Perineal Repair – Numb or Not?
The baby came out through the vagina, the placenta passed through shortly after, and now there may be a need for perineal repair…
A perineal tear is a laceration of the soft tissue between the opening of the vagina and the anus. As we know, vaginal birth is the primary cause of perineal tearing, and these tears range in levels of severity from a 1st through 4th degree laceration.
A 1st degree laceration, more commonly referred to as a superficial tear, effects the outermost layer of skin and tissue. These tears or in some cases, abrasions, may heal on their own and may not require any sutures. In some cases, a single suture or more is necessary. The discomfort associated with a 1st degree laceration typically dissipates within a couple of days as the swelling associated with birth decreases.
A 2nd degree laceration is a deeper tear that effects the skin, and the muscle under the skin and may extend into the vagina. This degree of laceration requires sutures for repair and may take a few weeks to thoroughly heal. Pain and discomfort is likely associated with this tear (and the repair of it) and may last a couple of weeks. It is expected that the discomfort will become less and less as days progress. The sutures used are self-dissolving and do not require removal.
A 3rd degree laceration is a deeper tear that effects the skin and the perineal muscle and extends into one or both of the muscles surrounding the anus. This degree of laceration requires sutures for repair and should be performed by a medical doctor. This tear and perineal repair may take many weeks to months, for complete healing.
A 4th degree laceration is a very deep tear that effects the skin and the perineal muscle as well as the muscles surrounding the anus. This tear goes through the anal sphincter, into the anal canal and mucous membrane that lines the rectum (rectal mucosa). Similar to a 3rd degree laceration, this degree of tearing requires perineal repair by a medical doctor and can take months for complete healing.
So let’s talk about these perineal repairs….
We’re doulas and we support our clients, right?
We are not medical professionals and we have not been trained on how, when or where these repairs should take place. But there are some scenarios that impact us as doulas and how we navigate them can be quite a dilemma.
Let’s say we are with a client who has had a 1st degree laceration and it has been decided by the provider that a single “stitch” is necessary. Let’s imagine that that client has had no pain medication during the birth, therefore is not numb in that area.
The provider says, “You only need one stitch and I’d have to “poke” you with the needle to numb you, so I’ll just do the stitch without it.”
The client ends up needing 2 or 3 stitches and is writhing in pain. You are doing your very best to support them but are simply not sure how to coach someone through the pain of having their vagina sewn back together without pain medication.
The provider may even try to remind the client of how capable of enduring pain they are since they just had a baby without pain meds…
What do you do?!
How do you feel?!
What do you say?!
What coping methods or techniques do you recommend?!
You see, there is a difference between external pain and internal pain.
When the pain comes from within our body, we are able to use our body to absorb it. We can breathe, move, apply pressure, etc. But when the pain is inflicted on the body from an external source, we only have a few options.
Suffer through it, stop it OR NUMB IT!
Lidocaine, a medication used as a local anesthetic or “numbing agent” for perineal repair, offers a rapid onset of action and an intermediate duration of efficiency. It is injected at the site and shortly after a perineal repair can take place without much pain. In some rare instances, a person may be resistant to anesthesia and may require a different type of anesthetic.
But let’s get back to you, doula. You are in the support role and you are bearing witness to this.
You must support this client in navigating this and witnessing this may leave a lasting impact on you.
You didn’t become a doula because you like medical procedures or wanted to watch surgical ones.
You may even get queasy at the sight of blood or needles piercing delicate parts of a person’s anatomy.
You may feel light headed.
You may have re-occurring thoughts about the procedure; about your client suffering.
You may have nightmares about the process. You may experience PTSD.
Doula processing is a thing. It’s a real thing and it can be the difference between staying in this work for a lifetime verses a season.
Doula, you are not alone. We have been there and we have made it past there. Call us. Lean on us. Rely on us. We won’t let you fall and we will point you in the direction of a vetted resource when we know you need one.