An episiotomy is a procedure in which a doctor or midwife makes a cut in a woman’s perineum during childbirth. The perineum is the area between the vagina and anus. The cut enables the vagina to extend more fully, making the process of childbirth easier. For more information, see How it is done.

Reasons for an episiotomy

An episiotomy will be recommended if:

• there is thought to be a risk to the baby’s health and a quick childbirth is required
• mechanical assistance, such as forceps (tongs) or suction, is required during childbirth due to complications
• there is a risk of the mother’s perineum being severely torn unless her vagina is widened

For more information see Why it is done.

Recovery

The stitches used during an episiotomy should heal within one month. Usually, dissolving stitches are used, so you won't need to go back to hospital to have them removed. For more information see episiotomy – recovery.

It is common to feel pain at the site of the episiotomy; especially during the first 2-3 weeks after it is performed. Sex can also be painful for the first few months after an episiotomy. For more information see episiotomy - complications.

How common are episiotomies?

Before the 1980s, many doctors recommended that episiotomies should be carried out on all pregnant women as it was thought to prevent problems after delivery, such as urinary incontinence.

This is no longer the case as researchers found that episiotomies carried out in otherwise healthy women have no important health benefits and exposes them to unnecessary pain.

Today, in England, an estimated 1 in 7 pregnancies now involves an episiotomy to help protect the health of the baby and/or the mother.

Anus

The anus is the opening at the end of the digestive system where solid waste leaves the body.

One common reason for carrying out an episiotomy is when it is necessary to widen your vagina so that instruments, such as forceps or suction, can be used to assist with the birth.

This may be necessary if:

• you are having a breech birth – the baby comes out of the vagina feet first
• your baby’s shoulder gets stuck inside your vaginal region
• you have been unsuccessfully trying to give birth for several hours and are now extremely exhausted
• you have a serious health condition, such as heart disease, and it is recommended that labour should be as quick as possible to minimise any further health risk

Foetal distress

An episiotomy may also be recommended if your baby develops a condition known as foetal distress.

Foetal distress is where the baby’s heart rate significantly increases or decreases before birth. This means that the baby may not be getting enough oxygen and has to be delivered quickly to avoid the risk of birth defects or stillbirth.

If a caesarean section is not appropriate – for example, because the baby's head is already moving down the birth canal, an episiotomy can be the best way to speed up birth.

Scarring

An episiotomy may also be recommended if there is extensive scarring to your vagina due to a severe tear in the perineum after a previous birth.

Anus

The anus is the opening at the end of the digestive system where solid waste leaves the body.

Caesarean section

A caesarean section is an operation to deliver a baby by cutting through the mother’s abdomen to open the womb.

Foetal

A foetus is an unborn baby, from the eighth week of pregnancy until birth.

Heart

The heart is a muscular organ that pumps blood around the body.

Oxygen

Oxygen is an odourless, colourless gas that makes up about 20% of the air we breathe.

Urethra

The urethra is a tube that carries urine from the bladder to the outside of the body.

An episiotomy is usually a very simple operation. Local anaesthetic is used in order to numb the area around the vagina so you will not feel any pain. Alternatively, if an epidural anaesthetic has already been given, the dose can be ‘topped up’ before the cut is made.

Whenever possible, the doctor or midwife will make a small, diagnonal cut from the back of the vagina and directed down and out to one side. This is called a mediolateral episiotomy.

Research has found that this type of episiotomy has a lower risk of complications compared to other types of episiotomies.

Following the birth of your baby, the cut is stitched together using dissolvable stitches.

Episiotomy incisions are usually repaired within an hour of the baby's birth. The incision may bleed quite a lot initially, but with pressure and stitches this should soon stop

Usually, dissolving stitches are used, so you won't need to go back to hospital to have them removed. Stitches should heal one month after the birth. Talk to your midwife or obstetrician about which activities you should avoid during the healing period.

After having an episiotomy, it is normal to feel pain at the site of the cut for one or two weeks after giving birth, particularly when walking or sitting. Stretching and passing urine can also cause the cut to sting.

Healing and pain relief

The following advice will help to provide pain relief and promote healing after having an episiotomy.

Painkillers

Painkillers, such as paracetamol and ibuprofen, can help to relieve pain and are safe to use if you are breastfeeding. Aspirin is not recommended because it can be passed on to your baby via your breast milk.

Using a donut-shaped cushion or squeezing your buttocks together while you are sitting may also help to relieve the pressure and pain at the site of your cut.

Ice

Placing an ice pack or ice cubes wrapped in a towel on the incision can often help to relieve pain. Avoid placing ice directly on to your skin because this could damage it.

Exposing the stitches that were used to seal the incision to fresh air can encourage the healing process. Taking off your underwear and lying on a towel on your bed for around 10 minutes once or twice a day may help.

Toilet hygiene

Keep the incision and the surrounding area clean to prevent infection. After going to the toilet, use a bottle that you can squirt liquid from, such as an empty shampoo bottle, to rinse the area between your vagina and anus.

When wiping your bottom, make sure that you wipe from front to back because this will help to prevent bacteria in your anus infecting the cut and surrounding tissue.

You may find that squatting over the toilet, rather than sitting on it, reduces the stinging sensation when passing urine. Pouring warm water over the outer area of your vagina may also help.

When you are passing a stool, you may find it useful to place a clean pad at the site of the cut and press up as you are straining down. This can help to relieve pressure on the cut.

If you find passing stools particularly painful, you may benefit from talking a short-course of bulk-forming laxatives. This type of medication is usually used to treat constipation and makes stools softer and easier to pass. See constipation - treatment for more information.

Infection

Look out for any signs that the cut or surrounding tissue has become infected, such as red, swollen skin or a discharge of pus or liquid from the site of the cut. Report any possible signs of infection to your GP or midwife as soon as possible.

Exercises

Strengthening the muscles around the affected area by doing pelvic floor exercises can help to promote healing and will reduce the pressure on the incision and surrounding tissue.

Pelvic floor exercises involve squeezing the muscles around your vagina and anus. Your midwife can show you how to perform the exercises correctly. A downloadable NHS information sheet is available called Pelvic floor exercises for women (pdf - 68KB).

Pain

Pain is an unpleasant physical or emotional feeling that your body produces as a warning sign that it has been damaged.

Painkillers

Analgesics are medicines that relieve pain. For example paracetamol, aspirin and ibuprofen.

The most commonly reported complications of an episiotomy are:

• post-operative pain
• pain during sex

These complications are discussed in more detail below.

Post-operative pain

It is common for women to feel mild to moderate pain after having an episiotomy. However, research suggests that around 1 in a 100 women will feel severe pain that seriously affects their day-to-day activities and quality of life.

In such circumstances, it may be necessary to treat the pain with stronger prescription-only painkillers, such as codeine. If you are prescribed prescription-only medication, it may affect your ability to breastfeed safely. Your GP or midwife will be able to advise you further about this.

It is unusual for post-operative pain to persist for longer than two to three weeks.

Pain during sex

Pain during sex is very common in the first few months after an episiotomy. Studies have found that around 9 out of 10 women who had an episiotomy reported that resuming sex after the procedure was very painful, but that the pain improves over time.

Many women have reported that the pain is often related to persistent vaginal dryness, so using artificial lubrication, such as lubricating gels, may help.

Water-based lubricants are recommended rather than petroleum based lubricants, such as petroleum jelly (Vaseline) because these types of lubricants can damage the vagina and make barrier forms of contraception, such as condoms or diaphragms, less effective.

You may find that using methods of sexual interaction other than penetrative sex, such as mutual masturbation, is more satisfying in the initial months after childbirth.

Scar tissue

In a few women, excessive, raised or itchy scar tissue forms around the place where a tear happened or where an episiotomy was performed. A small operation called a Fenton's procedure can be done to remove the scar tissue. This is done at least six months after childbirth, when the tissues have healed from the stretching, bruising and tearing of childbirth.

The operation involves neatly cutting out the scar tissue and sewing together the clean-cut edges with small stitches.

As with all wounds, there is a small risk of infection, so keep your stitches clean at all times.

Anaesthetic

Anaesthetic is a drug used to either numb a part of the body (local), or to put a patient to sleep (general) during surgery.

Anus

The anus is the opening at the end of the digestive system where solid waste leaves the body.

Constipated

Constipation is when you pass stools less often than usual, or when you have difficulty going to the toilet because your stools are hard and small.

Pain

Pain is an unpleasant physical or emotional feeling that your body produces as a warning sign that it has been damaged.

Incontinence

Incontinence is when you pass urine (urinal incontinence), or stools or gas (faecal incontinence), because you cannot control your bladder or bowels.

Painkillers

Analgesics are medicines that relieve pain. For example, paracetamol, aspirin and ibuprofen.

Swelling

Inflammation is the body's response to infection, irritation or injury, which causes redness, swelling, pain and sometimes a feeling of heat in the affected area.

Stool

Stool (also known as faeces) is the solid waste matter that is passed from the body as a bowel movement.

Tissue

Body tissue consists of groups of cells that perform a specific job, such as protecting the body against infection, producing movement or storing fat.

Perineal massage

Some midwives and obstetricians have claimed that gently massaging and stretching the tissue of your perineum in the last six weeks before you are due to give birth helps to make the tissue more supple and ‘stretchy’. This may help to reduce the risk of you needing an episiotomy.

The evidence to support this claim is mixed. Some studies have found no benefit associated with perineal massage, while others have found a mild to moderate benefit. However, all studies could find no evidence that perineal massage posed a threat to the mother or her baby.

So, if you find that regular perineal massages are relaxing, there is no reason to discontinue them.