Persistent pain after childbirth: perineum, caesarean scar and pelvis

After a vaginal birth with a tear or episiotomy, the RCOG says soreness for 4 to 6 weeks is likely, especially when walking or sitting, and the NHS says it is unusual for pain after an episiotomy to last more than 2 to 3 weeks. After a caesarean, the NHS says most women have discomfort for the first few days and for some it lasts several weeks, and you should have regular painkillers at home for as long as you need them. The NHS also notes that you may feel period-like tummy pains as the womb shrinks, particularly while breastfeeding, which is normal.

None of this means you should put up with pain that is escalating. NICE asks midwives to enquire at each contact about pain that is not resolving or is worsening, and about an increasing need for pain relief.

NICE says perineal pain that persists or gets worse within the first few weeks after birth may be associated with symptoms of depression, long-term perineal pain, problems with daily functioning and psychosexual difficulties, and lists risk factors for persistent pain: episiotomy or a labial or perineal tear, an assisted vaginal birth, wound infection or breakdown, and a birth experienced as traumatic. It advises considering a validated pain scale, offering an examination if you or the professional have concerns, discussing pain relief that suits breastfeeding, and urgent same-day referral if the wound breaks down.

The NHS says for a few women excessive, raised or itchy scar tissue forms where a tear or episiotomy was, and that pain during sex is very common in the first few months after a tear or episiotomy. It says to say so if penetration hurts, and suggests a water-based lubricant for vaginal dryness. The RCOG adds that after a third- or fourth-degree tear, sex may be uncomfortable at first but the discomfort should not persist; ask your professional if it does, and say if you are still having symptoms 6 months after the birth.

The NHS says to make sure you have regular painkillers such as paracetamol or ibuprofen to take at home for as long as you need them, while aspirin and the codeine in co-codamol is not usually recommended if you are breastfeeding, and your doctor can advise on the most suitable painkiller. It says to contact your midwife or GP straight away for severe pain, a wound that becomes more red, painful and swollen, pus or foul-smelling discharge, a cough or shortness of breath, or swelling or pain in the lower leg, which may signal infection or a blood clot.

Pain that is changing is more important than pain that is steady. The NHS says you may not be able to drive, exercise, carry anything heavier than your baby or have sex straight away, perhaps for 6 weeks or so, and to ask your midwife or GP if unsure. Do not change prescribed medicines without advice.

The RCOG describes pelvic girdle pain (PGP) as pain at the front and/or back of the pelvis that can also affect the hips or thighs, common in pregnancy (affecting 1 in 5), with walking, climbing stairs and turning in bed typical triggers. It says PGP usually improves after birth though around 1 in 10 women will have ongoing pain, in which case you should continue treatment and regular pain relief, keep using any walking aids until pain settles, and become gradually more mobile. If the pain persists, it advises seeing your GP, who may refer you to another specialist to exclude other causes such as hip problems or hypermobility syndrome. Treatment is safe at any stage during or after pregnancy, and physiotherapy is the usual route.

The RCOG separately defines chronic pelvic pain as pain in the lower abdomen or pelvis lasting more than 6 months, affecting around 1 in 6 women, and says it is usually due to a combination of physical, psychological and social factors; causes can include endometriosis and pelvic inflammatory disease, and often no single cause is found. Persistent pain after birth should be assessed on its own merits and may need referral.

NICE says to seek advice without delay for abdominal, pelvic or perineal pain with fever, shivering or unpleasant-smelling discharge, for leg swelling and tenderness or shortness of breath, for chest pain, and for a persistent or severe headache. The NHS says to call 999 for sudden very heavy bleeding with feeling faint or a pounding heart, and its postnatal table lists calf pain, chest pain with difficulty breathing, heavy blood loss, a high temperature with a tender tummy, and headache with vision changes as symptoms to report straight away.

NICE says all healthcare professionals should refer appropriately if they are concerned about your health and that at 6 to 8 weeks the GP should assess and respond to any concerns, which may include referral to physiotherapy or specialist services. The NHS says to tell the GP at your postnatal check about bladder control problems that pelvic floor exercises have not helped, and that you may be referred to a physiotherapist. The RCOG says there is additional support for people whose mental health has been affected by their birth experience or the effects of a tear, and that those with ongoing anal incontinence are referred to a specialist team. Local pelvic health physiotherapy and postnatal clinics differ across the UK nations.