Well... I have a few "hot spots" where i think there were sutures. But mostly my pain is from the 4th degree tear I had with dd2's birth. DS's birth came with a 2nd degree tear along the scar line so while there is the surface ouch of his tear, the real problem is one I've dealt with for a few years now.
I put together a "how to heal tears" list over the years... here it is! It's aimed at 4th degree tears but will obviously work for any perineal trauma.
Right off the bat:
---Alterate warm with cold. Although the cold packs will reduce swelling you also want to encourage circulation, which is what a warm pack does. Start out with cold packs, but after the first hour or two (12 hours max) start alternating a warm chem pack, heated rice sock, or warm cloth with the cold pack.
---for the cold/warm therapy, make an herbal tea (see sitz bath ideas below). Soak clean wash cloths or fabric menstrual pads in the herbal blend then freeze or place in a crock pot (depending on whether you want cold or hot). Use these instead of the "glove full of crushed ice" the hospital offers.
---Rock Rose and Star of Bethlehem are Bach Flower Remedies that address shock, trauma, and birth injury. Rescue Remedy is great for any birth, but start taking Star of Bethlehem and Rock Rose as soon as possible... even during suturing!
---homeopathic arnica, 200c, taken orally every 15 minutes on the first day, then 3-4x a day. Again, safe to start during suturing.
After the first few hours:
---sitz baths! At least twice a day for 15 minutes (though I found that a sitz bath before/after every bathroom visit was very helpful during the first weeks... and I even nursed while sitting on the toilet topper sitz bath). An herbal blend can be purchased or make your own. For example, epsom salt, sea salt, lavender, calendula, rosemary, comfrey (note-comfrey contains liver toxins and topical use can
cause unsafe levels so be aware), uva ursi, garlic, shepherd's purse, or ginger in any combo can be added to the hot water. One recipe (if you want a recipe) is:
1/4 cup dried herbs (see above for ideas)
1/2 cup sea salt
Put the herbs into an 8-qt pot filling with water 1/2 to 2/3 up the side. Bring to a boil, immediately reduce to simmer and set timer for 20 minutes. When timer dings strain out the herbs and add sea salt.
---use some of the sitz bath "tea" in a peri bottle for bathroom visits
---"Sun you Bum": Use the sitz bath for 10-15 minutes. Then smear the healing tissue with topical aloe vera gel. Lay down on the bed so that your nekkid bum is sticking up, hopefully in a sun beam. Wait 5-10 minutes then get dressed or take another sitz bath.
---keep your legs together! Don't do things where the tissue is "pulled" against for a few weeks. Be careful getting into and out of cars, or walking up and down stairs, to make sure your legs stay together. When picking up your child make sure you don't squat! You'll only do it once (and then you'll NEVER forget to avoid squatting), but it can cause damage to the healing tissue as well as being darned uncomfortable so try to avoid that once.
---some mamas like those donut pillows, but a pillow or cushion made from memory foam may be better. Donut pillows allow the healing tissue to "sag" while the memory foam provides some support. If you do choose a donut pillow, try not to use it for more than a few weeks before moving to a more supportive pillow.
---along with topical aloe vera gel (look in a natural food store for the kind sold as a beverage, it's usually purer than the other brands) applied 1-2x a day to the healing tissue, try patting the healing tissue with honey (a little honey, dabbed on, then "tapped" so that the skin pulls a little with your finger tips) or smooshing on some plain (no added sugar) yogurt. You can leave them in place or rinse them off (rinse off or rinse in a sitz bath).
---Kegel! Kegel kegel kegel.
---Stay hydrated and make sure you don't strain with bowel movements. In general, for the first month or two having stools that are "too loose" is better than "too hard". Try starting with colace (as directed on package) and Milk of Magnesia (once a day) and maintaining this for at least the first month. Also eat high fiber foods and remember that all the fiber in the world wont help if you're not getting enough liquid. Propping your feet up so you're in a sort of supported squat position can help, and don't "push"... just relax and wait for gravity to do the work for a while.
---Add more protien to your diet. It takes protien to build new tissue and you're building tissue on top of dealing with a new baby, possibly older kiddos, the rest of the world, etc. So try eating whole foods, in season, with a bit more protien than you'd normally have.
---Take a prenatal multivitamin (with iron, you're building tissue after all and probably have some blood loss due to the tear). Add flax or cod liver oil. Take a probiotic or eat live culture yogurt (plain, without sugar).
---scar massage: rub firmly across the scar, then along the scar. Rub in little circles along the scar and then "roll" the scar between your fingers (insert a finger vaginally so you're "holding" the scar between your fingers). The goal is to lift the scarred tissue off the underlying muscles so adhesions are minimized and pain is reduced. Although some people suggest doing this dry, I think vitamin e oil or aloe gel is a good addition to the scar massage.
---rest as much as possible. And if you don't feel like penetrative intimacy, do something else. Many women avoid all penetration for 4-6 months and then go slow. Some mamas heal quickly and are ready to go, but don't feel pressured. A 3rd or 4th degree tear repair is urogenital surgery and needs to be respected as such.
---Belly Dance! It sounds odd, but the gentle stretching and increased blood flow to the pelvic area that comes from belly dance is a good healer. In addition, some people feel that genital trauma or birth injury can cause the body to "shut down" the pelvic area. Basically the body responds to the pain by isolating the area, but re-integration of the pelvic area isn't automatic. You need to encourage the body to re-integrate. Belly dance and gentle yoga (svaroopa or kundalini) that encourage focus and awareness of the pelvic muscles while stretching/enhancing blood flow encourages the body to heal on more than just the physical level.
---Tapping, kundalini yoga, chiropractic, acupuncture/acupressure or other energy work. Many traditions believe that there are "energy lines" in the human body. Alternate health therapies like acupuncture, reiki, and some chiropractic schools focus on these channels. Many traditions teach that the perineal area is the root chakra, or that lines of energy flow through this area. Tears damage the energy chanels and chakras as well as the physical tissue so spending some time restoring energy flow can help you heal completely.
---physical therapy by a therapist trained in women's health. Or at the least, check out books like The Core Program, Lose the Mummy Tummy, and Beyond Kegels. The Core Program is designed to be done in 15 minutes a day and focuses on helping women create/maintain proper posture and joint stability. The Mummy Tummy book focuses on healing the diastasis that happens during pregnancy and includes detailed exercises for healing the pelvic floor. And Beyond Kegels addresses other exercises that can aid in healing the pelvic floor and reducing incontenance.
---Incontenance (urinary, fecal, gas) is COMMON following a 3rd or 4th degree tear Do not be embarassed to tell your care provider! Most of the time the condition will improve on it's own but TELL SOMEONE if you are having problems. There are medical and alternative treatment options.
In a future birth:
---avoid induction and/or augmentation. Try to avoid assisted delivery tools like forcepts or vacuum.
---practice Optimal Fetal Positioning during pregnancy and labor.
---avoid an episiotomy even if your care provider tries to tell you it's necessay.
---if it feels good, warm compresses can be held on the perineum during labor or warm oil poured on the perineum during crowning, but only mama's hands should touch the perineum directly.
---labor and birth in water
---avoid perineal massage during the third trimester and during birth. But do massage the tissue during the first and second trimester.
---avoid pushing. Use hypnobabies, meditative focus, breathing, or a low dose epidural to avoid pushing until the baby is on the perineum.
---give birth in a side lying or hands/knees position to reduce tissue stress and slow the birth a bit.