Episiotomy

What is an episiotomy?

Episiotomy is a procedure in which your obstetrician makes a small cut between the bottom of your vaginal opening and anus (an area called the perineum) during childbirth. An episiotomy makes the opening of your vagina wider, which allows your baby to come through more easily. Sometimes your perineum will tear naturally as your baby comes out. This is called perineal tear (or laceration).

Healthcare providers don't recommend routine episiotomies and prefer that you tear naturally. However, the procedure is still used in certain cases.

When is an episiotomy necessary?

While episiotomies are uncommon, there are still instances when your healthcare provider feels it's the safest option. These instances include:

• Your baby is in distress and needs to be delivered quickly.
• You're exhausted and dehydrated from prolonged labor.
• Your obstetrician needs to use forceps or a vacuum to deliver your baby. Your vagina may need to be wider to use these instruments.
• Your baby is breech or has shoulder dystocia (shoulders are stuck in your pelvis).
• Your baby is large.
• You've been pushing for too long or can't control pushing.

Is it better to tear or have an episiotomy?

The latest research suggests it's better to let the perineum tear naturally.

Healthcare providers once thought making a surgical incision would help the vagina stretch and prevent severe tears. Some also believed it could prevent complications like urinary incontinence and pelvic floor dysfunction. Your pelvic floor consists of muscles and tissue that support your uterus and help prevent urinary and bowel dysfunction. But newer research has shown episiotomies may not prevent complications and may make tears extend farther than intended.

How is an episiotomy done?

An episiotomy is performed during a vaginal delivery. The specific process may vary depending on your obstetrician and your condition.

Generally, an episiotomy follows this process:

• You'll get anesthesia so you don't feel pain. If you've already had an epidural, you don't have feeling from your waist down. You may not need any additional anesthesia. If you haven't had an epidural, your provider injects a local anesthetic into the perineum.
• Once your baby is crowning (your baby's head is at your vaginal opening) and pushing against the perineum, your provider uses episiotomy scissors to make the episiotomy incision.
• Your baby is delivered, followed by the placenta.
• Your provider uses absorbable stitches to repair the tissues and muscles affected. They evaluate the degree of the tear and check for complications.

Types of episiotomy incisions

There are two main types of incisions:

• Median (midline): A vertical (up and down) incision beginning at the vaginal opening extending toward the anus. This type has a higher risk of tearing to the anal sphincter or rectum, but is an easier incision to make.
• Mediolateral: An angled or diagonal incision. The incision begins at the vaginal opening and extends at a 45-degree angle. There's less chance of the incision extending to the anal sphincter and rectum. Disadvantages of mediolateral incisions include difficulty to repair, greater blood loss and more discomfort during recovery.

What are the degrees of episiotomy?

Like perineal tears, healthcare providers describe the levels (or degrees) of episiotomy in relation to how severe the tear is. The degrees of an episiotomy are:

• First-degree: A small tear that involves just the lining of your vagina.
• Second-degree: A tear that extends through the lining of your vagina to the underlying vaginal tissue. Most episiotomies are second-degree.
• Third-degree: A tear that involves your vaginal lining, vaginal tissues and extends to your anal sphincter.
• Fourth-degree: The tear affects the vaginal lining, vaginal tissues, anal sphincter and rectum. The most severe type of tear with the most complications.

How painful is an episiotomy?

You shouldn't feel anything during an episiotomy. Your obstetrician uses a local anesthetic (typically injected into the area) to numb your perineal area so you don't feel pain. In some cases, you've already had an epidural and can't feel anything from your waist down. You can expect some pain and soreness once the anesthesia wears off.

What are the advantages of getting an episiotomy?

In certain situations, an episiotomy helps reduce the risk of a bad natural tear. If you have an episiotomy, it's because it was the safest for you or your baby.

What are the risks of an episiotomy?

Complications that can occur due to an episiotomy include:

• Bleeding.
• Infection.
• Painful sex (dyspareunia).
• Injury to the anal sphincter and rectum.
• Scarring.
• Urinary incontinence.
• Prolonged recovery time.

It’s important to note that the complications listed above can also occur with a natural tear.

Can you refuse an episiotomy?

Since episiotomies aren't routine, your healthcare provider will likely not recommend one unless it's necessary. Talk to your provider ahead of time and share your concerns about the procedure and your desire to avoid it.

Preventing an episiotomy

It's hard to prevent perineal tears or an episiotomy since a lot of it is out of your control. Some healthcare providers recommend stretching your perineum during pregnancy to help prevent tearing. Massaging your perineal tissue (area between the vaginal opening and anus) in the weeks leading up to delivery may reduce the chances of tearing or needing an episiotomy. The research is mixed and providers aren't entirely sure stretching the perineum works, but it's usually harmless.

Another technique to reduce tearing is to apply a warm compress to your perineum during the second stage of labor. This may help make the tissue more flexible. Talk to your provider about perineal massage or other techniques to avoid tearing during childbirth.

How long does it take to heal after an episiotomy?

Healing takes about one month, but this can vary depending on the degree of episiotomy. Natural tears usually require the same recovery time.

It's common to feel pain and soreness for the first few weeks and have some discomfort with sex (once you're given the OK for intercourse). Let your provider know how you're recovering and what your pain level has been. They can tell you if it's normal based on the type and severity of episiotomy you had.

How do I heal after an episiotomy?

The perineal area will be sore and painful for a few weeks after an episiotomy. Some things you can do at home to relieve your discomfort are:

• Use an ice pack or perineal cold pack (an ice pack and absorbent pad in one) to reduce swelling and ease soreness. Most hospitals have perineal cold packs, but you can also purchase them yourself.
• Take warm sitz baths. A sitz bath involves filling a sitz bathtub (it usually goes over your toilet) or bathtub with warm water and submerging your genital area in the water. It promotes healing and can offer temporary pain relief.
• Put warm water in a "peri bottle" and squirt your perineal area when using the bathroom or changing your absorbent pad. Your healthcare provider will give you a peri bottle in the hospital.
• Use numbing sprays like Dermoplast® several times a day for pain and itching.
• Use an over-the-counter (OTC) pain reliever — like acetaminophen or ibuprofen — as recommended by your provider. Severe pain may need treated with stronger prescription medication, such as acetaminophen with codeine.
• Apply witch hazel pads to the perineal area. Witch hazel helps to soothe the area and relieve irritation. Some people line their sanitary pads with witch hazel pads for extra relief.
• Sit on a donut pillow. This donut-shaped pillow takes the pressure off the perineal area when you sit. You can find inflatable donut pillows at your local drug store.

Talk to your midwife or obstetrician about what you can expect and what activities you should avoid during the recovery period. Don't use tampons, have sex or insert anything into your vagina until your provider says it's OK.

When can I have sex after an episiotomy?

Pain during sex after an episiotomy is common for several months. It might be helpful to use a water-based lubricant during sex to make it more comfortable. Your perineum should be healed by about six weeks postpartum, but you should wait until you've been examined and given the OK for sex at your postpartum visit.

When should I see my healthcare provider?

If you've had an episiotomy, call your obstetrician if:

• Pain continues to get worse instead of better.
• Smelly discharge or pus is coming from the incision.
• The skin around the cut (incision) is red or swollen.
• You're bleeding at the incision site.
• You have fever, chills or body ache.

Why do doctors no longer recommend an episiotomy?

In 2006, the American College of Obstetricians and Gynecologists (ACOG) issued a recommendation against routine episiotomy. Studies found that an episiotomy doesn't prevent severe lacerations and may cause worse tearing. Additionally, it doesn't prevent complications like urinary or bowel incontinence or painful sex any better than a natural perineal tear.

A note from Cleveland Clinic

Needing an episiotomy is not as common as it once was. It involves your provider making an incision near your vaginal opening to allow more room for your baby to come out. When it’s done, it’s because it’s the safest way to deliver your baby. Talk with your healthcare provider about your chances of needing an episiotomy at one of your prenatal visits. They can help you understand the circumstances where one may be needed for your baby's health.