I am thrilled to have Obstetrician, Dr Colin Walsh, back on the blog to answer all your burning questions on vaginal birth recovery….
Why do we need to talk about vaginal birth recovery?
Pregnancy is one of the most physically stressful processes that can happen to your body and labour is like running a marathon! Don’t expect to bounce back immediately. You need time to adjust and recover, even after the most straightforward of births.
Keep in mind there is a spectrum of vaginal births, from spontaneous deliveries through to assisted births using vacuum or forceps. Don’t assume that one type of birth is automatically better or worse. I’ve seen women who had instrumental deliveries moving around easily on Day 1 and spontaneous vaginal births where women took much longer to recover. Try not to compare yourself to other women because every birth is different.
You can improve your recovery by following some simple advice and by knowing when to ask for help.
What should you expect in the first few days?
Use the time in hospital to get back on your feet, bond with your baby and learn enough to feel confident about going home.
Initially, the doctors and midwives will keep a close eye on your vital signs, bleeding, pain levels and any medical problems you might have. It is really important to make sure you are medically stable and well, so bear with the healthcare team during these frequent checks.
If you had an epidural, it will take a few hours for the movement and sensation to return to your legs. Please don’t try to get out of bed on your own. Wait until your midwife gives the ok and is there to assist.
You can eat and drink immediately after birth (unless medical staff say otherwise). Start with small meals and avoid anything too sugary, spicy or fatty. During labour your digestion slows down, so eating heavy or unhealthy foods straight away will make you feel sick. As your appetite increases, aim for a healthy balanced diet with plenty of fibre. Keep your fluids up, particularly if you are breastfeeding.
Once you are on the postnatal ward, get moving! This is one of the main things you can do to improve your recovery. You might be sore initially but we can give you pain relief. Moving around reduces your chance of blood clots, gets your bowels working and helps you return to normal daily activities.
Expect your body to feel quite different in the first 24-72 hours. You will get period-like cramps as your uterus contracts down to a smaller size. Breastfeeding releases hormones that cause uterine contractions, so the cramps often peak at feeding time. It is safe for the majority of women to use simple pain killers such as paracetamol and ibuprofen.
The birth process also stretches the vaginal and perineal tissues and often causes mild bruising and grazes. (The perineum is the area between your vagina and anus). Ice packs are very helpful to reduce perineal swelling and discomfort. Urinary alkalinisers (e.g. ural) can relieve the stinging associated with grazes.
Take advantage of the wealth of knowledge offered by the postnatal midwives and lactation consultants. They can advise you on normal baby behaviours, feeding, bathing, changing and settling – all key skills to help you feel confident about going home.
How do you know if your bleeding is normal?
You will have vaginal bleeding after any birth. Your uterus, including the lining, grew a lot during pregnancy. There is also a raw area on the uterus where the placenta has come away. Normal postpartum bleeding is called the “lochia” and it occurs as the uterus slowly returns to its pre-pregnancy state.
Immediately after birth, the midwives and doctors will keep a very close eye on the amount of bleeding. They will also regularly check your fundus (the top of the uterus) by feeling your abdomen. We want to feel a nice firm fundus, at or below the level of your belly-button.
The lochia will be heaviest immediately after birth and will slowly decrease until it ceases altogether. It will start off bright red and slowly turn to old brown over several days or even a few weeks. Think of the lochia as being like a heavy, prolonged period.
However, around 10% of women will need treatment for excessive blood loss. This is called postpartum haemorrhage. Haemorrhage can occur immediately or anytime up to 6 weeks after the birth. Immediately notify your midwife or obstetrician if you experience any of the following:
- Soaking more than one pad per hour
- A sudden return to period-like bleeding, after the lochia had significantly slowed or stopped
- Passing large clots
- Feeling dizzy or faint
- Severe abdominal pain
- Fevers
- Foul-smelling vaginal discharge
What about your bladder and bowels?
Immediately after the birth, you may have a catheter in your bladder. This will be the case if you had an epidural, or if you have tears or severe swelling near the urethra. Both of these situations can stop you from emptying your bladder. The catheter prevents damage to your bladder while the anaesthetic or swelling has time to resolve. The catheter is usually removed after one night.
Initially, you may notice changes when passing urine. Take note of any difference in the feeling of needing to empty your bladder, difficulty passing urine, poor stream or incontinence. Don’t panic if you experience these symptoms – for the majority of women the symptoms will resolve within a few days. However, please discuss the symptoms with your midwife and doctor so we can put a plan in place.
It’s normal to be frightened of opening your bowels for the first time. Do not hold back though! Getting your bowels working properly is really important for your comfort and the healing of your perineum. Reduce the chance of constipation by drinking at least 3.0 L fluid per day and eating a high-fibre diet. If it is hard to open your bowels, please let us know early so we can start you on laxatives. I cannot emphasise enough the importance of treating constipation as early as possible.
Help your bladder and bowels by using the correct sitting position on the toilet. Place your elbows on your knees, lean forward and ideally support your feet on a low stool.
As soon as you are comfortable, start pelvic floor exercises. If you aren’t sure how to do PFEs, ask to see a physiotherapist before you go home from hospital.
A final word on bowel and bladder symptoms. We expect you to notice changes in the first few days. Equally, we expect those symptoms to resolve, or at least show significant improvement, within a couple of weeks maximum. If your symptoms are not improving please talk to your doctor or women’s health physiotherapist.
I worked for several years in a specialist Pelvic Floor Clinic and it amazed me how many women had put up with years of terrible incontinence and pelvic floor symptoms because they were told it was normal after childbirth. Persistent symptoms are not normal. Treatment is available. We should be taking a more pro-active approach to postpartum pelvic floor care. I personally think most women would benefit from seeing a women’s health physiotherapist 6 weeks after a vaginal birth.
What should you know about vaginal tears?
Once the baby and placenta are delivered, your doctor or midwife will check your vagina and perineum. Provided there is no emergency, the check can be done while you are enjoying skin-to-skin time with your new baby.
Birth often causes the vagina or perineum to tear. A small number of women may also need an episiotomy. Large tears and episiotomies must be stitched back together. We repair tears as soon as possible after birth, to reduce blood loss and infection.
Tears in the perineum are graded from 1st degree through to 4th degree.1st degree tears involve the skin and 2nd degree tears also involve the perineal muscles. These tears are common and can be repaired fairly easily. The majority of women with1st and 2nd degree tears will recover well, with no long-term problems.
3rd degree tears extend from the vagina into, or through, the anal sphincter (the ring of muscle around the anus). 4th degree tears go through the sphincter and all the way into the anus. Overall, 3rd and 4th degree tears occur in around 3-4% of deliveries.
The anal sphincter gives you control over your bowels. If it is damaged, you can become incontinent, meaning you leak faeces or wind. 3rd and 4th degree tears require special care, both at the time of repair and during your recovery. You’ll be prescribed antibiotics and laxatives and usually you’ll see a women’s health physiotherapist before leaving hospital.
If you’ve had a 3rd or 4th degree tear it’s important to have a follow-up appointment with an experienced obstetrician. When I ran the Perineal Tear Clinic, I usually saw women back around 3 months after the birth. I found this was a good time to assess how well the perineum had healed and identify any ongoing problems. This should be in addition to seeing your Women’s Health Physiotherapist at 6 weeks postpartum.
How do you look after your stitches?
The stitches we use are designed to dissolve with time, so you do not need to have them removed.
Keep your stitches clean and dry. Change your pad frequently throughout the day, even if it is not soaked. Shower at least once a day and wash the area with warm water after using the toilet. Gently pat dry each time. If you are struggling to dry the area, you can try one of two things. The first is to use a hair dryer on the cold setting only (do not use the hot setting, you’ll burn yourself). The second is to expose the area and allow it to air-dry.
Avoid applying anything that might be irritating to the wound. This includes highly perfumed soaps and washes, Sitz baths, essential oils or any type of cream/ointment. Really, apart from keeping the wound clean and dry, it’s best to leave it alone.
When resting or feeding, try lying flat or on your side to reduce perineal swelling. Avoid donut cushions as the shape may worsen swelling. This in turn puts pressure on your stitches. If you do notice swelling or discomfort, apply an ice-pack for 20 minute intervals several times a day.
Support your stitches gently with your hand when coughing or opening your bowels.
Your stitches will initially be sore. We usually prescribe painkillers for the first few days. The pain should improve each day and most women will be able to stop pain medication within one week. Once the wound starts to heal, it’s common to feel some itching over the stitches. Try not to scratch as this can disturb the delicate new skin.
Keep an eye out for signs of infection. Notify your obstetrician if the stitches become very painful, the surrounding skin looks very red and angry, there is purulent discharge or you develop fevers.
Occasionally, women may experience persistent scar pain or painful intercourse. If you are still symptomatic after 3 months please see your obstetrician and women’s health physiotherapist.
The baby blues and postnatal mental health:
Around Day 3 to 5, a significant number of women experience mood swings, sadness, anxiety or anger. This is often referred to as the “baby blues.” The mood changes are largely due to fluctuations in key hormone and neurotransmitter levels. Sleep deprivation and the upheaval of having a newborn baby certainly contribute.
The good news is that for most women, the baby blues will pass in a few days. During this time, don’t be afraid to ask your friends and family for understanding, support and practical help. They are probably desperate to be helpful!
Some women will experience more than the baby blues. Post-natal anxiety and depression are common, affecting more than 1 in 10 new parents (both mums and dads). As well as feeling sad or anxious, you may feel angry, irritable, have trouble sleeping, notice a changed appetite or feel detached from your baby and partner. If these symptoms last more than a few days, are severe or you have any thoughts of hurting yourself, please seek medical help immediately. Your GP and obstetrician are good points of first contact.
If you are experiencing a crisis and need immediate help, please call:
- Lifeline on 13 11 14 (24 hours a day)
- Perinatal Anxiety & Depression (PANDA) National Helpline on 1300 726 306 (Mon-Fri 9am to 7.30 pm AEST/AEDT)
Bio:
Dr Colin Walsh is an Obstetrician, Gynaecologist and accredited Maternal-Fetal Medicine specialist. He has advanced qualifications and extensive experience in high-risk obstetrics and female pelvic floor disorders, having completed major fellowships in both these areas. He undertook his specialist training in Dublin, New York, Cambridge and Sydney, finding this international experience invaluable in his practice today. Before entering full-time private practice, he ran the Medical Disorders in Pregnancy Clinic at Royal North Shore Hospital for five years. He has published more than 90 scientific papers, written chapters for major medical textbooks, acted as a reviewer for international medical journals and holds a PhD from the University of New South Wales.
Colin provides comprehensive antenatal care, birth and post-natal care for both low-risk and high-risk women. Contact Colin at:
Email: info@drcolinwalsh.com.au
Social: @drcolinwalsh