What's an episiotomy, and why is it sometimes necessary?

pregnant belly purple shirt
Credit: MilaSupinskaya/shutterstock.com

Episiotomies 101

An episiotomy is an incision in the perineum (the area between the vagina and the anus) made just before the time of birth in order to enlarge the vaginal opening and prevent spontaneous tearing. The incision is stitched closed under local anesthesia after the baby has been delivered.

The number of American mothers getting episiotomies has decreased from 64 percent to 39 percent in the last 20 years. But many experts say the current figures are still too high.

Do You Need an Episiotomy?

There are cases where an episiotomy can be beneficial: to hasten the delivery of a baby in trouble, ease a breech birth, enlarge a too-tight vaginal opening, or prevent painful tearing toward the front of the vagina.

But most of the time, with local massage and control of the delivery, the vaginal tissue will stretch and then return to normal on its own. And if natural tears occur, they typically require less extensive stitching than an episiotomy.

A review of existing studies published in Obstetrics & Gynecology found that not only is the procedure performed too frequently, but that benefits doctors have long attributed to routine episiotomy -- including that it helps women heal faster by reducing tearing and prevents brain damage to the baby by reducing labor time -- appear not to be true.

What Are the Risks?

Research has long suggested that the risks of a routine episiotomy outweigh its claimed benefits. In fact, the American College of Obstetricians and Gynecologists doesn't recommend routine episiotomies. Studies show that unless the baby is in distress, an episiotomy may cause more pain and suffering for the mother than benefit for the baby. Possible problems for the mother include:

  • Tears to the anus or into the rectum, which may require surgery
  • Additional blood loss
  • Infection and swelling
  • Postdelivery pain
  • Weakness of pelvic-floor muscles
  • Fecal and urinary incontinence
  • Delayed ability to have intercourse

Avoiding an Unnecessary Episiotomy

Ask when and how often the individual doctors or midwives in your provider's group find it necessary to perform this procedure. Make sure that you're on the same page with them about when and if an episiotomy is necessary.

A caregiver who does few episiotomies will probably recommend several strategies to help you avoid an unnecessary cut:

  • Practice Kegels. Kegels are exercises that tone the vaginal muscles so they can stretch more easily for birth. To do a Kegel, tighten and relax the muscles around your urethra, vagina, and anus, as if you're trying to hold back urine. Keep the muscles contracted for about 10 seconds. Repeat 10 to 20 times in a row, two to three times a day.
  • Perform prenatal perineal massage. With your doctor's okay, start about six weeks before your due date. Here's how: Sit up, leaning back, in bed, or stand with a foot resting on a chair. Lubricate your fingers with vegetable oil or a water-soluble gel like K-Y Jelly. With your thumbs on the inside and other fingers on the outside, make a U-shaped movement around the bottom portion of your vagina (the part toward your back). For about five minutes, apply just enough pressure to create a stinging sensation while you focus on relaxing. Your partner could also do this massage for you, with index fingers inside and thumbs outside.
  • Control your pushing. During the birth, you can help by controlling your pushing according to your birth attendant's directions, by letting your knees fall far apart, and by completely relaxing your pelvic floor muscles (the opposite of a Kegel). Your doctor or midwife may apply warm compresses to help you relax, topical lubricants to ease out the baby's head, and firm hand pressure to keep the baby's chin flexed to present a smaller diameter at birth.

The Second Child

Once you've had a baby, you're more likely to avoid an episiotomy the next time. If the vaginal area has been stretched once, it should stretch more easily with less tearing for subsequent deliveries, according to Cynthia Hanna, MD, an assistant clinical professor in obstetrics and gynecology at Brown University. And even though the scar tissue from an old episiotomy isn't as elastic as normal tissue, a second-time mother can usually stretch enough to accommodate another baby without tearing badly.

Healing Hints

Whether or not you had an episiotomy or stitches from a tear, you'll feel sore or swollen for a few days to weeks after giving birth. Experts say you'll heal faster if you:

  • Use an ice pack for 24 hours, then take frequent warm sitz baths (you should receive one from the hospital; they're also available at your local pharmacy).
  • Keep the area clean and apply witch hazel or a topical anesthetic.
  • Do frequent Kegels to improve circulation and speed healing.
  • Drink lots of water to keep your urine diluted so it doesn't sting.
  • Don't sit on an inner tube to avoid pain -- this pulls stitches apart. Instead, choose a firm seat and do a Kegel before you sit down.
  • Don't baby the area; the sooner you move around, the faster your pain will decrease.

Adrienne B. Lieberman, a childbirth educator, is coauthor of Nine Months and a Day (Harvard Common Press).

All content here, including advice from doctors and other health professionals, should be considered as opinion only. Always seek the direct advice of your own doctor in connection with any questions or issues you may have regarding your own health or the health of others.

American Baby