can also be found by applying cold packs. Some women suggest a water soaked and frozen sanitary napkin, which seems to fit just right. Wrap it in a light towel first.

Perhaps the most unexpected changes to the perineum, though, are those caused after delivery by the hormone prolactin, which allows you to breastfeed. Hickey explains that prolactin is “anti-estrogenic, and causes dryness. During this time, the tissue of the perineum is therefore less mucousy, and more friable, that is, thinner, or brittle.” To sum up, it means that nature’s sexy lubricant appears to have disappeared!

Even after the standard six week period mothers are often advised to wait before resuming sexual intercourse, those anti-estrogenic hormones may affect the perineum in ways that make sex a rueful prospect.

Don’t worry: you haven’t lost your desire for good. As your hormones return to normal, your natural lubrication will return, and with it, your libido. Be aware, though, that this may not be complete until your nursing child is weaned.

The best perineal news is that much can be done to prevent tearing or episiotomy during labour, and even more can be done to soothe and pamper these delicate tissues postpartum.

Perineal Massage: Do Me Now
Jaylene Mory, of the Kawartha Community Midwives in Peterborough, Ontario, recommends perineal massage from the 34th week of pregnancy on. It gradually softens and stretches the perineal tissues, and can be done by you or your partner. A member of your delivery team can also do the massage during birth if you wish, and if it feels good.

Your midwife or caregiver can show you how to do the massage, or read about it in Essential Exercises for the Childbearing Year (by Elizabeth Noble, New Life Images, 1995). Please note that perineal massage is no guarantee against tearing or episiotomy, but it may reduce the possibility. Mory adds that this massage does allow women to become familiar with new and increased sensations in the perineal area.

Perineal Tea: Sit in Me
This tea can be drunk, but you’re supposed to bathe your perineum in it.

From a reliable herb supplier, purchase equal parts uva ursi, shepherd’s purse and calendula. Put the herbs into a large jug, fill the jug to the top with boiling water, seal the jug, let it steep for eight hours at room temperature, strain the herbs from the liquid, and add the tea to your bathwater.

A plain old sitz bath - a shallow, very warm, 20-minute soak - also feels great.

Kegel Exercise: Do Me Forever
Imagine achieving immortality by being having a vaginal exercise named after you. Thus was the source of fame of Dr. Arnold Kegel. Kegel also invented a device called the perinometer to measure how efficiently his exercise was being done (it has since fallen out of popular use!). To do your Kegels without the perinometer, start by flexing as you would to stop the flow of urine. This will isolate the perineal muscles.

Before childbirth, daily Kegels increase the flexibility and strength of the perineum. Kegels done after delivery will increase circulation to the area, which helps reduce swelling and promotes healing.

Some people claim continued Kegel exercises result in other bonuses, including enhanced sexual pleasure, and avoidance of the dreaded “sneeze pee,” or stress incontinence.

Peri Bottle: Squirt Me
Your health care provider will give you a perineal squirt bottle for use after delivery. Fill it with warm water, and irrigate the area during and after urination. Feels great. Use it after a bowel movement as well for scrupulous cleanliness, and remember: no straining!

In the days after your beautiful babe is born, you will undoubtedly have many visitors who, if they are clever, will do your laundry, wash your dishes, walk your dog, put a casserole in the oven and scoot out the door. Many will remind you to “take care.” We know that’s what you’ve been doing all along, and what you will do with your little one in the years to come. Remember, too, that “taking care” means taking care of you - and all your private parts.

Peri Care
Here's an overview of the standard perineal care regimen suggested by many caregivers for all new moms:

• Avoid touching the affected area.

• Use the peri-bottle to squirt warm water on your perineum during urination. The water will dilute the urine so it won’t sting.

• Pat the area dry from front to back to avoid introducing germs from the rectum into the vaginal area.

• Change your sanitary pad every four hours.

• When you get home and have some privacy, lie in bed without the sanitary pad and let your perineum “air dry.” Put some old towels down first.

• Apply ice packs every couple of hours for the first 12 to 24 hours. The ice will help reduce swelling.

• After the first day, heat helps increase circulation to the site and promotes healing. Try a heat lamp, blow dryer or warm sitz bath.

• Avoid standing or sitting for long periods, which can strain an already over-taxed perineum.

• Consult your midwife or doctor if you’re not finding relief or if you experience any fever. For pain, your caregiver may prescribe pain relievers or medicated pads. Fever may be a sign of infection — always a possibility if you have stitches or cuts — but with proper perineal care the risk is considered minimal.

• Relax and give yourself time to heal. Every new mom recovers in her own way and on her own schedule. Follow your caregiver’s instructions, focus on healing, and begin the lifelong process of getting to know your baby.

Originally published in Today's Parent Pregnancy & Birth, Autumn/Winter 2002