The Vagina Bible. Jen Gunter
You have the pain you have.
Pain after delivery is important to manage because it is important to manage. Many guidelines talk about how important it is for a woman to have pain control so she can breastfeed, but to me that ignores the fact that women need pain control because they need pain control. A healthy mother is the best thing for a healthy baby, so I am of the belief that if we focus on the mother then everything else will fall into place.
Topical anesthetics for the perineum are used in many American hospitals, but they have never been shown to be effective at reducing pain after delivery. Benzocaine, the most commonly used anesthetic for this purpose, is a common allergen, and there are rare causes of it being absorbed and leading to a severe blood condition called methemoglo-binemia. Also, when someone has stitches for other indications—for example, they accidentally cut their hand with a knife—we don’t prescribe or recommend topical anesthetics for pain control. As there is no supportive data for topical anesthetics and there is a risk of causing irritation or even an allergic reaction, give them a pass.
Evidence-based options for pain control after delivery include the following:
• ICE PACKS: Reduce swelling and pain, especially when applied for 10–20 minutes immediately after delivery.
• SITZ BATHS: Getting in a tub of warm water. You don’t have to add anything. You can even empty your bladder in the sitz bath if urine stings when it hits your skin.
• ACETAMINOPHEN AND IBUPROFEN (OR ANY OTHER MEDICATION CALLED A NONSTEROIDAL ANTI-INFLAMMATORY, OR NSAIDS): These are oral medications. Ibuprofen may be slightly better than acetaminophen. Both are safe for breastfeeding.
• KETOROLAC (BRAND NAME TORADOL): An intravenous NSAID that may be especially helpful for women with a third- or fourth-degree laceration.
• HEMORRHOID CARE: Options include astringents like witch hazel, topical steroids, and topical numbing gel or creams like lidocaine (anesthetics are okay to use here). If you have a third- or fourth-degree tear, you should not use suppositories in the rectum as this could disrupt the stitches, so only creams, ointments, or gels.
• PREVENT CONSTIPATION: Straining will hurt, can worsen hemorrhoids, and can tear stitches. Stimulant laxatives such as Senokot or lactulose are the most effective and are safe for breastfeeding. Ducosate sodium is completely ineffective. No study has shown it works, yet for some reason almost everyone recommends it. The biggest issue with a stool softener is people think they are taking something effective when they are not, and then they wonder why they are still constipated.
If your pain is not well controlled in the hospital, a hematoma (a collection of blood that rapidly expands and causes pain—think massive bruise) must be ruled out. A hematoma may need drainage or even surgery so it doesn’t lead to tissue damage or an infection.
It is also important to make sure you can empty your bladder within six hours of delivery. Urinary retention, the inability to empty your bladder, can affect up to 4 percent of women and can injure the bladder if not treated appropriately. Incontinence immediately after delivery is uncommon, so if this happens make sure to tell your doctor or midwife.
If your pain was improving and then takes a turn for the worse, do not assume that it is normal. Check with your doctor or midwife. Potential reasons could be stitches coming apart or an infection.
A word on opioids
Opioids are medications such as morphine, hydrocodone, hydromorphone, or codeine. They are often called narcotics, but that is not a medical term. Some women with a third- or fourth-degree laceration or episiotomy may need a few doses of opioid medications, although it is very important to maximize non-opioid options, as constipation is a known side effect. Opioids are also transferred into the breast milk. An opioid medication is best added in when needed on top of regularly scheduled acetaminophen or NSAIDs.
There is valid concern that opioids are overprescribed to women after delivery. One study tells us that 30 percent of women in the United States received a discharge prescription for opioids after a vaginal delivery, and the number of pills did not vary by size of the laceration or episiotomy. This is overprescribing, and whether it happens because it is a “routine” (not an excuse, just an explanation), doctors and midwives are not educated about other non-opioid medications, women ask for them, or health professionals are trying to prevent follow-up calls for pain is not known.
Studies tell us that 1 out of every 300 women who has never had opioids before delivery will become addicted if she is given a prescription to take home. It takes two doses of an opioid to develop physical dependence, meaning when the medication is stopped, physical symptoms of withdrawal, like feeling unwell and pain, appear. It is easy to mistake symptoms of withdrawal as a false sign that the opioids were helping, and so these symptoms can lead people to restart the opioid medications under the false belief that they need them medically.
Even if you take a prescription of opioids home and never use them, they can still cause harm just by sitting in your medicine cabinet. Children, especially teens, are curious about medications, and taking leftovers found in the medicine cabinet accidentally or on purpose could lead to an overdose or start an addiction.
Lochia
Vaginal bleeding after delivery is called lochia. It starts as bright red and gradually becomes paler in color due to inflammatory cells (a sign of healing in the uterus). Any leftover bits of the lining of the uterus that did not come out with the placenta may also pass with the lochia. Stitches will also add to the discharge as they dissolve.
It is normal to have a heavy, mucusy, blood-tinged, brownish, pretty gross discharge for up to eight weeks after delivery. I remember thinking this was going to go on forever, but it didn’t. You shouldn’t wear a tampon or menstrual cup for this bleeding until you get the all clear from your provider.
Checking In with Health Care Providers After Delivery
The newest World Health Organization (WHO) guidelines recommend four checkups after delivery. At each one, you should be asked about how your perineum is healing, how your bladder is working, and about your lochia, and any tear or stitches should be evaluated to ensure healing is proceeding as expected. The timing for these checkups is as follows:
• Day one (within twenty-four hours)
• Day three (48–72 hours)
• Between days seven and fourteen
• Six weeks
Healing Process: 6–8 Weeks and Beyond
By eight weeks after delivery, many women are still reporting vulvar and vaginal health issues related to delivery. The most common are hemorrhoids (23 percent), constipation (20 percent), and vaginal discharge (15 percent). However, with time, most issues resolve.
If you think your stitches have come out or your wound is falling apart, do not wait for your six-week checkup. Also, if you have an increase in pain, develop a fever, or have a foul-smelling discharge, call your provider or make an appointment. These can be signs of infection.
When to start pelvic exercises
The French system is often held up as a standard for postpartum pelvic floor therapy—the implication online is that there is a nationwide program for pelvic floor rehabilitation at 6–8 weeks postpartum, although according to the 2016 guidelines by the French College of Gynaecologists and Obstetricians (CNGOF), routine pelvic floor physical therapy is not recommended in the absence of incontinence. This is not shade on the French; they are ahead of many countries in this regard, but there does not appear to be a standardized French technique or timing.
Some recommendations for pelvic floor therapy after delivery include the following:
• Pelvic floor physical therapy should not start sooner than two months after delivery, to allow for the tissues to heal and return to baseline.
• Women who have persistent urinary or fecal incontinence at three months after delivery should be offered pelvic floor physical therapy. At least three sessions with an appropriately trained therapist are recommended, as well as home exercises.