Ep 08: Perineal tears and episiotomies - The Flow On Effect Podcast

Perineal tears and episiotomies

PODCAST EPISODE #08

CHARLOTTE CONLON AND HEIDI BARLOW ARE WOMEN’S HEALTH PHYSIOTHERAPISTS FROM FLOW PHYSIO CO, BASED IN THE SUTHERLAND SHIRE.

In today’s episode Charlotte and Heidi talk through perineal tears and episiotomies.

What is the perineum and what causes it to tear?

The perineum is the area between the vagina and the anus. 

Tears are generally sustained in childbirth.

9/10 first time mothers will experience some sort of perineum tear following childbirth - Grade 1 and 2 tears are the most common, it’s the nasty grade 3 and 4 tears we are aiming to prevent.

What are the different degrees of tearing? 

1st degree - a tear of the perineum skin 

2nd degree - tearing of the perineum skin and into the pelvic floor muscle 

3 a - <50% external anal sphincter torn 

3 b - >50% external anal sphincter torn 

3 c - external and internal sphincters are torn 

4th degree - tear through entire epithelium 

Who stitches these up, what is the process here? 

1st and 2nd degree tears are generally stitched up in the delivery suite by Dr/Obs.

3rd and 4th degree tears require you to be taken to theatres after birth to be stitched up by a team of gyno/colorectal surgeons.

What are the risk factors for tearing? 

According the the Royal Australian and New Zealand College of Obstetricians and Gynaecologists:

• First delivery 

• Asian ethnicity 

• VBAC (Vaginal birth after C-Section)

• <20 years old 

• Shortened perineal body length of less than 25mm (we measure this in the clinic) 

• Baby bigger than 4kg 

• Shoulder dystocia 

• Posterior position of bub 

• Instrumental delivery (forceps, vacuum) 

• Prolonged pushing stage in labour > 60 mins 

• Epidural use 

• Delivery in deep squatting position 

• Midline episiotomy 

What is an episiotomy and how is this different to a tear ? 

An episiotomy is where the Dr will make the decision to cut the perineum usually off to the side. It is usually done if they need to get the baby out in a hurry, if they are using instruments that need to fit in the vagina such as forceps or if they think you are likely to suffer a nasty tear.. Often healing is a little more painful with this.

Can you have both a tear and episiotomy ? 

Unfortunately, yes. It is not very common but it does happen as you can tear in a different place to where the episiotomy is done.

Can anything else tear? 

Yes, anything in the vulva area can tear.

The labia is also a common place to tear.

What do you do in the early days postpartum if you have a tear or episiotomy?  

1. Manage bowels (fluid, diet, laxatives, stool softeners) - no straining, wait for natural urge 

2. Supporting the area when defecating

3. Ice 10 mins on 10 mins off 

4. Wear comfortable maternity pads that do not irritate the area such as TOMS organic brand 

5. Keep the area clean 

Does this management differ between the grades of tears? 

3rd and 4th degree tears need more specific care, likely the surgeons will tell you not to use toilet paper and to use a spray bottle and dab clean instead.

What is the follow up care on tears?

Everyone should have a follow up after birth, no matter whether you tear or not. 

Generally if you have a 3rd or 4th degree tear you will get a referral to a physio in the hospital and also have endoanal scans at 6 months to track how it is healing. You will also have follow ups with both your GP/obstetrician and colorectal surgeons. 

When should women see a pelvic floor physiotherapist? 

The general rule is at around 6 weeks post partum, after seeing your GP/Obstetrician. This is when we can perform an internal vaginal or rectal examination to check your pelvic floor muscles. However, we can still see women before this time if they are having any issues or concerns.

Do tears/episiotomies have long term issues ? 

Generally, no, but some can. The main complaint is of pain or increased sensitivity along the scar. Pain with intercourse can also be an issue as the partner hits the sensitive scar tissue.

Is there anything that can help with the pain ? 

We teach women scar tissue massage that women can start from 6 weeks to try and desensitise the area.

Therapeutic ultrasound and TENS can also help to reduce the scar tissue sensitivity and pain in the area.

Sometimes the area can become really dry and sore due to low Oestrogen while breastfeeding and if this is the case, your GP can prescribe an Oestrogen cream that can be applied to the area to help with this.

Is the management different for 3rd/4th degree tears ?

The initial management is much the same in the initial weeks after birth. However, because the anal schincters are involved, some women experience fecal urgency, they have have the inability to hold wind in or a feeling that wind escapes without their control, and they may experience fecal incontinence. At one year follow up 20-40% of women with these 3rd and 4th degree tears have fecal and wind incontinence.

Why does this fecal urgency and incontinence happen? 

Our internal anal sphincter which is made of smooth muscle which we have no active control over, is responsible for 70% of our rectal control when there is a stool inside. 

Our external anal sphincter which is made of skeletal muscle which we can voluntarily contract, is responsible for 30% of control. 

Therefore, if there is damage to the external sphincter muscles we can lose up to 30% of our ability to control our bowels. That’s why pelvic floor exercises are crucial. 

When should women start pelvic floor exercises? 

Straight away! Once you have emptied your bladder for the first time after giving birth, light gentle squeezes can help with reducing swelling and gaining the connection back to the pelvic floor. 

Does having a tear affect future deliveries? 

For 1st and 2nd degree tears and episiotomies, there is generally no implication provided the recovery has been fine and they are not experiencing any long term issues.

For 3rd and 4th degree tears, the advice normally is not to give birth vaginally again. However, if it is something you really want, normally your care team can try and accommodate. 

What can we do to prevent tearing and episiotomy ? 

1. Perform perineal massage starting from 36 weeks in pregnancy

2. Use of the Epi-No device - an alternative to doing perineal massage is using a device to help stretch the entrance.

3. Ensure the pelvic floor muscles are able to relax well

4. Use a wet washer for heat compression inbetween contractions/pushing in labour 

5. Maintain mobile hips in pregnancy 

6. Trying to avoid giving birth in a deep squat position 

Thank you for listening!

Thanks for joining us for this episode. We’d love to hear if you have any questions or feedback! Let us know in the comments section below.

If you enjoy listening to this podcast, please share or leave a review for us. We’d love to know what you think.

Materials and information shared are for educational purposes only.

Ep 07: Pain with sex - Dyspareunia

PODCAST EPISODE #07

CHARLOTTE CONLON AND HEIDI BARLOW ARE WOMEN’S HEALTH PHYSIOTHERAPISTS FROM FLOW PHYSIO CO, BASED IN THE SUTHERLAND SHIRE.

In today’s episode Charlotte and Heidi talk through Dyspareunia (or pain with sex), including:

What is dyspareunia? 

How common is dyspareunia? 

Is it just about pelvic floor muscle tightness? 

What is vaginismus?

What are the symptoms of vaginismus? 

What causes the muscles to be tight? 

What are the treatment options for vaginismus?  

What is vulvodynia? 

What causes vulvodynia? 

Does this make treatment harder?

What are the treatment options for vulvodynia? 

Why do some women experience dyspareunia post-partum?

Treatment options for women who have dyspareunia post partum

Thank you for listening!

Thanks for joining us for this episode. We’d love to hear if you have any questions or feedback! Let us know in the comments section below.

If you enjoy listening to this podcast, please share or leave a review for us. We’d love to know what you think.

Materials and information shared are for educational purposes only.

Ep 06: Pelvic Girdle Pain - The Flow On Effect - A Women's Health Physio Podcast

PODCAST EPISODE #06

CHARLOTTE CONLON AND HEIDI BARLOW ARE WOMEN’S HEALTH PHYSIOTHERAPISTS FROM FLOW PHYSIO CO, BASED IN THE SUTHERLAND SHIRE.

In today’s episode Charlotte and Heidi talk through Pelvic Girdle Pain, including:

What is included in the term pelvic girdle pain and where does it present in the pelvis?

So why are these conditions so common in pregnancy?

What symptoms might someone present with in pregnancy that would lead us to think they have PGP?

When does it normally come on in pregnancy ?

How do we treat PGP?

How can women modify what they are doing day-to-day to help reduce the irritation through the joint?

Is it likely to get better in pregnancy?

What exercise is safe to do?

Can it stay around after you have given birth?

What can be done if it does hang around? 

Thank you for listening!

Thanks for joining us for this episode. We’d love to hear if you have any questions or feedback! Let us know in the comments section below.

If you enjoy listening to this podcast, please share or leave a review for us. We’d love to know what you think.

Materials and information shared are for educational purposes only.

Ep 05: Overactive Bladder with Women's Health Physiotherapists Charlotte Conlon and Heidi Barlow

PODCAST EPISODE #05

CHARLOTTE CONLON AND HEIDI BARLOW ARE WOMEN’S HEALTH PHYSIOTHERAPISTS FROM FLOW PHYSIO CO, BASED IN THE SUTHERLAND SHIRE.

In today’s episode Charlotte and Heidi talk through an overactive bladder (OAB), including:

• What is overactive bladder (OAB)? 

• What exactly is urgency ? 

• How does this differ from a “strong urge”?

• What happens when a normal bladder is filling compared to when the bladder is overactive?

• What are the symptoms?

• What age do people get OAB? 

• What is a normal amount of times to go to the toilet daily?

• Possible causes

• Treatment options

Thank you for listening!

Thanks for joining us for this episode. We’d love to hear if you have any questions or feedback! Let us know in the comments section below.

If you enjoy listening to this podcast, please share or leave a review for us. We’d love to know what you think.

Materials and information shared are for educational purposes only.

Ep 04: Abdominal Separation (aka Diastasis Recti)

PODCAST EPISODE #04

CHARLOTTE CONLON AND HEIDI BARLOW ARE WOMEN’S HEALTH PHYSIOTHERAPISTS FROM FLOW PHYSIO CO, BASED IN THE SUTHERLAND SHIRE.

In today’s episode Charlotte and Heidi talk through abdominal separation in pregnancy (also known as diastasis recti), including:

• What is a diastasis recti

• What is the linea alba

• What happens during pregnancy

• What are things should you look out

• Is it normal

• When is it considered abnormal

• What are the risk factors

• What can you do about it

• How can a Women’s Health Physio help

• General recommendations for managing abdominal separation postnatally

• Interesting exercise research

Thank you for listening!

Thanks for joining us for this episode. We’d love to hear if you have any questions or feedback! Let us know in the comments section below.

If you enjoy listening to this podcast, please share or leave a review for us. We’d love to know what you think.

Materials and information shared are for educational purposes only.

Ep 03: Pelvic Organ Prolapse

PODCAST EPISODE #03

CHARLOTTE CONLON AND HEIDI BARLOW ARE WOMEN’S HEALTH PHYSIOTHERAPISTS FROM FLOW PHYSIO CO, BASED IN THE SUTHERLAND SHIRE.

In today’s episode Charlotte and Heidi talk through the pelvic organ prolapse and management strategies.

Pelvic Organ Prolapse

What is a pelvic organ prolapse?

There are three organs in the female pelvis. The bladder, uterus and the rectum. A pelvic organ prolapse is the slipping down of one or more of the pelvic organs into the vagina. 

How common is it?

1 in 2 women who have had a baby will experience prolapse symptoms at some stage in their life. 

How does it occur?

In understanding how prolapse occurs, you first need to understand what normally holds the pelvic organs up in place. Two main support structures:

1. Fascia

2. Pelvic floor muscles 

The fascia is the primary support holding the organs up inside the pelvis.

Stretch and damage to the fascia can occur due to increased downwards pressure during the pushing stage of labour. It can also result from chronic constipation due to long term straining.

The strength of the fascia is dependent on your genetics. Women who have loose connective tissue are at higher risk of getting a pelvic organ prolapse, whereas women who have strong connective tissue have a lower risk.

Therefore, a woman with a strong pelvic floor can still have a prolapse if there is damage or stretch to the fascia. We like to refer to the pelvic floor muscles as the “back up” support system to the fascia support system. 

What types of prolapse are there?

The type of prolapse is defined according to which organ is slipping down.

In a uterine prolapse, the uterus drops down into the vagina. This is sometimes called a urethrocele. 

In a bladder prolapse, the bladder drops down and creates a bulge into the anterior wall of the vagina. This is sometimes called a cyctocele.

In a rectal prolapse, the rectum drops down and creates a bulge into the posterior wall of the vagina. This is sometimes called a rectocyle.

How is the severity of the prolapse determined?

The stage of the prolapse is determined by how far the organ(s) is descending into the vagina. 

Stage 1: The organ descends into the upper half of the vagina/vaginal wall

Stage 2: The organ descends into the lower half of the vagina/vaginal wall

Stage 3: The organ descends past the entrance of the vagina

Stage 4: The organ descends out completely

What symptoms might someone have if they have a pelvic organ prolapse?

• Heaviness or dragging sensation in the vagina, lower abdomen or lower back 

• Lump or a bulge in the vagina

• Incomplete emptying of the bladder or bowel 

• Discomfort with sexual intercourse 

Can a prolapse be fixed?

It is important to be aware that we cannot “cure” a prolapse, we can not magically fix the damage to the fascia however we can definitely make you symptom free and stop the prolapse from worsening overtime. 

What does treatment involve?

There are three goals for treatment of prolapse: 

1. Increase upward support

2. Reduce strain down through the organs and fascia

3. Symptom management

1. Increase Upward support

PELVIC FLOOR MUSCLE TRAINING

By strength training the pelvic floor this can help take the strain of the fascial support system and for many women can take away the symptoms of prolapse. We need to work on the coordination, power and endurance of the pelvic floor muscles. 

INTERNAL SUPPORT

Pessaries are a medical grade silicone support system that can work for many women to help provide upward support to the pelvic organs and fascia. See pessary section for further information. 

EXTERNAL SUPPORT

Many women find wearing supporting clothing such as the EVB compression underwear or activewear helps manage symptoms of prolapse. 

Strengthening of the pelvic stabiliser muscles can also give some added support so general lower and upper body strength training is essential. 

2.  Reduce strain down through the organs and fascia 

REDUCE HEAVY LIFTING 

Reduce heavy lifting where possible. We want to try to avoid lifting anything that makes us hold our breath. This increases intra abdominal pressure and can put added strain on the fascia. This does not mean that you can never lift heavy again, we need to slowly build your lifting capacity up so that your pelvic floor and others muscles can tolerate the load. 

MANAGE CONSTIPATION 

Sitting on the toilet and straining puts a lot of stress on the fascia and doing this daily can be very detrimental. Make sure you are drinking plenty of fluid and eating a balanced diet. Talk with your GP about medication that could help if things are not improving 

MANAGE RESPIRATORY CONDITIONS 

Coughing can put a lot of strain on your fascia so managing symptoms of this is crucial.

MANAGE BODY WEIGHT

If you are overweight this can put lots of strain on your pelvic floor and fascia. 

3.  Symptom management 

REST IN A SUPINE POSITION DAILY 

Resting for 10-15 minutes in a supine position as shown below can give the fascia and pelvic floor muscles a break from gravity and it can be really helpful with symptoms.

TOILET HABITS

If you have trouble with urinating and feel like the urine will not come out or you struggle to empty your bladder: 

• Lean forward if you have a bladder prolapse this can allow for easier emptying or standing up move hips around sit back down and try again 

• Lean back if you have a uterine prolapse this position may be helpful to empty your bladder

If you are having trouble emptying your bowels your prolapse is most likely from the posterior wall (rectum):

• Leaning back can help emptying the bowels

• Pressure on the perineum (area of skin between the vagina and anus) can help gently lift the prolapse. This can also be done internally by putting a thumb inside to gently push the rectum back while emptying your bowels, if this helps talk to us about tools we can send you that aid with this. 

What is a pessary? 

Pessaries do not work for everyone, about 80% of women find relief from them, but we like every woman to know what they are and that they are an option to help support their prolapse and minimise symptoms. A pessary is a silicone device that is inserted by a physiotherapist or gynecologist, into the vagina to help support a pelvic organ prolapse . A pessary can be very useful to help you continue  to be physically active and participate in chosen activities which may typically worsen a prolapse. A pessary can be worn all the time or it can be worn just when demands are high i.e. when running or jumping. 

Every woman's body and their prolapse is different therefore the type and size of pessary will vary immensely from woman to woman. The type and size will depend on the type of prolapse, the symptoms it causes and your anatomy. The pessary has to be fitted correctly and it may take several tries to get the right one. 

Can I have surgery ? 

For some women if conservative approaches are unsuccessful, surgery is an option that women can consider. It is never the first line approach and we highly recommend trialing conservative management including pelvic floor exercises and a pessary for at least 6-12 months. It is also important to remember that surgery is not successful on everyone and if you continue to have downward pressure on the area such as constipation or increased body weight the surgery can often fail, so it is important that all the conservative options are exhausted first.  

Thank you for listening!

Thanks for joining us for this episode. We’d love to hear if you have any questions or feedback! Let us know in the comments section below.

If you enjoy listening to this podcast, please share or leave a review for us. We’d love to know what you think.

Materials and information shared are for educational purposes only.

Ep 02: The Pelvic Floor with Charlotte Conlon and Heidi Barlow

PODCAST EPISODE #02

CHARLOTTE CONLON AND HEIDI BARLOW ARE WOMEN’S HEALTH PHYSIOTHERAPISTS FROM FLOW PHYSIO CO, BASED IN THE SUTHERLAND SHIRE.

In today’s episode Charlotte and Heidi talk through the pelvic floor, including:

• What is the role of the pelvic floor and why is so important?

• The anatomy of the pelvic floor

• How they teach women to do their pelvic floor?

• What are the things some women are doing incorrectly when trying to squeeze their pelvic floor?

• How can you strengthen your pelvic floor?

• How often do you need to do pelvic floor exercises?

• Can you get an exact measure of pelvic floor strength?What is overflow incontinence? 

• What if someone can’t squeeze their pelvic floor?

• What symptoms might someone experience if they have weakness in their pelvic floor muscles?

• Can the pelvic floor muscles be too strong?

• What can happen if the pelvic floor is too tight?

• How can physio help with a tight pelvic floor?

Thank you for listening!

Thanks for joining us for this episode. We’d love to hear if you have any questions or feedback! Let us know in the comments section below.

If you enjoy listening to this podcast, please share or leave a review for us. We’d love to know what you think.

Materials and information shared are for educational purposes only.

Ep 01: Urinary Incontinence with Charlotte Conlon & Heidi Barlow

Podcast Episode #01

Charlotte Conlon and Heidi Barlow are Women’s Health Physiotherapists from Flow Physio Co, based in the Sutherland Shire.

In today’s episode they introduce themselves and talk through urinary incontinence, including:

• What is stress urinary incontinence? 

• What symptoms would someone present to the clinic with? 

• What are the treatment options for SUI? 

• What is urgency and urge incontinence? 

• What are the symptoms of urge urinary incontinence?

• What are the treatment options? 

• What is overflow incontinence? 

• Who should women see if they think they have this? 

• What is mixed incontinence? 

Thank you for listening!

Thanks for joining us for this episode. We’d love to hear if you have any questions or feedback! Let us know in the comments section below.

If you enjoy listening to this podcast, please share or leave a review for us. We’d love to know what you think.

Materials and information shared are for educational purposes only.