MOTHERING, CAREGIVING.

Tissue Healing Postpartum.

The cycles of reproduction from conception through birth and into postpartum implicates the most intimate and sensitive of tissues and reproductive organs, in a body/mind wide coordiation of bringing forth life. It’s a time of rawness and reverence.

The changes of pregnancy and through into birth, progressively instigate normal bodily adaptions including a lengthening and softening of muscle and connective tissues and reproductive organs.

Through pregnancy and during childbirth the tissues of the pelvic floor and the reproductive organs including the vagina and the vulva stretch and length to facilitate the bringing forth of life. The natural adaptions of the reprductive tissues are reflected body wide- no more evidently than through the cycles of reproduction and most emphatically in birth do we see that brain and body are inseparable.

During birth the combined effects of stretching forces, uterine activity and pressure of the babies head on the floor of the pelvis can contribute to swelling and bruising around the vulva and vagina and the tissues of the perineum (the area of tissue between the vulva and the anus) causing pain for women/ and persons in these tissues during and after birth. If the vagina and vulva do not stretch quite so comfortably as it is required to do so during birth, a tear can occur.

Such tears vary in degree according to which layers of tissue in and around the vulva, and perineum are injured. Within the body our tissues and are organised into layers beginning with skin on the outside, progressing through layers of connective tissues, muscle and organs and bones on the inside. Nerves and blood vessels run through these various layers. After birth in the first type of tearing injury, referred to as a grade one tear, the superficial layer of skin is damaged. These injuries heal most quickly as they involve less layers of connective tissue. In the second type of injury, a grade two tear, the skin and the muscles of the pelvic floor are impaired and can require stitches to repair. In the third or fourth type of injury, grade three or four tear, the tear in the perineum is larger and deeper and extends into the sphincter muscle that controls the anus. These types of tears usually require surgical assistance to repair and may impact the function of the anal sphincter and can cause great distress to those that incur these injuries. Care for grade three to four tears is specialised and those with these injuries require referral to health pracitioners such as pelvic health physiotherapists trained in the care of these injuries.

If it is necessary for the birth to be hastened, or if assistance in the form of forceps or ventouse is required, then in these instances an incision maybe made to help make space for the babies head. The technical term for this is an episiotomy. In an episiotomy the incision is made through through the skin and muscle layers of the pelvic floor and often requires stitches. An episiotomy maybe carried out in one of two ways one, a cut is made in a straight line from the vulva through the connective tissues back towards the anus. In this type of cut, there is less pain and it is easier for the body to repair. However this also runs the risk of the cut extending backwards into the anus and its sphincter muscle. In the second type of cut there is a diagonal incision from the vaginal wall into the muscles of the pelvic floor. This type of incision reduces the risk of injury to the sphincter muscles around the anus, but may cause an asymmetry in the muscles of the pelvic floor. Following birth it may not be possible to know exactly which type of episiotomy or tear may have occurred, but it is useful to understand the variance in injury so we can develop self understanding towards our body as it heals.

Recuperation of the pelvic tissues afterbirth is conventionally conceived to be complete at six weeks at which time it is commonly believed that women can resume normal activity. In most instances this is true however there is increasing evidence to suggest that this time period of six weeks is an insufficient representation of the time required for pelvic tissues to sufficiently recover afterbirth. An article published by pelvic health physiotherapists Grainne Donnelly, Emma Rockwell and Tom Goon in 2019 suggested that pelvic tissues may not be fully recuperated after birth until at least 4-6 months postpartum, and there may even be more conjecture around this time frame.

Elucidation of the phases of tissue healing provides insight for women in regards to their physiology and expectations of timeframes associated with tissue recovery afterbirth.

Healing of pelvic tissues occurs in four phases, facilitated by the immune system though not in isolation, in which damaged tissues are closed, repaired, rebuilt by the secretion of collagen an elastic tissue that helps to repair the skin and tissues by acting as a scaffold upon which other cells can be laid. In the last phase tissues are strengthened and matured. This final stage of maturation and strengthening of tissues has a varied timeframe and for deeper wounds such as those encountered during abdominal births or in grade 3-4 tears, where multiple layers tissues are incised or implicated full wound maturation where the deeper layers of tissue are repaired can take up to two years. This process, like all within the body does not occur linearly or sequentially. These phases occur cyclically and engage the entireiy of the body/mind.

Utilising time scales solely as an indicator of pelvic tissue recovery post childbirth can be misleading for persons in the inference that the closure or repair of wounds, abrasions or surgical interventions implying that tissue function restored. Health emerges from a state of integration, referencing timescales for wound closure do not take into account the re integrated function of the pelvic floor with other tissues of the body. Childbirth and caregiving irrefutably moves us forward and to recognise these changes of birth requires that persso’s are empowered with self knowledge and awareness alongside supportive care that acknowledges the lived experience of those transitioning through care.

By Helen Coutts

3rd August.

Tissue Healing Postpartum.

HELEN COUTTS