Pregnancy and baby

Episiotomy

Sometimes during the process of giving birth, a doctor or midwife may make a cut in a woman’s perineum (the area between the vagina and anus). The cut makes the opening of the vagina a bit wider, allowing the baby to come through it more easily.

Why you might need an episiotomy

How it is performed

Recovering from an episiotomy

Preventing an episiotomy

In England, episiotomies aren't carried out routinely. NICE (the National Institute for Health and Care Excellence) recommends that an episiotomy should be considered if the baby is in distress and needs to be born quickly, or if there is a clinical need, such as a delivery that needs forceps or ventouse. Around one in seven deliveries involves an episiotomy.

In some women, the perineum may tear during childbirth as the baby comes out. If you have a tear or an episiotomy, you will probably need stitches to repair it, depending on the nature of the wound. If your doctor or midwife feels that you need an episiotomy when you’re in labour, they will discuss this with you.

The stitches used during an episiotomy should heal within one month. Dissolving stitches are usually used, so you won't need to return to hospital to have them removed.

You will probably feel some pain around the episiotomy for two or three weeks after your baby is born. Sex can also be painful for the first few months after an episiotomy.

Why you might need an episiotomy

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

Another reason for carrying out an episiotomy is when it is necessary to widen your vagina so that instruments, such as forceps or ventouse suction, can be used to assist with the birth. This may be necessary if:

  • you are having a breech birth (the baby is not head first)
  • you have been trying to give birth for several hours and are now exhausted
  • you have a serious health condition, such as heart disease, and it is recommended that delivery should be as quick as possible to minimise any further health risks 

If you’ve had a severe tear in a previous delivery, this doesn’t make it more likely that you’ll need an episiotomy in subsequent deliveries.

How an episiotomy is performed

An episiotomy is usually a simple operation. A local anaesthetic is used to numb the area around the vagina so you will not feel any pain. If you’ve already had an epidural, the dose can be "topped up" before the cut is made.

Whenever possible, the doctor or midwife will make a small, diagonal cut from the back of the vagina, directed down and out to one side. Following the birth, the cut is stitched together using dissolvable stitches.

Recovering from an episiotomy

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

Dissolving stitches are usually used, meaning you won't need to go back to hospital to have them removed. Stitches should heal within one month of 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 around the cut for two to three weeks after giving birth, particularly when walking or sitting. Passing urine can also cause the cut to sting.

Coping with pain

It’s common to feel mild to moderate pain after an episiotomy. Painkillers, such as paracetamol, can help to relieve pain and are safe to use if you are breastfeeding. Ibuprofen is safe to use as long as your baby was not premature (born before 37 weeks of pregnancy), was not a low birth weight and has no medical condition. Aspirin isn't recommended, because it can be passed on to your baby via your breast milk.

Using a doughnut-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.

Research suggests that, after an episiotomy, around 1% of women will feel severe pain that seriously affects their day-to-day activities and quality of life. If this happens, it may be necessary to treat the pain with stronger prescription-only painkillers, such as codeine. However, 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 about this. It is unusual for post-operative pain to last for longer than two to three weeks.

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

Exposing the stitches 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.

Going to the toilet

Keep the cut and the surrounding area clean to prevent infection. After going to the toilet, pour warm water over your vaginal area to rinse it. Pouring warm water over the outer area of your vagina as you pee may also help to ease the discomfort. You may find that squatting over the toilet, rather than sitting on it, reduces the stinging sensation when passing urine.

When you are passing a stool, you may find it useful to place a clean pad at the site of the cut and press gently as you poo. This can help to relieve pressure on the cut. When wiping your bottom, make sure that you wipe gently from front to back, because this will help to prevent bacteria in your anus infecting the cut and surrounding tissue.

If you find passing stools particularly painful, taking a short course of bulk-forming laxatives may help. This type of medication is usually used to treat constipation and makes stools softer and easier to pass. For more information, read about treating constipation.

Pain during sex

There are no rules about when to start having sex again after you've given birth. In the weeks after giving birth, many women feel sore as well as tired, whether they’ve had an episiotomy or not. Don’t rush into it. If sex hurts, it won’t be pleasurable.

You can get pregnant as little as three weeks after the birth of a baby, even if you’re breastfeeding and your periods haven’t started again. Use some kind of contraception every time you have sex after giving birth, including the first time (unless you want to get pregnant again).

You will usually have an opportunity to discuss your contraceptive options before you leave hospital (if you’ve had your baby in hospital) and at the postnatal check. You can also talk to your GP or health visitor, or go to a contraception clinic at any time. Find sexual health services near you.

If you’ve had a tear or an episiotomy, pain during sex is very common in the first few months. 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.

If penetration is painful, say so. It’s not pleasant to have sex if it causes pain. If you pretend everything is all right when it isn’t, you may start to see sex as a nuisance rather than a pleasure, which won’t help either of you. Read some tips on talking about sex. You can still be close without having penetration (for example, mutual masturbation).

Pain can sometimes be linked to vaginal dryness. You can try using a water-based lubricant (available at pharmacies) to help. Don’t use an oil-based lubricant, such as Vaseline or moisturising lotion, as this can irritate the vagina, and damage latex condoms or diaphragms.

Infection

Look out for any signs that the cut or surrounding tissue has become infected, such as red, swollen skin, discharge of pus or liquid from the cut, or persistent pain. Tell your GP or midwife as soon as you can about any possible signs of infection, so that they can make sure you get any treatment you need. 

Exercises

Strengthening the muscles around the vagina and anus 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, as though to stop yourself from going to the loo or farting. Your midwife can show you how to perform the exercises correctly. You can also read this NHS leaflet for advice: pelvic floor exercises for women (PDF, 68kb).

Scar tissue

For 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 can be carried out 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.

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.

Preventing an episiotomy

A midwife can help you avoid a tear or episiotomy during labour when the baby’s head becomes visible. The midwife will ask you to stop pushing, and to pant or puff a couple of quick short breaths, blowing out through your mouth.

This is so that your baby’s head can emerge slowly and gently, giving the skin and muscles of the perineum time to stretch without tearing. The skin of the perineum usually stretches well, but it may tear. Sometimes, to avoid a tear or to speed up delivery, the midwife or doctor will inject local anaesthetic and cut an episiotomy.

Research suggests that massaging the perineum in the last few weeks of pregnancy can reduce the chance of having an episiotomy during birth. A review of four trials showed that in women who had not given birth vaginally before, massaging the perineum from 35 weeks of pregnancy reduced the likelihood of perineal trauma (mainly episiotomies) and ongoing perineal pain. The benefit was less clear for women who had given birth before.

The type and frequency of massage varied across the trials. Most involved inserting one or two fingers into the vagina and applying downward or sweeping pressure towards the perineum. The benefit was more marked among those women who carried out perineal sweeping twice a week. 

Page last reviewed: 17/07/2014

Next review due: 17/07/2016

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The 2 comments posted are personal views. Any information they give has not been checked and may not be accurate.

zenko said on 16 June 2014

Cochrane Collaborate Reports are produced by government independed research workers and specialists of 120 countries collaborating or working together , and NICE (National Institute of Clinical Excellence) bases its recommendations to the NHS of England on Cochrane Reports. Tears and episiotomy is avoidable by a good firm massage, a gentle massage is a sham massage.
Cochrane report 2013 on Antenatal Massage says in its Plain English Summary, 'women should be informed of the benefits' and in the Clinical Summary -women who have not had a previous vaginal birth, benefit significantly. This is supported by logic. But the massage must be more than a single 'gentle' massage; i.e. one repeated 3-4 times on different days to achieve a 10cm diameter opening for baby's head to pass through, so using the thumbs of both hands and pulling sideways if mum is doing it herself (finger tips on buttocks) or if her partner is performing the massage, index middle and ring fingers of both hands pulling sideways, to mimic the massaging action of baby's head on the opening realistically and before the start of birth, as once baby's head intermittently causes lymphatic obstruction and the skin becomes stretched by tissue fluid and swells, any attempt once baby's head is becoming visible risks tearing the now stretched skin. The massage should be done as neck of the uterus has not reached 10cm dilatation, early on in labour.

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Mrs_CH said on 28 June 2013

I'm very surprised about the dismissing of perineal massage in this article. Having been literally scoffed at by both a doctor and a midwife when I mentioned doing it, I looked up the evidence.

The Royal College of Midwives says in 2008 Practice Guidelines:"Antenatal perineal massage is an effective approach to increasing the chance of an intact perineum (Labrecque et al. 1999; Shipman et al. 1997) and in reducing instrumental deliveries (Shipman et al. 1997)"

A 2012 guidance note from the same organisation on evidence-based approaches to Care of the Perineum begins "Antenatal perineal massage carried out by the mother or her partner in the third trimester is an effective approach to reduce perineal trauma among women who have not had a previous vaginal birth (Beckmann and Garrett 2006)."

The NICE website also points as its top search result to a paper published in April 2013 that summarises its conclusion as: "Antenatal digital perineal massage reduces the likelihood of perineal trauma (mainly episiotomies) and the reporting of ongoing perineal pain, and is generally well accepted by women. As such, women should be made aware of the likely benefit of perineal massage and provided with information on how to massage."

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