Episiotomy: Faqs

What Is an Episiotomy and Why Is It Performed?

An episiotomy is an incision through the perineal tissue at the vaginal opening. A doctor or midwife makes the cut late in the second stage of labor when there is a specific reason to enlarge the opening or speed delivery.

The World Health Organization recommends against routine or liberal episiotomy in spontaneous vaginal birth. A Cochrane review also found that, when an unassisted vaginal birth was expected, selective use led to fewer severe perineal injuries than routine use.

Two common incision directions are:

• Midline or median: a vertical cut toward the anus. It is generally easier to repair, but it has a greater risk of extending into the anal sphincter or rectum.
• Mediolateral: an angled cut away from the midline. It is designed to reduce the chance of extension into the anal area, although recovery can be more uncomfortable.

If an episiotomy is needed, the area is numbed with local anesthetic unless an epidural or other effective anesthesia is already working. After the baby and placenta are delivered, the incision is repaired with stitches that usually dissolve on their own.

What Are the Potential Risks Associated With Episiotomy?

Episiotomy can be useful in selected births, but it is still a surgical wound. Possible problems include pain, bleeding, infection, wound breakdown, pain during sex, and extension of the incision into a deeper perineal tear.

A deeper extension can involve the anal sphincter or rectum and may contribute to bowel-control problems. The Cochrane review of selective versus routine episiotomy found no maternal or infant benefit that justified routine episiotomy in women expecting an unassisted vaginal birth.

It is also inaccurate to assume that an episiotomy always prevents a severe tear or protects the pelvic floor. An episiotomy can itself extend into a third- or fourth-degree tear, and long-term evidence does not show that routine episiotomy prevents urinary incontinence or pelvic organ prolapse.

How Is the Recovery Process After an Episiotomy?

Most people improve steadily over the first few weeks after an episiotomy, although tenderness can last longer. The skin usually heals within several weeks, and the stitches are normally absorbable.

The Royal College of Obstetricians and Gynaecologists notes that soreness is common for about two to three weeks and that the skin portion of the wound usually heals within a few weeks.

How to care for the wound

• Keep the area clean and follow your maternity team’s instructions for washing and pad changes.
• Use a wrapped cold pack if recommended. Do not place ice directly on the skin.
• Take only pain medicine that your clinician says is suitable for you, especially if you are breastfeeding.
• Drink fluids and eat enough fiber to reduce constipation and straining.
• Resume pelvic floor exercises when your clinician says you can do so comfortably.

MedlinePlus episiotomy aftercare guidance also advises keeping the area clean and dry, easing constipation, and contacting a clinician if pain worsens, the wound opens, or discharge develops an unpleasant smell.

When to get medical help

Contact your healthcare professional promptly if pain or swelling is getting worse instead of better, you develop fever or chills, the wound opens, or you notice pus or a bad smell. New trouble controlling bowel movements or gas also needs medical assessment.

When Is an Episiotomy Considered Necessary?

An episiotomy is considered when there is a clinical reason, not simply because it is a first birth or because the baby is thought to be large. The decision is usually made during the second stage of labor after the clinician assesses the baby, the progress of birth, and the need for assisted delivery.

Current NICE intrapartum-care guidance says not to perform routine episiotomy during spontaneous vaginal birth. It advises performing one when there is a clinical need, such as a forceps or vacuum birth or suspected fetal compromise.

Situations in which an episiotomy may be considered include:

• The baby needs to be born quickly because there are concerning signs of fetal compromise.
• Forceps or vacuum assistance is needed and the clinician judges that an incision is necessary for the assisted birth.
• There is concern about a severe perineal tear and the clinician believes a carefully placed incision may reduce that risk in the specific situation.
• More space is needed for a difficult vaginal birth, such as certain complicated breech or shoulder-dystocia situations, when the clinician needs room to perform delivery maneuvers.

Breech presentation, a suspected large baby, or a first vaginal birth does not automatically mean an episiotomy is required. The need is assessed at the time of birth.

Can anything reduce the chance of needing one?

No method can guarantee that you will avoid an episiotomy or tear. However, RCOG guidance on reducing perineal tears says perineal massage from 35 weeks may reduce tearing, particularly for a first vaginal birth.

NICE also recommends offering a warm, wet compress to the perineum once it is distended in the second stage of labor, unless the birth is in water. These measures are discussed with the woman and do not remove the possibility that an episiotomy could still become necessary.

Can an Episiotomy Impact Future Pregnancies or Deliveries?

Having one episiotomy does not mean you will need another in a later birth. The need for an episiotomy should be reassessed during each delivery based on your condition, the baby’s condition, and how the birth is progressing.

Some people develop tender or firm scar tissue, and a small number may need additional treatment if the scar causes persistent pain or discomfort. According to RCOG, a few women with excessive scar tissue may need a repeat episiotomy, but this is not routine.

Evidence also does not support the idea that a previous episiotomy by itself means future pelvic organ prolapse or incontinence is inevitable. If you have ongoing pain, painful sex, bowel or bladder symptoms, or concerns about scar tissue before another pregnancy, discuss them with an obstetric clinician or pelvic health physiotherapist.

Frequently Asked Questions

How Does an Episiotomy Differ From a Tear During Childbirth?

An episiotomy is a deliberate surgical incision, while a perineal tear happens spontaneously as the tissues stretch during birth. A tear can be minor or deep, and an episiotomy can also extend into a deeper tear. Neither should be assumed to heal better in every case.

Can I Request an Episiotomy During Labor?

You can discuss or request an episiotomy, but it should not be done routinely without a clinical reason. Your doctor or midwife should explain why they recommend or do not recommend it and consider your preferences alongside the safety of you and your baby.

What Pain Relief Options Are Available During an Episiotomy?

Effective anesthesia should be provided before an episiotomy whenever the situation allows. If an epidural is already working, it may provide adequate pain relief; otherwise, local anesthetic can numb the perineum before the cut and repair.

How Can I Prepare for the Possibility of an Episiotomy?

Discuss episiotomy during prenatal care, including when your clinician uses it, how consent is handled, and what pain relief is available. You can also ask about perineal massage late in pregnancy and warm compresses during labor, while understanding that no preparation can guarantee you will avoid an episiotomy.

What Should I Do if I Experience Complications After an Episiotomy?

Contact your healthcare professional if pain is worsening, the wound opens, you develop fever, or you notice pus, unusual odor, increasing redness, or swelling. Seek prompt assessment for heavy bleeding or new bowel-control problems rather than waiting for a routine postpartum visit.

Conclusion

Episiotomy is a selective tool for specific situations, not a routine requirement for vaginal birth. Talk with your maternity team before labor about when they use it, how they obtain consent, and what recovery care to expect so you can make informed choices if the need arises.

Sources

1. World Health Organization: Intrapartum care recommendations: Supports avoiding routine or liberal episiotomy.
2. Cochrane: Selective versus routine episiotomy: Supports selective rather than routine use and summarizes maternal outcomes.
3. Royal College of Obstetricians and Gynaecologists: Episiotomy: Supports indications, recovery, wound care, and future-birth guidance.
4. MedlinePlus: Episiotomy aftercare: Supports wound care, pain relief, constipation prevention, and warning signs.
5. NICE: Intrapartum care recommendations: Supports non-routine use, clinical indications, anesthesia, and warm compresses.
6. RCOG: Reducing your risk of perineal tears: Supports perineal massage from 35 weeks and perineal protection measures.

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