You probably know enough about episiotomies, an incision that enlarges the vaginal opening so your infant can emerge during a vaginal birth, to know that you'd prefer to avoid a snip down there, thank you very much. The good news? These days, episiotomies are no longer the norm. In fact, midwives and most doctors rarely perform the procedure without good reason.
Until recently, practitioners routinely made the cut under the assumption that episiotomies protected women from spontaneous tears that were more difficult to heal and could lead to future problems like urinary incontinence. Doctors also feared that newborns faced birth trauma from the head pushing for too long against the perineum during labor.
However, research has debunked these theories, showing that both moms and newborns fare as well, if not better, without a standard episiotomy, and the American College of Obstetricians and Gynecologists (ACOG) now no longer recommends that episiotomies be performed routinely.[1]
Still, this doesn’t mean that all women can avoid this procedure at every birth. Here’s more about episiotomies, including how common they are today and when they may be necessary, plus how to help them heal and steps you can take to lower the chance of having one.
What is an episiotomy?
An episiotomy is a minor surgical cut in your perineum (the muscular area between your vagina and anus). These cuts are made right before a vaginal delivery to enlarge the opening for your baby's exit.
How common are episiotomies?
Since the policy of routine episiotomies changed in 2006, the procedure’s rate has declined significantly. For example, in 2000, 33% of vaginal births involved an episiotomy, but just 12% did in 2012. Data from The Leapfrog Group, a nonprofit organization that collects information from some hospitals, suggests that it fell even lower in 2018, to about 7%.
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Still, whether you have this cut or not may depend on where you get your medical care, as some episiotomy rates are as low as 1% and others as high as 40%.
“The decision to perform an episiotomy will depend on your doctor, who will take into account your health history as well as other factors,” says Andrei Rebarber, M.D., an OB/GYN and maternal-fetal medicine specialist in Englewood, New Jersey, and a member of the What to Expect Medical Review Board. “There isn’t any specific situation in which episiotomy is essential.”
Is there anything you can do to avoid an episiotomy?
Keep in mind that, occasionally, episiotomies turn out to be necessary, and the final decision should be made in the delivery room. Still, it may be possible to reduce your risk. Here’s what you can try:
- Discuss the topic. Talk to your practitioner about your desire to avoid an episiotomy, if that's how you feel; it's very likely they’ll agree that the procedure can be skipped unless there's a good reason.
- Write it down. Note your wish to not have an episiotomy in your birth plan.
- Use warmth. When applied to your perineum during labor, warm compresses can soften the skin, enabling it to stretch more easily.
- Go slowly. Push for only five to seven seconds at a time and bear down gently (instead of pushing hard for 10 seconds while holding your breath).
- Add counterpressure. Your practitioner can gently push back on your perineum as the baby's head emerges so that he doesn’t come out too quickly and cause an unnecessary tear.
When is an episiotomy procedure considered necessary?
While episiotomies are not recommended as often as they once were, there’s still a place for them in some birth scenarios:[2]
- Big head. A larger noggin may need a roomier exit, so an episiotomy may be performed in these situations.
- Forceps or vacuum delivery. These tools may also need more space to maneuver.
- Complications. These can include a breech presentation (feet or bottom first) or shoulder dystocia, which means the shoulder is stuck in the birth canal.
- Fetal distress. When the fetal monitoring of your baby's heart rate shows he’s in distress and not getting enough oxygen, this cut may be made so he can be born faster.
What happens during an episiotomy?
If it looks like you’ll need an episiotomy, your doctor will inject a local anesthetic into the perineal area to numb it — though if you’ve already had an epidural, you won’t need this extra step.
Next, during the second or pushing stage of labor, either scissors or a scalpel will be used to make a median, or midline, incision (a cut made directly back toward the rectum) or, more commonly in the U.S., a mediolateral incision, which slants away from the rectum.
After the delivery of your baby and the placenta, your practitioner will stitch up the cut. You'll get a shot of local pain medication if you didn't receive one before or if your epidural has worn off.
Episiotomy vs. natural tears: What’s better?
In the past, episiotomies were performed to prevent spontaneous tearing of the perineum and to reduce the risk of fetal birth trauma. But studies have shown that both infants and mothers generally fare just fine without one.
In fact, when comparing women who have had an episiotomy to those who haven’t, the women who were allowed to tear spontaneously during labor:
- Recover in the same (or less) time and with less pain
- Have fewer complications, such as fecal and urinary incontinence, infection, and blood loss
- Are less likely to have tears turn into more serious third- or fourth-degree lacerations
- Experience less perineal pain and faster healing
"I had an episiotomy with my first (dilated too quickly) but didn’t have a bad recovery," says What to Expect Community mom sadesmarie. "No episiotomy and a first-degree tear with my second."
Are there risks associated with episiotomies?
Yes, as with any type of surgical procedure, there are some risks, such as a deeper wound than a natural tear would produce, possible infection, and pain, including painful sex in the months post-birth.
A midline episiotomy may up the risk of a fourth-degree vaginal tear, which is one that goes close to or through the rectum, sometimes causing fecal incontinence.
How long does it take for an episiotomy to heal?
Everyone who delivers vaginally (and some moms who have a C-section) can experience some perineal pain after birth, which, unfortunately, is likely to be compounded if the perineum was surgically cut.
Like any new wound, the site of an episiotomy will take time to heal, usually seven to 10 days. While you're in the hospital, a nurse will check your perineum at least once daily to be certain there's no inflammation or sign of infection.
How should you care for an episiotomy?
Keep in mind that the stitches you received won’t need to be removed — they’ll be absorbed by your body. You should also take it easy for a few weeks and wait for the green light when it comes to having sex and starting to exercise again.
To help prevent infection, your health care provider will instruct you in postpartum perineal hygiene, which includes the following:
- Ice packs. Cold compresses or ice wrapped in a washcloth or plastic bag can ease swelling and decrease pain.
- Sitz baths. Sit in shallow, warm water a few times a day to speed healing.
- Pain relief. Ask your doctor about over-the-counter medications like ibuprofen or a numbing application such as a spray or cream.
- Squirt clean. Use a small plastic water bottle to spritz your perineum during and after using the bathroom, and then gently pat the area dry with a soft towel or baby wipe. If using the bathroom is painful, stool softeners recommended by your health care provider may be helpful.
- Expose your stitches to fresh air. Lying on your bed in your birthday suit for five to 10 minutes once or twice a day may also help speed along the healing process.
It’s unusual for pain to last for more than two or three weeks. If the pain gets worse, you see pus, or you develop a fever, call your doctor. You may have an infection.
Otherwise, while healing, be sure to avoid heavy lifting and press pause on using tampons and having sex until your doctor says it's okay to do so.
- Episiotomies are no longer routine. Once a standard part of childbirth, episiotomies are now rarely performed without medical necessity. Research has shown that spontaneous tearing may result in fewer complications and faster healing compared to surgical cuts.
- Episiotomies are still needed in certain situations. Episiotomies might be needed if complications arise, including if the baby is in distress and needs to be delivered quickly, the baby's head is large, tools like forceps or a vacuum are used, baby is in the breech position, or shoulder dystocia occurs.
- There are ways to lower your chances of having an episiotomy. You can discuss it with your doctor, include it in your birth plan, use warm compresses and push gently during labor, and apply perineal counterpressure when you're giving birth.
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