The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

Postpartum Perineal Care

Subsections on this page:

• Comfort Measures for Postpartum Perineum
• Heat Instead of Cold
• Fourth-Degree Care
• Use of Honey or Tea Tree Oil for Perineal Infection
• Postpartum Vulvar Dermatitis
• Postpartum Perineal Massage
• Long-Term Postpartum Perineal Pain
• Postpartum Sex - How Soon?

Comfort Measures for Postpartum Perineum

Reusable frozen ice pack

Easiotomy Cream™ - Natural soothing cream for the perineum – for use before and after birth

Also as a result of its anti-inflammatory effect, bromelain has been found to dramatically reduce postoperative swelling in controlled human research. Double blind research has found bromelain effective in reducing swelling, bruising, and pain for women having minor surgery after giving birth (episiotomy). [from MotherNature.com's encyclopedia.]

For the severe tearing, I have a tea bag sort of thing that has powdered comfrey and plantain in it. My clients really like it for their soreness. I can't say as it works for severe tearing but why not test it. Also I have a recipe for something called People paste, or (Goose Poops). These can be put just inside where the most soreness is felt and left to do their job. Not all day or anything but for an hour or so. Then it can be changed. This is a real good paste for anything, scrapes, bruises etc. Inside and out. There are only 3 ingredients, equal parts of all 3 powdered, slippery elm, golden seal and myrrh. This is the base and now for vaginal tears you can add comfrey and plantain if wanted. Now you can add clover powder if strong pain relief is needed. You can mix these herbs with honey, molasses, aloe vera, water, etc. You want the mixture a little on the med. dry side so it will stay in a form. Make a big tear drop shape. These can be inserted just slightly or as much as the lady feels comfortable with. At least it should be in contact with the damaged tissues. I forgot all about these as I have only been using them for the past 6 months and haven't had to use them enough to have it right on the top of my head. I have been using the tea bag things for a few years and I have had ladies ask for more.

Regarding the "tea bag sort of thing": I have found that unbleached coffee filters work really well for this. You can put the herbs in it and staple or glue it together. I make them up in bulk and carry them in my postpartum visit bag.

Do you mean unbleached paper coffee filters? Do you make a tea or infusion then, or put these directly on the perineum?

I do both! I pour boiling water over the (single cup size paper) coffee filter in a small bowl. Let it steep for 10 min. or so and then, after checking for temp, apply it directly on the perineum. I put the leftover tea water from the bowl in the mom's peri bottle. I do this at the first day visit usually and then leave a few for the mom to use if they want to (and have time). Mom's usually love it!

You can use the unbleached coffee filters if you want. You do like you are going to make a tea, hot water etc. Put the bag in the hot water just long enough till you see the herbs leak into the water. Then press out the excess water not to much though and carefully separate the labia and set bag on sore tissues or perineum. Leave on till cold dip very fast in to the hot water and turn over the bag and use the other side do the same to the tissues. Can be repeated with same tea bag 3 times on each side.

Can't remember someone else said about stapling and carrying in post partum bag. the only thing about the staples they might rust and/or poke tender tissues. If they rust that wouldn't be very hygienic. Mine are sealed or fused together. I have someone make them. Hope this is clearer.

You can sew these up, too. By hand or by machine. That way you wont have metal staples or chemicals from glue on the perineum. I use cheesecloth fabric to make these, but coffee filters would sure be easier.

Favorite Postpartum Herbal Mixtures

• Shepherd's purse
• uva ursi
• comfrey leaves and roots
• sea salt
• calendula flowers
• lavender flowers
• 1 bulb fresh garlic
• myrrh or ginger (optional)

Yes, you can boil the fresh leaves and use them for compresses - however, the large old leaves will have those little spines on the back. Rub the leaves a lot to break the spines or wrap them in paper towels, or something similar to keep the spines from causing further irritation.

Here's something I have each of my clients make up at about 37 weeks for sore bottoms (whether they tear or not).

First make up a strong pot of comfrey tea. Bring aprox. 2 quarts of water to a boil, remove from heat then throw in clean fresh comfrey leafs. (about 8-10 large leaves or if not available, about 1/2 to 1 ounce of dried leaves). Let steep overnight or at least 4 or 5 hours.

Then take 4 to 6 large sized sanitary napkins (not the super absorbent b/c they usually contain chemicals - though all store-bought ones probably have dioxins) and cut them in half so you have 8-12 shorter ones. Cover a shallow baking pan or cookie sheet w/sides with foil and lay the pads out. Pour the tea over each pad, soaking well, then put them in the freezer. After they are frozen cover each with plastic wrap (so they don't stick together) and stack them in a container (or not) and keep frozen till birth.

After the birth remove the plastic wrap and cover a pad with a clean sterile wash cloth or several layers of sterile gauze. This feels great on the perineum, aids swelling and the comfrey (which contains allantoin) aids healing. This can go on right away and again after stitches. They can be worn for the next few days. Your regular sanitary pad helps hold it in place, of course change it after about 45 mins to an hour as it gets soggy.

Favorite bath or sitz bath herbs are comfrey (you can get fresh during summer), uva ursi (helps prevent infection), and rosemary (also fresh if you can, smells great too).

I usually order the herb baths from Cascade; however, I found this "formula" in a magazine or journal. Forgot to write down source so I don't know where I read it. Anyway, here it is:

• 1/8-1/4 cup sea salt
• 1 ounce Uva Ursi
• 2 ounces Comfrey
• 1 ounce Shepherd's Purse
• 1 clove Garlic

Most of the birth supply houses or birth herbal suppliers carry some kind of sitz herbs or perineal healing salves.  mamasoaks.com specializes in organic herbal baths to reduce soreness and swelling of the perineum.

The herbs I use for perineal compresses are the same herbs I use for the herbal bath. We start the tea for the bath while mom is in labor and then use some for the birth and the rest for the bath. They include comfrey, rosemary, shepherd's purse, uva ursi, garlic and salt.

Grated ginger steeped in the crockpot water is to increase blood circulation to the area the compress is applied to, thereby aiding in stretching. If we don't get around to using the crockpot water, we might drink it for "perking up" (but not the mom as it can increase bleeding).

We have the parents grate about 1/2 cup, put it in a clean piece of stocking and freeze. When labor starts, put frozen gingerroot in crock pot or sauce pan.

The best recovery I've had of my own stitches are the times I used a fresh comfrey tea as wash. I'd just keep a squirt bottle of lukewarm comfrey tea in the bathroom and my healing time was drastically reduced. I've also offered this suggestion to others and they have reported good results.

My Favorite Postpartum Sitz Bath Uses

1. Frozen pads - this is my favorite! - It worked so well for me after having a 3rd degree tear with stitches.  I had virtually no pain and no swelling and it was so incredibly soothing.  Many of my other clients have said the same thing.  Here's how:  make the tea as directed.  Fold sanitary napkins in half (hold top and bottom ends together with adhesive on the inside and pad on the outside).  Dip pad into tea soaking middle of the pad.  Lay dipped pads into tupperware or other container side by side.  Place waxed paper or saran wrap on top of pad layer and then make another dipped pad layer on top of that (kind of like pad lasagna!  The wax paper will keep them from freezing together and becoming one large ice cube).  Place entire container of pads in freezer before the birth to have ready.  To use: wrap one frozen pad in a nice, soft, white (no colors or design), paper towel) to prevent freezer burn).  Place in a waterproof pair of underwear (you can get Kotex Personals at any drug/grocery store and they are perfect.  They are disposable, waterproof, reasonably priced and very comfortable.)  Or you can use a disposable diaper in your own underwear also.  The Kotex Personals are much better, much more comfortable, and less bulky.  And then you just wear the frozen pad, which will help with pain and keep the swelling to a minimum, while the herbs help the area to heal.  Use a new pad each time you use the bathroom or as you like.
2. Peri Bottle - make the tea as directed.  Pour cooled tea into peri bottle and have available for rinsing vaginal/perineal area during and after urination.  This idea is recommended for use along with any of the other ways you choose to use your sitz bath herbs.
3. Sitz bath - make the tea as directed.  Pour tea into sitz bath and soak.
4. Regular bath - make tea as directed.  Add to bathwater and soak.  Great for baby too (helps heal umbilical stump).

Salt on a wound? On a mucous membrane?

yes!  I'm surprised you've never heard of this. Soaking wounds in salt water is the oldest medical treatment in history and still one of the most effective and most commonly used around the world.

salt is mildly antiseptic. Salt water promotes healing. Salt water is actually soothing to open-tissues.  You want the salt solution to be about equal to "the salty taste of blood" -- about a teaspoon tablespoon per pint.

Heat Instead of Cold

from Gloria Lemay in "Tricks of the Trade" Midwifery Today, Spring, 2009

Putting cold packs on the perineum is something we learned in Western medicine that should now be discarded in practice.  Chinese medicine says "never put cold against a new mother or baby" and I have had great success with putting heat on bruised, scraped or torn perineums right after birth.  Even thought the tissues feel "hot" after birth, hot compresses give instant relief.

Also, discomfort and swollen tissues can be caused by wearing commercial pads with "extra absorbency" chemicals.  After three or four days, the postpartum woman is well advised to stop wearing store-bought pads and switch to cotton reusable pads, cloth diapers or folded face cloths for the remaining days of lochia.

[Ed. Women birthing in warm birthing tubs have the benefit of warmth on the perineum both before and after birth.  The warmth before the birth is like a huge hot compress, which seems to help the tissues stretch nicely.  The water pressure reduces swelling during labor and birth, and the warmth after the birth seems to feel very comfortable.]

My experience has always been that if there is edema in the tissues, the cold will help the fluid redistribute back into the general circulation over the first 24 hours. Then during the second 48 hours, the warmth will bring healing fluids to the area and promote the further repair.  The only exception to this is if the woman has varicosities in the vulva and vaginal area, and then we use cold packs during pushing (instead of warm compresses) and for the following 48 hours and not warm sitz baths, to keep the fluid from accumulating in the vulvar tissues and causing further edema.

I have  heard that warmth is best for healing as it brings blood to the area, and I know that in many; traditional cultures post partum women are not allowed anything cold at all and are kept in very warm rooms.

I prefer heat and strongly recommend it.

I offer moms their choice of heat or cold, and often let them try warmth first. I've never yet had a woman who decided she preferred cold after she'd tried warmth.

I think  there is more pain relief, less swelling and faster reduction of swelling, and faster healing of any tears.

For the moms who birth in the birthing tub and stay in it for about 10-20 minutes afterwards, there is very little perineal swelling, and they often don't want any cold.

What do you use for a hot pack postpartum?  A hot water bottle? Warm washcloths?

Usually the same hotpacks which we've been using during crowning. (well, same water anyway. They need to be clean!)

Sometimes we put ginger and comfrey in the water and that's even better than plain water.

It's really easy to do --- any cloth, washcloth, diaper -- will work for a hot compress.

Someone said that women go "Ahhhh, that feels good" when they get an icepack, but I'll bet if you try a warmpack you'll hear the same thing!
Maybe a longer "Ahhhhhhhhhh".

I think that the warmth actually "prevents" swelling, not just reduces it. I've been pretty impressed with it anyway.

Fourth-Degree Care

Start her on stool softeners right away, and then encourage LOTS and LOTS of fibrous fruit juices, water and more stool softeners.  I also like vitamin C as a mild laxative and its immune-supportive effect.

Remind her not to "push" when moving her bowels, and avoid iron supplements that could be constipating.

Make sure she has a Fleets enema in case she needs one for a painful BM.

I tell moms with a repair to take a pad of toilet paper and hold it over the repair - counterpressure.  It makes them less fearful that they are pushing hard enough to rip out the sutures.

Use of Honey or Tea Tree Oil for Perineal Infection

"Raw honey is a great remedy for first-degree [perineal] tears. Honey's thick consistency forms a barrier defending the wound from outside infections. The moistness allows skin cells to grow without creating a scar, even if a scab has already formed. Meanwhile, the sugars extract dirt and moisture from the wound, which helps prevent bacteria from growing, while the acidity of honey also slows or prevents the growth of many bacteria. An enzyme that bees add to honey reacts with the wound's fluids and breaks down into hydrogen peroxide, a disinfectant. Honey also acts as an anti-inflammatory and pain killer and prevents bandages from sticking to wounds. Laboratory studies have shown that honey has significant antibacterial qualities. Significant clinical observations have demonstrated the effectiveness of honey as a wound healing agent. Glucose converted into hyaluronic acid at the wound surface forms an extracellular matrix that encourages wound healing. Honey is also considered antimicrobial." [Excerpted from "Herbs for Postpartum Perineum Care: Part I,"The Birthkit, Issue 46]

TEA TREE OIL...essential oil antifungal, antibiotic, antiviral promotes healing of tissue, reduces risk of infection bonus...relieves itching!

absolutely fantastic results with vaginal yeast, pimples, sores, bug bites, itching sites of any kind...applied neat in all but mucous membrane and large wound applications (have, out of desperation, personally applied neat vaginally/orally on myself :-}). When used on abraded vaginal tissue can cause a stinging/tingling sensation that myself and others report as fleetingly strong but welcome. The spray formula below brings cooling relief immediately in even strong candida overgrowth vaginally...just made up a new batch last evening to treat vaginal candida overgrowth of my own.

formula: 3 drops of tea tree oil (essential oil only!), 1 cup DISTILLED water, put in mister bottle and spray away

DISCLAIMER: have not yet had the need to use this with nursing newborns or cracked nipples...adapt to your situation as you see reasonable. (maybe try cutting TT to 1 drop per cup water and use on breasts between nursing??).....keep us posted, please

I've been reading the "honey" mail and thought I'd add my two cents worth. I've worked in hospitals and nursing homes over the past 23 years and have seen the sugar and or honey use for sores, bedsores (decubitus ulcers) over the years. Just thought I'd tell the theory behind it's use. The sugar supposedly feed the bacteria which caused the destruction of the dead tissue and exposed "healthy" fresh tissue. The betadine was used to kill off the unwanted more harmful bacteria or "germs". I saw this used until about 1987 or so and saw some dramatic wounds get better. Don't know if it was the sugar or not. I wouldn't use this with diabetic persons because there glucose blood levels are already potentially high sugar levels.

This honey thing sounds great, because I know that honey has some great antibacterial properties. BUT in my wound care seminar this week, we were discussing the fact that diabetics take a long time to heal. One reason given for that was the high blood sugar that diabetics have.

Hmmm.. but isn't it more a matter of the diabetic not being able to USE that sugar (since they lack insulin, or the insulin they have is no longer effective)?

Impaired circulation is certainly a large part of the problem with diabetic healing. But an important thing to remember about bacterial growth and sugar (think back, way back, to high school biology experiments with molasses and water...) is that bacteria and fungus feed on sugar, but can only thrive within a relatively narrow range of sugar- to-substrate concentration. In other words, very low concentrations of sugar provide insufficient nutrition and very high concentrations of sugar inhibit growth of bacteria. They like their sugar levels juuust right.

I was surprised to find that honey doesn't stick to the pad the way you'd expect it to.  It stays moist and soft and almost a bit slippery, forming a layer on top of the skin.

Postpartum Vulvar Dermatitis

See also: Vulvodynia / Vulvar Vestibulitis / Pelvic Pain

I had a severe dermatitis vulvar/vestibular dermatitis after giving birth to my first child in 1974.  We determined that part of the problem was an allergic reaction to 1) the betadine used for every vaginal exam in labor (my labia actually swelled shut at one point) and 2) the carrier for the topical anesthetic spray (I had previously had a similar reaction to Solarcaine spray used for sunburn!).

I do not recommend Dermoplast for that specific reason.  Epifoam is actually more soothing, if one wants an allopathic remedy.

Also - what suture material did the doc use? I have seen some pretty nasty allergic reactions to both chromic and to vicryl....has she tried PO benadryl?

Estrogen cream may be helpful, too.

Some of my clients have found the OB pads to be very irritating, especially the standard ones that might have been bleached with dioxin.  Some have found great relief by switching to NatraCare pads.

Postpartum Perineal Massage

If you had an episiotomy, you can do gentle perineal massage about 10-14 days after the birth.  This will help to prevent the formation of scar tissue.

Before resuming regular sexual activity, some women like to prepare the vaginal tissues through gentle perineal massage: put the thumb inside the vagina and put gentle pressure in the shape of a half moon from back to front or front to back.  Don't do anything that causes pain!

Long-Term Postpartum Perineal Pain

I'm wondering if any of you have had a problem similar to this.  What did you do?  How long did it take you to heal?  Are there breastfeeding-safe foods or herbs that I can consume that would accelerate the healing process? Other advice or support you can offer?

I had a  similar problem I had "a small epis" .....( that is what she said I needed after about 15 min of pushing.....but that is another story ) anyway.... sex was uncomfortable right up until my son was 10 months old,    I thought this was all a normal part of birth. what helped was astro glide. then one day it was like magic it stopped hurting, I thought to my self wow it took ten months.  personally I wouldn't mess with injections unless sex was unbearable.

This happened to me when my baby was born.  At the time, I could not find anyone who had gone through what I was going through (even in a new moms group) and I felt alone, like there was something wrong with me.  No other new moms I talked to about this had any idea what I was talking about.  It took a little over a year until it "didn't hurt" anymore.  I saw my OB who recommended steroid injections but one of the problems with that would be injections "down there" (no thanks!), and also, it just builds scar tissue faster and potentially more of it.  It "might" have helped heal faster but it would have been painful.  I cannot remember the medical definition of what I had but it was basically a hypersensitivity to touch, etc...  When the tissue at the site of the cut/tear starts to heal the nerves in that tissue re-generate.  Well, sometimes the nerves don't heal together right and that is where the sensitivity to pain/touch comes from.  Some women that experience this actually cannot wear underwear, pants, wash themselves, or even sit down!  It can last anywhere from a few months to a few years.  It is the same thing that happens to women that have had c-sections and have scar tissue problems at the site of the incision.  I saw two doctors about this and my primary care physician actually knew more about it than my OB did and was able to help me more and feel more comfortable about it.  He was great about it! :)  After talking to someone at the office I work at they recommended I go and see a pelvic floor physical therapist.  I actually went to see a specialized PT.  She did some work with me and within a couple of months or so I was "healed" to the point of no more pain.  It did take over a year to somewhat heal and it took almost two years before I got a pap again.  One thing that honestly helps and what the therapist was telling me is to do perineal massage and kegels.  (Done at a certain frequency and pressure.)  Ironically, but those are two of the things that the PT had me doing daily.  If anyone you know has this or has had this let them know that they are not alone and that there is a light at the end of the tunnel.  It will get better, with the right care/treatment and thinking.

I have a recommendation regarding slow-healing perineal tears.  Medical qigong therapy would probably help.  I do a lot of work dealing with neurological issues as chi emission activates neural transmission.  Medical qigong therapy is holistic so also can help to release emotions held in the tissues.  As the energetic bodywork is non-touch, with the client fully clothed, it would be quite appropriate for this kind of chronic health issue.

Postpartum Sex - How Soon?

6 weeks is usually mentioned because that's when the postpartum checkup is usually scheduled.  For women who've had episiotomy wounds or significant suturing of tears, it makes sense to make sure they're well healed before being subjected to the stress of intercourse.

A woman who wants to have this checked sooner than six weeks could schedule an appointment earlier.  (Six weeks is chosen as the timing for the last normal postpartum checkup because the uterus has usually completed its return to a nonpregnant state by then.  If you schedule your appointment earlier than six weeks, you might be advised to schedule another appointment to check the uterus.)

The cervical os is generally closed to infection by 3 weeks postpartum and has resumed its nonpregnant state by 4 weeks postpartum.  For  a woman with an intact perineum, her decision to resume intercourse after 4 weeks can be safely based on desire and comfort.