Vaginal Conditions After Delivery
Frederick R. Jelovsek MD
"Does taking a bath increase your chances of getting an infection, yeast or UTI?
I am 29 years old, always have menstrual periods on time, although I am 9 weeks post partum. I seem to get a lot of yeast infections". A.N.
If someone told you there would not be any short or long term vaginal changes after delivery of a baby through the vagina, I am sure you would not believe them. Anytime a 4 inch (10 cm) diameter round object goes through an opening that cannot normally stretch beyond a 2 inch (5 cm) diameter opening, there is a strong likelihood of stretching, tearing and pain afterwards. When that is added to hormonal changes after delivery with or without breast feeding, a postpartum woman can have significant vaginal pain, dryness, burning, fear of intercourse, vaginal opening looseness, and even difficulty with losing control over urination, bowel movements or holding bowel gas.
Changes Caused By Child Birth
Let us look at some of the changes that can take place in the lower genital tract after normal, uncomplicated vaginal deliveries.
Are vaginal infections or vaginal burning common after delivery?
The hormones of pregnancy, high estrogen and progesterone, decline rapidly after delivery. The result is an almost menopausal state with respect to vaginal lubrication. The condition is called vaginal atrophy with a rise in the pH of the vagina and a shift away from superficial vaginal cells that lubricate the vagina and provide protection from irritation. This change also takes place on the outside of the vulva and is subject to any irritation from soaps, rubbing, or contact with chemicals in pads, condoms, lotions or other topically applied agents.
To answer your questions about whether baths can cause vaginitis or urinary tract infections (UTIs) in the postpartum time period, the answer is that they can produce SYMPTOMS of UTIs or vaginitis, i.e., pain with urination, frequency, vulvar burning, but they are NOT thought to produce actual infections. They produce symptoms if soaps or bath oils are used that irritate the already very thin, sensitive skin in those areas around the vagina and urethra. This is more of an irritant vulvitis and urethritis rather than a vaginal yeast infection or a UTI. This does not mean that you cannot get a yeast infection or a UTI after delivery -- you certainly can -- but often it is a case of mistaken etiology.
If one looks at vaginal smears to after delivery to see how predominant this problem is, we find that about one third of non lactating women have atrophic changes for about six weeks before they start improving, but in 5% the atrophic pattern persists for a long time.
How long will the perineal pain from delivery last so I can know how long before I can resume intercourse?
One study that looked at how long, on the average, it took women to recover various functions after normal vaginal delivery found that the median time (time for 50% of subjects) "for perineal comfort in general (including walking and sitting) was 1 month (range, 0-6 months); 20% of women took more than 2 months to achieve general perineal comfort. For comfort during sexual intercourse, the median time was 3 months (range, 1 to more than 12 months); 20% of women took longer than 6 months to achieve comfort during sexual intercourse. ".
You would think that the pain with intercourse is only present if you have an episiotomy but that is not the case. In another study that looked at postpartum painful intercourse (dyspareunia), they found that 72% of postpartum women had pain especially at entrance to the vagina. While this pain was more likely if a woman had a vaginal delivery, it was also present in over 20% of women who had Cesarean sections. Women who were nursing also had a higher incidence of painful sexual intercourse.
Therefore, in general, you should expect that it takes about month before perineal discomfort with walking or sitting goes away but it may easily take 2 months. Also it will take about 3 months before the discomfort with vaginal intercourse goes away but it may be 6 months or more.
What differences are there in vaginal symptoms after delivery if I have an episiotomy versus having no episiotomy?
It is very difficult to say for sure what difference in vaginal symptoms occur on the basis of having or not having an episiotomy. Even in older studies in which episiotomies were routinely performed, about 25% of women did not get one either because they delivered too fast or there was no concern whatsoever that the baby would cause tearing. The randomized trials that have been performed in which half the women had routine episiotomy (only 73% actually had them as intended) and the other half had episiotomies in restricted to situations in which the doctors thought they would significantly tear if it was not performed (27%), can show us what happens when there is a decrease of almost 50% in the episiotomy rate. These studies tell us that there is no difference in painful intercourse or incontinence by whether episiotomy was performed routinely or not. If episiotomy was causative of painful intercourse (dyspareunia) then we would have expected there to be a higher incidence of such problems in the group that had 50% more episiotomies. This is also consistent with the study that found that the postpartum pain with sex was only located at the exact site of the incision line in 6% of cases when over 45% of women complained of discomfort with intercourse upon vaginal entry.
I have heard of women having problems of uncontrolled passing of gas or even stool from the anus after delivery. Is this likely to be a problem for me?
After vaginal delivery, some women do have difficulty holding their stool or gas. It occurs much more commonly after injury to the anal sphincter muscle, even if that injury is surgically repaired at the time of delivery, than it does if there is no tearing of the muscle. Ultrasound imaging in one study demonstrated separated anal sphincter muscles in 40% of the women with obstetric anal sphincter lacerations, despite repair at the time of delivery but it also demonstrated sphincter lacerations 20% of the time that were apparently unrecognized at the time of delivery. At 4 months after delivery continued anorectal dysfunction was reported by 43% of subjects in the laceration group versus only 7% of the control subjects
Recent studies suggest that the incidence of anal dysfunction as measured by ultrasound and anal pressure measurements is 8.7% but only 1-2% admit to significant symptoms. While incontinence of stool is not frequent, passing gas from the rectum involuntarily may happen as often as 26% of the time in some groups of women after delivery.
What about vaginal opening looseness or pelvic prolapse after delivery?
This is a common concern that both women and their partners have about delivery. Unfortunately there is almost no data concerning to what degree the vaginal opening is significantly loosened on a permanent basis. Similarly there is a lack of studies determining how many women develop pelvic organ prolapse after delivery. No one even knows if episiotomy and repair results in less long term vaginal gaping.
Most investigators agree that postpartum perineal muscle strengthening exercises such as Kegel exercises, will help restore perineal tone. They have even been shown to decrease the incidence of urinary incontinence but they need to be carried on for at least several months.
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