Episiotomy: When It’s Needed, Alternatives, and Recovery Guide

An episiotomy is a surgical incision made in the perineum – the area of tissue between the vaginal opening and the anus – during childbirth. While this procedure was once routinely performed during vaginal deliveries, modern medical practice has significantly reduced its use. Understanding when an episiotomy is truly necessary and what alternatives exist can help expectant parents make informed decisions about their birth plans.

What Is an Episiotomy?

During vaginal delivery, the perineal tissue stretches to accommodate the baby’s head and body. An episiotomy involves making a controlled incision in this tissue to enlarge the vaginal opening. Healthcare providers perform this procedure using surgical scissors, typically during the final stages of labor when the baby’s head is crowning.

The procedure is usually performed under local anesthesia or epidural anesthesia, ensuring the birthing person feels minimal to no pain during the incision. After delivery, the healthcare provider repairs the incision with dissolvable stitches.

The Evolution of Episiotomy Practice

For many decades, episiotomies were performed routinely during vaginal deliveries, with some hospitals reporting rates as high as 60-70% of all vaginal births. Medical professionals believed that making a controlled incision would prevent more severe, irregular tearing and promote faster healing.

However, extensive research over the past several decades has fundamentally changed this perspective. Studies have shown that routine episiotomies do not provide the benefits once attributed to them and may actually lead to more complications than allowing natural tearing to occur when necessary.

Today, major medical organizations, including the American College of Obstetricians and Gynecologists, recommend against routine episiotomy use. The procedure is now reserved for specific medical situations where the potential benefits outweigh the risks.

When Is an Episiotomy Necessary?

While episiotomies are no longer routine, certain circumstances may warrant the procedure. Healthcare providers may recommend an episiotomy in the following situations:

Fetal Distress

When the baby shows signs of distress during delivery, such as an abnormal heart rate pattern, expediting the birth becomes critical. An episiotomy can help speed up delivery by providing additional space for the baby to pass through more quickly.

Operative Vaginal Delivery

When forceps or vacuum extraction instruments are needed to assist with delivery, an episiotomy may reduce the risk of severe uncontrolled tears. The controlled incision provides more room for the healthcare provider to maneuver the instruments safely.

Shoulder Dystocia

This emergency situation occurs when the baby’s shoulder becomes lodged behind the mother’s pelvic bone after the head has already been delivered. An episiotomy can provide additional space needed to perform maneuvers that release the stuck shoulder.

Breech Delivery

In cases where a vaginal breech delivery is attempted, an episiotomy may facilitate the delivery of the baby’s body and head.

Maternal Exhaustion

When the birthing person has been pushing for an extended period and is too exhausted to continue effectively, an episiotomy might help expedite delivery.

Types of Episiotomy

There are two primary types of episiotomy incisions, each with distinct characteristics, advantages, and disadvantages:

Midline Episiotomy

A midline episiotomy involves a vertical incision made straight down from the vaginal opening toward the anus. This approach offers several characteristics:

• Easier to repair with more straightforward anatomy
• Typically results in less blood loss
• Generally associated with less postpartum pain
• Heals more quickly than other types
• Higher risk of extending into the anal sphincter or rectum (third or fourth-degree tear)

Mediolateral Episiotomy

A mediolateral episiotomy involves an incision made at an angle, typically 45 to 60 degrees from the midline. This technique has different characteristics:

• Lower risk of extending into the anal sphincter
• More difficult to repair due to asymmetric anatomy
• May result in more blood loss
• Often associated with more postpartum pain
• May take longer to heal completely

The choice between these techniques depends on various factors, including the healthcare provider’s training, the specific delivery circumstances, and anatomical considerations.

Risks and Complications of Episiotomy

Like any surgical procedure, episiotomies carry potential risks and complications. Understanding these risks is important for informed decision-making:

Pain and Discomfort

Postpartum pain in the perineal area is common after an episiotomy. The discomfort can affect sitting, walking, and using the bathroom. Pain typically decreases gradually over several weeks but may persist longer in some cases.

Bleeding

Increased blood loss can occur with an episiotomy compared to natural tearing or an intact perineum. While usually manageable, excessive bleeding may require additional intervention.

Infection

The episiotomy site can become infected, particularly if proper hygiene isn’t maintained during the healing period. Signs of infection include increased pain, redness, swelling, fever, unusual discharge, or foul odor.

Extended Tears

One of the most significant risks, particularly with midline episiotomies, is that the incision may tear further during delivery. These extensions can result in third-degree tears (extending into the anal sphincter) or fourth-degree tears (extending through the anal sphincter into the rectal lining).

Sexual Dysfunction

Some individuals experience painful intercourse (dyspareunia) for months following an episiotomy. The scar tissue that forms may be less elastic than the original tissue, leading to discomfort during sexual activity.

Fecal Incontinence

When an episiotomy extends into the anal sphincter, it can damage the muscles that control bowel movements. This may result in difficulty controlling gas or stool.

Prolonged Healing

Episiotomy incisions sometimes heal more slowly than natural tears, particularly when complications arise or the incision is extensive.

Recovery and Healing After Episiotomy

Proper care during the recovery period is essential for optimal healing and minimizing complications. Here’s what to expect and how to care for yourself:

Immediate Postpartum Period

The first few days after delivery are typically the most uncomfortable. The episiotomy site will be tender, and you may experience throbbing or stinging sensations, especially when urinating or having a bowel movement.

Pain Management

Your healthcare provider can recommend appropriate pain relief options. Always consult with your healthcare provider before taking any medication, especially if you are breastfeeding.

Non-medication pain relief strategies include:

• Ice packs applied to the perineal area for the first 24 hours
• Sitz baths (sitting in warm shallow water) several times daily
• Cooling pads or witch hazel pads
• Using a squirt bottle with warm water when urinating to dilute urine and reduce stinging

Hygiene Practices

Keeping the episiotomy site clean is crucial for preventing infection:

• Wash your hands thoroughly before and after using the bathroom
• Gently cleanse the perineal area with warm water after each bathroom visit
• Pat dry gently with toilet paper or a clean towel, moving from front to back
• Change sanitary pads frequently
• Avoid tampons until your healthcare provider approves their use

Bowel Movements

Many people worry about bowel movements after an episiotomy. Your healthcare provider may recommend strategies to make this easier. Eating high-fiber foods, drinking plenty of water, and not delaying bowel movements when you feel the urge can help prevent constipation.

Activity Restrictions

While it’s important to move around to promote circulation and prevent blood clots, you should avoid strenuous activity during the initial healing period:

• Avoid heavy lifting for several weeks
• Don’t do high-impact exercises until cleared by your healthcare provider
• Use proper body mechanics when caring for your baby
• Rest whenever possible to promote healing

Timeline for Healing

Most episiotomy incisions heal within three to six weeks, though complete healing and return to normal sensation may take longer. The stitches used are typically dissolvable and don’t require removal.

Warning Signs

Contact your healthcare provider immediately if you experience:

• Increasing pain rather than gradual improvement
• Fever or chills
• Foul-smelling discharge
• Severe swelling or redness spreading beyond the incision site
• Pus or bleeding from the incision
• Separation of the incision edges
• Difficulty urinating or having bowel movements
• Signs of infection

Alternatives and Prevention Strategies

Several techniques and approaches may reduce the likelihood of needing an episiotomy or experiencing severe tears:

Perineal Massage

Starting around 34-35 weeks of pregnancy, regular perineal massage may help increase tissue elasticity and reduce the risk of tearing. This involves gently stretching the perineal tissue using clean fingers and a lubricant.

Warm Compresses

Applying warm compresses to the perineum during the second stage of labor may help the tissue stretch more easily and reduce trauma.

Controlled Delivery

Allowing the baby’s head to emerge slowly and in a controlled manner, rather than rushing the delivery, gives the perineal tissue time to stretch gradually. Healthcare providers may use techniques like supporting the perineum and guiding the baby’s head.

Positioning During Delivery

Certain birthing positions, such as side-lying or upright positions, may reduce the risk of severe perineal trauma compared to the traditional lithotomy position.

Labor Support

Having continuous support during labor from trained professionals or doulas may reduce the need for interventions, including episiotomy.

Avoiding Prolonged Pushing

Working with your body’s natural urge to push rather than directed, forceful pushing for extended periods may reduce perineal trauma.

Natural Tearing vs. Episiotomy

Research has consistently shown that for most women, allowing natural tearing to occur if needed results in better outcomes than routine episiotomy:

Advantages of Natural Tearing

• Natural tears are often smaller and more superficial than surgical incisions
• They follow the natural tissue planes, potentially healing better
• Lower risk of severe tears extending to the anal sphincter
• Less blood loss on average
• Reduced long-term complications
• Many women experience no tearing at all

Degrees of Perineal Tears

Understanding the classification of tears can help put the risks in perspective:

First-degree tears: Involve only the skin and superficial tissue. These usually heal quickly with minimal intervention.

Second-degree tears: Extend into the perineal muscles but not the anal sphincter. These require stitches but generally heal well.

Third-degree tears: Extend into the anal sphincter muscle. These require more extensive repair and carry higher risks of complications.

Fourth-degree tears: Extend through the anal sphincter into the rectal lining. These are the most serious and require skilled repair.

Research shows that routine episiotomy does not reduce the risk of third or fourth-degree tears and may actually increase this risk, particularly with midline incisions.

Having the Conversation With Your Healthcare Provider

Open communication with your healthcare provider about episiotomy is an important part of birth planning:

Questions to Ask

• What is your approach to episiotomy?
• What percentage of your patients receive episiotomies?
• Under what circumstances would you recommend an episiotomy?
• What alternatives do you use to prevent tearing?
• Will you ask my permission before performing an episiotomy except in emergencies?
• What can I do during pregnancy to reduce my risk of needing an episiotomy?
• What pain management options are available during recovery?

Including Preferences in Your Birth Plan

Consider including your preferences regarding episiotomy in your birth plan. You might state that you prefer to avoid episiotomy unless medically necessary and would like to be informed if it becomes necessary (when time permits).

Remember that birth plans are guidelines, not contracts. Medical emergencies may arise where an episiotomy becomes necessary for your or your baby’s health, and you may not be able to participate in the decision-making process in those moments.

Long-Term Outcomes and Considerations

Understanding the potential long-term effects of episiotomy can inform your decision-making:

Pelvic Floor Health

Contrary to earlier beliefs, episiotomies do not protect pelvic floor function better than natural tearing or an intact perineum. Some research suggests they may actually increase the risk of pelvic floor disorders.

Future Pregnancies

Having an episiotomy in one pregnancy does not necessarily mean you will need one in subsequent pregnancies. Each delivery is unique, and many women who had an episiotomy with their first child deliver without one in later pregnancies.

Sexual Health

While many women experience temporary discomfort during intercourse following childbirth regardless of whether they had an episiotomy, some research suggests episiotomies may be associated with longer-lasting sexual dysfunction. However, multiple factors affect postpartum sexual health, and experiences vary widely.

Scar Tissue

Episiotomy scars may remain sensitive or tender for months or even years after delivery. Some women report persistent numbness or altered sensation in the perineal area.

Special Considerations

First-Time Mothers

Women giving birth for the first time (primiparous) have a higher overall risk of perineal trauma than those who have given birth before. However, this does not justify routine episiotomy, as research shows the procedure does not improve outcomes even in first-time mothers.

Operative Deliveries

When forceps or vacuum extraction is necessary, the decision about episiotomy becomes more nuanced. Some research suggests episiotomy may reduce the risk of severe tears in these situations, though the evidence is not conclusive.

Cultural and Personal Considerations

Cultural backgrounds, personal experiences, and individual values all play a role in how people feel about episiotomy. Some may prefer a controlled incision over the possibility of tearing, while others strongly wish to avoid the procedure. Both perspectives are valid.

The Current Evidence

Multiple large-scale studies and systematic reviews have examined episiotomy outcomes. The consistent findings include:

• Routine episiotomy does not reduce the risk of severe perineal trauma
• It does not prevent pelvic floor dysfunction or urinary incontinence
• It does not protect against fecal incontinence
• Restricted (selective) use of episiotomy leads to better outcomes than routine use
• When episiotomy is necessary, mediolateral incisions may have a lower risk of extending to the anal sphincter than midline incisions

Based on this evidence, medical guidelines now recommend against routine episiotomy use and encourage a selective, individualized approach.

Emotional and Psychological Aspects

The physical aspects of episiotomy are only part of the picture. The emotional and psychological impacts deserve attention as well:

Processing the Experience

Some women feel disappointed, angry, or traumatized if they had an episiotomy they didn’t want or weren’t expecting. These feelings are valid and deserve acknowledgment. Others feel grateful that the procedure helped ensure a safe delivery. There’s no “right” way to feel about the experience.

Seeking Support

If you’re struggling emotionally with your birth experience, including having had an episiotomy, consider:

• Talking with your healthcare provider about what happened and why
• Joining support groups for postpartum women
• Seeking counseling if feelings of trauma persist
• Connecting with other mothers who have had similar experiences

Conclusion

Episiotomy has evolved from a routine procedure to a selective intervention used only when specific circumstances warrant it. While the procedure may be necessary in certain situations to protect the health of mother and baby, evidence clearly shows that routine use provides no benefits and may cause harm.

As an expectant parent, understanding when episiotomy might be needed, what the procedure involves, and how to optimize your recovery empowers you to make informed decisions and communicate effectively with your healthcare team. Discuss your preferences with your provider during prenatal visits, but remain flexible knowing that unexpected situations may arise during delivery.

Remember that every birth is unique, and what matters most is that you and your baby are healthy and safe. Whether you have an episiotomy, experience natural tearing, or deliver with an intact perineum, your body will heal with time and proper care. Focus on recovery, bonding with your baby, and seeking support when you need it.

Sources:

• American College of Obstetricians and Gynecologists – Episiotomy Practice Bulletin
• Mayo Clinic – Episiotomy
• National Library of Medicine – Episiotomy and Perineal Tears
• Cochrane Library – Restrictive vs Routine Episiotomy
• Office on Women’s Health – Recovering from Birth