What is the best treatment for a postpartum woman experiencing perineal tearing and stitches pain after giving birth?

Treatment of Postpartum Perineal Tearing and Stitches Pain

For postpartum perineal pain and healing, use a stepwise approach starting with scheduled acetaminophen and ibuprofen as first-line agents, combined with sitz baths twice daily, stool softeners for 6 weeks, and ice packs to the perineum, with early follow-up within 2 weeks to assess healing. 1, 2

Pain Management Protocol

First-Line Analgesics (Start Immediately)

• Acetaminophen and ibuprofen should be prescribed as scheduled medications (not as-needed) and continued regularly throughout the postpartum period 3, 1, 4, 5
• These non-opioid analgesics form the foundation of pain control and should be administered after delivery of the baby 3
• Reserve opioids only for severe breakthrough pain that is unresponsive to first-line agents 1, 5

Adjunctive Pain Relief Measures

• Apply ice packs directly to the perineum for local pain relief and reduction of inflammation 1, 4, 6
• Consider transcutaneous electrical nerve stimulation (TENS) as an additional analgesic adjunct if pain persists 3

Wound Care and Healing Protocol

Hygiene and Cleansing

• Perform sitz baths twice daily until the first wound check (typically 2 weeks postpartum) to promote healing and maintain cleanliness 1, 2
• Water cleansing is appropriate for postpartum perineal wounds 3
• Emphasize careful perineal hygiene to prevent infection 7

Bowel Management (Critical Component)

• Prescribe stool softeners (such as polyethylene glycol 4450 or mineral oil) twice daily for 6 weeks postpartum 1, 4, 2
• The goal is to achieve toothpaste consistency stools to prevent straining that could disrupt healing 1, 4, 2
• This is a critical intervention that is frequently overlooked—inadequate bowel management leads to constipation, straining, and potential wound disruption 1, 2

Follow-Up Care

Timing and Assessment

• Schedule early follow-up within 2 weeks of delivery for proper evaluation of perineal healing 1, 4, 2
• Ideally, this should occur in a specialized postpartum perineal clinic if available 4, 2
• Clear documentation of the original laceration type helps guide appropriate ongoing management 1, 4

Patient Education

• Educate the patient on the degree of injury and expected healing timeline to ensure compliance with the treatment regimen 1, 4, 2
• Discuss the importance of completing the full 6-week course of stool softeners even if symptoms improve 1, 2

Antibiotic Considerations

When to Use Antibiotics

• For third and fourth-degree tears (obstetric anal sphincter injuries), prophylactic antibiotics should be administered as they reduce postpartum wound complications from 24.1% to 8.2% 4, 2
• First-generation or second-generation cephalosporins are appropriate choices 1
• For penicillin-allergic patients, use gentamicin with clindamycin or metronidazole 1

For First and Second-Degree Tears

• Routine antibiotics are not indicated for uncomplicated first or second-degree lacerations unless signs of infection develop 3, 8

Red Flags and Complications

Signs Requiring Urgent Evaluation

• Wound infection occurs in 0.1% to 23.6% of cases, with higher rates (up to 19.8%) after anal sphincter injuries 3, 8
• Wound dehiscence (separation) occurs in 0.21% to 24.6% of cases 3, 8
• If concern exists for anal sphincter compromise or persistent symptoms, perform endoanal ultrasound to assess the full extent of damage 1, 2

Common Pitfalls to Avoid

• Failing to prescribe adequate stool softeners for the full 6-week duration is the most common error leading to wound complications 1, 2
• Omitting prophylactic antibiotics in third and fourth-degree tears increases infection risk by approximately 300% 4, 2
• Using locked sutures during repair creates excessive tension and tissue necrosis—continuous non-locking techniques distribute tension more evenly and result in less pain 1

Special Considerations

Persistent Pain Beyond Expected Timeline

• Perineal pain can persist and interfere with the mother's ability to care for her newborn, affect sexual function, and contribute to postpartum depression 3, 6, 8
• Untreated pain is associated with greater opioid use and development of chronic pain 5
• In 30% of women, wound healing may be delayed, particularly with larger initial wound areas, bacterial colonization, or anal sphincter injuries 8