What is an episiotomy?
An episiotomy is a surgical cut in the skin between the vagina and the anus (the area called the perineum) meant to enlarge your vaginal opening just before the delivery of the baby's head.
Obstetricians used to do episiotomies routinely to speed delivery and to prevent the vagina from tearing, particularly during a first vaginal delivery, in the belief that the "clean" incision of an episiotomy would heal more easily than a spontaneous tear. Many experts also surmised that an episiotomy might help prevent later complications, such as incontinence.
But many studies over the past 20 years have shown that this is not the case. In fact, there is no good evidence that episiotomy offers your vaginal tissue and pelvic floor muscles any real protection, and the procedure may actually cause problems. For this reason, the American College of Obstetricians and Gynecologists (ACOG) as well as a host of other experts now agree that the procedure shouldn't be done routinely.
The incidence of episiotomies has been on the decline, from about 17 percent of vaginal births in 2006 to 7 percent in 2018. (The number of episiotomies done for forceps or vacuum-assisted deliveries is significantly higher, though these have also showed a decline over time.) There are some experts, though, who think the number could be lower still.
The Leapfrog Group, a nonprofit organization advocating positive healthcare in the United States, for example, has set a goal of an episiotomy rate of under 5 percent.
Why is it better to tear naturally than to have an episiotomy?
Research has shown that women with a spontaneous tear generally recover in the same or less time and often with fewer complications than those who had an episiotomy.
Disadvantages of having an episiotomy:
- You can tear further through both skin and muscle layers, including occasionally the anal sphincter. (These are known as third- or fourth-degree lacerations.) These serious tears result in more perineal pain after the birth, require a significantly longer recovery period, and are more likely to interfere with the strength of the pelvic floor muscles. Tears that disrupt the anal sphincter make it more likely that the mom will have anal incontinence – trouble controlling bowel movements or gas.
- You're likely to lose more blood at the time of delivery
- You're likely to have more pain during recovery
- You're likely to have to wait longer before they have sex without discomfort
- You have an increased risk of tearing in the next birth, if they receive an episiotomy for their first vaginal birth
- You're at risk of asymmetrical healing of the skin and other physical long-term results
When might an episiotomy be necessary?
Rarely. There aren't any specific scenarios when an episiotomy is clearly indicated, and in most instances your healthcare provider will try to avoid doing one.
If your baby is crowning and her heart rate is low, for example, an episiotomy might be done to allow for a faster delivery of the head. However, heart rates usually recover, and there is usually ample time to allow for perineal stretching, so even in this instance an episiotomy would rarely be needed. In any case, your doctor will weigh the potential risks of the episiotomy against the potential benefits for your baby.
How can I avoid an episiotomy if it's not necessary?
Talk to your practitioner early on about the procedure.
Ask how often and under what conditions he would perform an episiotomy, and how he might help you avoid tearing. (Also ask about others in the practice, in case you end up with someone else at your delivery.)
Studies show that, as a group, midwives tend to do far fewer episiotomies than obstetricians. Midwives have also provided much of the research showing how an episiotomy weakens the perineal tissue, increasing the risk of third- or fourth-degree laceration.
Include in your birth plan that you don't want an episiotomy unless it's necessary.
How is an episiotomy done?
If your practitioner decides to do an episiotomy, she'll give you an injection of a local anesthetic and use surgical scissors to make a small, vertical cut in your perineum shortly before the birth of your baby. This is called a midline incision. (Sometimes, if your perineum is already numb and thinned out from the pressure of your baby's head – or if you already have an epidural – she can do the episiotomy without pain medication.)
In rare cases, a cut is made on an angle. (This is called a mediolateral incision.) When an assisted delivery (such as forceps) is needed, some providers feel that a mediolateral episiotomy is more likely than a midline to prevent tearing. Compared to median incisions, these lateral incisions can result in longer recoveries, more postpartum and perineal pain, and even some long-term scarring.
After you've given birth, you'll get another shot of local anesthesia to be sure you're completely numb before the cut is stitched up.
What's the recovery from an episiotomy like?
If you've had an episiotomy (or a tear), you'll have stitches in a very tender area, and you'll need some time to heal. Your stitches won't have to be removed – they'll dissolve on their own during the weeks after delivery.
Your doctor might recommend an over-the-counter pain reliever and stool softener. (Ointments and creams have not proven effective for episiotomy pain.)
If you need something stronger for pain relief, your doctor may provide prescription pain relievers. (If you're nursing your baby, discuss it with your doctor, because some medications are not compatible with breastfeeding.)
Some women feel little pain after the first week, while others have discomfort for a month or more, particularly if they have a third- or fourth-degree laceration.
Use ice packs on your perineal area immediately after the birth and intermittently for the next 12 hours or so to numb the area and prevent or reduce swelling. For more specific advice on how to take care of yourself, see our article on managing postpartum perineal pain.
When can I have sex again?
Your perineum should be completely healed by four to six weeks after delivery, so if your caregiver gives the okay and you're up to it, you can try having sex then. If you had a third- or fourth-degree laceration, it's particularly important to wait to have sex until after you've been examined.
You might feel some initial tenderness and tightness. Try taking a warm bath and leaving plenty of time for foreplay. You might prefer to be on top so that you can control the degree of penetration, or you may find that lying on your side is most comfortable.
Relaxing as much as possible and using a good water-soluble lubricant will help make sex more comfortable. This may be especially helpful if you're breastfeeding, because lactation lowers your estrogen levels, which reduces the amount of lubrication your vagina can produce. (Many women continue to use a lubricant during sex until they stop nursing.)
If you try these measures and find that sex is still uncomfortable or painful, talk to your caregiver about treatment. Consider seeing a physical therapist who specializes in pelvic rehabilitation. This type of therapy can help with many postpartum problems including pain during sex.