Episiotomy

An episiotomy is a procedure in which your pregnancy care provider makes a small cut to widen your vaginal opening during vaginal childbirth. Your provider makes the cut in your perineum — the area between your vaginal opening and anus. These days, providers only use an episiotomy if it’s necessary.

An episiotomy can allow your baby to come out more easily. Sometimes, your perineum will tear naturally as your baby comes out. This is called a perineal tear. After your baby is born, your provider repairs any tears or cuts with stitches that dissolve on their own.

Providers don’t recommend routine episiotomies. They prefer that you tear naturally (if at all). But they still use the procedure when it’s necessary to ensure the health of you and your baby. If you’re worried about the possibility of an episiotomy, talk to your provider at one of your prenatal visits.

When is an episiotomy necessary?

There’s no general guidance on when an episiotomy is necessary. Healthcare providers decide on a case-by-case basis. Instances when your provider may feel it’s the safest option include:

• Your baby is in distress and needs to be delivered quickly.
• Your provider needs to use forceps or a vacuum to deliver your baby. Your vagina may need to be wider to use these instruments.
• There’s a risk of a large tear to your anus (third- or fourth-degree tears).

How is an episiotomy done?

Your provider may recommend an episiotomy while your baby is crowning (your baby’s head is at your vaginal opening). They’ll tell you why and get your informed consent before doing the procedure.

Generally, an episiotomy follows this process:

1. You get anesthesia (numbing medication) so you don't feel pain. If you’ve already had an epidural, you may not need additional anesthesia. If you haven’t had an epidural, your provider injects a local anesthetic into your perineum.
2. Your provider supports your perineum. They use special scissors to make a single, deep cut during a contraction. The length of the cut can vary. It can also continue to tear after the initial cut.
3. You deliver your baby, followed by the placenta.
4. Your provider uses dissolvable stitches to repair the torn tissues. They evaluate the degree of the tear and check for complications.

The specific process may vary depending on why the episiotomy is necessary.

Types of episiotomy incisions

There are two main types of incisions:

• Median (midline): Your provider makes a vertical (up and down) cut from your vaginal opening straight toward your anus. It’s an easier incision to make. But it carries a higher risk of tearing your anal sphincter and rectum.
• Mediolateral: Your provider makes a diagonal cut that angles away from your vaginal opening at about 45 degrees. It’s less likely to extend into your anal area. But it can be a harder incision to make. It can also cause greater blood loss and more discomfort during recovery.

What are the potential benefits and risks of an episiotomy?

In certain situations, an episiotomy helps reduce the risk of a severe, large natural tear. It may also be necessary if your baby needs to be delivered as soon as possible. If you have an episiotomy, it’s because it’s safest for you or your baby.

Complications that can develop due to an episiotomy include:

• Bleeding
• Issues controlling when you poop (fecal incontinence)
• Infection
• Injury to your anal sphincter and rectum
• Weakened muscles that support your pelvic organs (pelvic floor dysfunction)
• Prolonged recovery time
• Painful sex
• An abnormal connection between your rectum and vagina (rectovaginal fistula)
• Scarring
• Issues controlling when you pee (urinary incontinence)
• A pelvic organ that sags down (prolapse)
• Improper healing of the cut or tear (wound dehiscence)

It’s important to note that these complications can also occur with a natural perineal tear.

What happens after this procedure?

Healthcare providers will check your stitches periodically while you stay in your postpartum recovery hospital room. They’ll look for any complications, like infection or bleeding.

A provider will let you know what type of tear you had and how to take care of it while you’re in the hospital and at home. They’ll give you supplies, like witch hazel pads and perineal cold packs, to help with pain and healing. They’ll also give you pills and powder medicines to help keep your poop soft and loose.

If you have a larger tear, known as a third- or fourth-degree tear, you may need a Foley catheter to pee while you’re in the hospital.

How long does it take to heal after an episiotomy?

Healing takes about one month but can be shorter or longer. Healing time can vary depending on the degree of episiotomy. And everyone heals differently. Natural tears usually have the same recovery time.

How painful is recovery?

It’s common to feel pain and soreness for the first couple of weeks. Everyone feels pain differently, though. You can take pills for pain that your healthcare provider recommends to help ease the discomfort. You may also 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.

It’s unusual for pain after an episiotomy to last longer than three to four weeks. If this happens to you, talk to your provider.

How can I help my episiotomy heal?

Some things you can do at home to relieve pain and promote episiotomy and tear healing include:

• Apply witch hazel pads to your perineal area to ease irritation.
• Sit on a donut pillow or waffle cushion to take the pressure off your perineal area when you sit.
• Take a laxative or stool softener to make pooping easier, as your provider recommends.
• Take sitz baths twice a day.
• Use a “peri bottle” to clean your genital area after using the bathroom instead of wiping with toilet paper.
• Use an ice pack or perineal cold pack to reduce swelling and ease soreness.
• Use an over-the-counter (OTC) pain reliever, as your provider recommends.
• Use numbing sprays, like Dermoplast^®, for pain and itching.

Your healthcare team will give you specific instructions on how to care for the tear. You’ll need to do these things at home for a few weeks. They may also recommend seeing a pelvic floor therapist.

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 should I call my healthcare provider?

If you've had an episiotomy, call your pregnancy care provider if:

• The pain continues to get worse instead of better.
• It hurts when you pee.
• Smelly discharge or pus is coming from the incision.
• The skin around the cut is discolored, red or swollen.
• You’re bleeding at the incision site.
• You have a fever, chills or body aches.

If you experienced birth trauma and it’s causing distress, reach out to a mental health professional for help. Your mental and emotional recovery from an episiotomy is just as important as your physical recovery.

Why is an episiotomy not done anymore?

Healthcare providers still do episiotomies, but much less often than they used to. In 2006, the American College of Obstetricians and Gynecologists (ACOG) issued a recommendation against routine episiotomies. This means doing an episiotomy automatically without assessing if it’s absolutely necessary.

Studies found that an episiotomy doesn’t prevent severe tears and may cause worse tearing. It also doesn’t prevent complications like urinary or bowel incontinence (uncontrolled loss of pee or poop) any better than a natural perineal tear.

The latest research suggests that it's better to let the perineum tear naturally. But providers use an episiotomy in certain cases to get the baby out quickly.