Stitches and bruising

Why might I need to have stitches?

You may need stitches after you've given birth to your baby vaginally. The area between the opening to your vagina and your back passage (called the perineum) may stretch so far that it tears a little as your baby is born. Your perineum is very stretchy. Even so, your baby may need a bit more room on his way out, resulting in a tear.

About seven out of ten mums tear to some degree when giving birth (Li et al 2011). This may sound alarming, but most tears are minor and don't need stitches. (It's possible that massaging your perineum in the weeks before your baby's birth helps it to stretch better on the day. Some midwives teach this in antenatal classes (Stepp et al 2006).) Your midwife or obstetrician will examine you carefully after you've given birth to see if you've torn, and if so, how far.

You'll also need stitches if you had a cut (episiotomy) to your perineum to help your baby out into the world. In Australia, around 13 per cent of women have an episiotomy (Li et al 2011). Episiotomies are often carried out if your baby needs help to be born with instruments such as forceps or ventouse. Occasionally, episiotomies go on to tear after the cut has been made.

As well as having a tear or needing a cut, you're likely to have some bruising. It's generally caused by the pressure of your baby's head passing through your vaginal opening. If you needed help to birth your baby, the forceps and ventouse are likely to leave you with bruises. Just having stitches for a tear or episiotomy can also leave you bruised.

Which kind of tears need stitching?

Your tear will be checked for how far it has gone. There are four degrees of tear:

• First-degree tear: a small, skin-deep tear that usually heals on its own and doesn't need stitches.
• Second-degree tear: a deeper tear that has torn the muscle as well as the skin and usually needs stitches.
• Third-degree tear: a deep tear that affects the skin and muscle of the perineum. The tear goes down into the sphincter of your anus and always needs stitching.
• Fourth-degree tear: a severe tear that reaches further than the sphincter of your anus and extends into your rectum and always needs stitching.

What makes it more likely I'll have a severe tear?

Only one or two mums in every 100 giving birth vaginally has a third or fourth-degree tear (Li et al 2011). It's hard to predict who they'll be. This is why severe tears are difficult to prevent. However, we do know that you may be more prone to having a severe tear if:

• you are having your first baby
• your baby is born in the back-to-back position
• your baby weighs more than 4kg (8lb 3oz)
• your baby has to be born with the help of forceps
  (Eason et al 2000, Herlihy 2003, Hudelist et al 2005, Macarthur and Macarthur 2004, Stepp et al 2006, Wu et al 2005)

We don't know whether having an epidural increases your chance of tearing badly. The decision to have an epidural may be linked to other events in your labour which lead to the tear itself (Albers et al 2007).

How is the stitching done?

If it's a simple tear, you won't need to leave the room where you've given birth. Your midwife or obstetrician will give you a local anaesthetic to numb the area. Then she'll quickly stitch up the tear. She'll probably use a running stitch, which is one thread that goes from side to side, rather than several stitches. This should be more comfortable for you (Kettle et al 2002, Morano et al 2006).

If you have a third or fourth-degree tear you'll be taken to an operating theatre, so an obstetrician can stitch your tear. You'll have an anaesthetic to stop you feeling any pain. This will probably be a local anaesthetic, via a spinal or epidural, which will numb the area. Occasionally, a general anaesthetic, where you're put to sleep, will be needed (RCOG 2007: 4).

You'll have a fine tube (catheter), passed into your bladder to collect your urine. This will make it easier for your perineum to recover. Painkillers will help you with pain relief once the anaesthetic has worn off. You will need lots of rest for the 24 hours after your stitches are put in. You will be advised not to sit for long periods, though.

How can I speed up the healing?

It's important to keep your stitches clean. This will reduce the chance of getting an infection in your wound (NICE 2006: 15). You can try these tips, too, to help you heal (RCOG 2008: 3):

• Take a shower or bath at least once a day.
• Change your sanitary pad regularly. Wash your hands before and after you do so.
• Keep doing your pelvic floor exercises. This may be the last thing you feel like doing. But it's really important for your health now and in the long run. It will reduce swelling, help you heal by bringing the blood flow to this area, and prevent leaking from your bowel or bladder (Hay-Smith et al 2008).
• Drink plenty of water every day and eat fibre-rich foods. This is to help you avoid becoming constipated. You'll be much more comfortable if you can open your bowels easily.

If you've had a third or fourth-degree tear, you may be advised to take antibiotics to guard against infection. You'll also be given laxatives to make it easier for you to go the toilet without straining your stitches(RCOG 2007: 5,RCOG 2008: 2).

How can I soothe the tender area?

If your stitches are really bothering you while you're waiting for them to heal, try these tips:

• Put a cooled gel pad, a bag of crushed ice or frozen peas, on your perineum (NICE 2006: 15). Wrap the ice pack in a clean, damp cloth first to make it more comfortable to use and to protect your delicate skin.
• Pour a jug of warm water over the area when you wee. This will dilute your urine and help reduce the sting.
• If it's uncomfortable to sit, try lying on one side or tilting your body to one side for the first few days. A rolled up towel wedged behind you may help support you to lie tilted to one side.
• Have a warm bath. You may like to put a few drops of lavender oil or tea tree oil in the water. There's no evidence it'll help you heal, but you may find it comforting. Pat your stitches dry with a clean, soft towel.
• Take painkillers. Try paracetamol first, then ibuprofen if you need something stronger. You can still breastfeed while taking these painkillers (RCOG 2008:2). If ordinary painkillers don't work for you, your doctor may prescribe more powerful ones (NICE 2006: 15).
• Take it easy. Being up and about is good for your circulation, but listen to your body. If you've got a heavy, dragging feeling in your perineum, take the weight off your feet for an hour or so.

Read more about easing perineal pain.

When should I seek help?

Most mums find that their tears or episiotomies heal well. The bruising usually gets better within a few days and your stitches should heal within three to four weeks of your baby's birth. By two months you should be pain-free (Andrews et al 2008) Most women fully recover from tearing within a year, however for some women there are ongoing issues and you should always see your doctor if you have any pain, leaking or discomfort.

Your doctor or midwife will ask you if you've got any concerns at your postnatal check-up. Make an earlier appointment if you're worried. You should ask for help if:

• your stitches become more painful or smelly, as you may have an infection
• you have to rush to the toilet when you need to move your bowels
• you can't control your bowels when you break wind
• you have any other worries or concerns
  (RCOG 2008: 3)

If the thought of resuming your sex life makes you feel anxious, you may want to discuss your worries with your doctor, midwife or child health nurse. It's only natural to feel concerned about sex if you've had stitches and bruising. Worrying about how your stitches have healed can make you even more fearful (Brauer et al 2007).

It will also help to share your feelings with your partner. Tell him if you are worried about having sex again. You could try a little foreplay with your partner to make you relaxed and aroused. The important thing is to take it slowly. Only try full intercourse when you feel completely ready.