An episiotomy is a minor surgical procedure where the skin and underlying muscles of the perineum—the area between the vagina and the rectum—is cut at the end of the second stage of labor (crowning) to assist in childbirth by enlarging the birth canal opening and allowing the baby to pass through more easily. Although episiotomies are common, they are not routine—in the U.S, about 60% of all vaginal births do not need an episiotomy. The final decision to do an episiotomy is not decided until you are ready to give birth. You can try to avoid needing an episiotomy with perineal massage, and listening to your labor and delivery team about when to push and when not to push. Having an episiotomy does not add time to your hospital stay.
The Episiotomy Procedure
An episiotomy begins with a local anesthestic (either a nerve block or an epidural injection) to numb the area where the cut will be made. Two fingers are placed between the scissors and the baby’s head for protection. This is followed by a one inch blunt-scissors cut, either a mediolateral cut (an angled cut to one side of the vagina to avoid the anal sphincter muscles) or a mid-line or median cut (a straight cut of less than an inch towards the anus). The cut enlarges the vaginal opening and helps in the delivery of your baby. If you need a forceps or vacuum delivery, the length of the incision will be longer than it would be without an instrument assisted birth. Once your baby is delivered and the placenta removed, the birth canal is examined for any tears that need repair. The episiotomy incision made in the vaginal skin, muscle and perineal skin is stitched closed in layers using absorbable sutures. The vaginal skin is repaired first, then the muscle and finally the skin of the perineum. Stitching usually takes about 10-20 minutes. The incision is closed soon after delivery to prevent blood loss and reduce the chance of infection.
The median incision is easiest to make and repair, but if it has to be extended or tears it does not give any protection to the anus. The mediolateral cut is more difficult to repair but it gives the best protection against damage to the anal sphincter and best suits the purpose of the cut.
Why Do You Need an Episiotomy?
A normal vaginal delivery involves intense labor contractions and requires a pushing on the mother’s part. Time and patience is required for the labor to produce a baby. Pushing by the mother can cause tears in the vagina.
An episiotomy may be performed to prevent jagged tears which are likely:
- if your baby presents face first and not the crown of the head first
- if you have a scar from earlier tears
- if you’ve had previous surgery to repair a tear or uterine prolapse
An episiotomy may also be performed:
- if your baby is suffocating due to lack of oxygen (the umbilical cord gets “kinked” or compressed, or there appears to be umbilical cord problems and the baby needs to be delivered quickly
- if your baby is large or its head is too big
- if your baby is in distress in the birth canal
- if your baby’s shoulder gets stuck in the vagina
- if there is an emergency and there is not enough room to deliver your baby with forceps
- if your baby presents bottom first (breech) and needs more room to get out
- to prevent overstretching of the muscles which may lead to prolapse later
One of the main reasons for an episiotomy is to avoid tears since it is felt that a clean, surgical cut is easier to repair than a natural tear. Natural tears in the perineum can happen as your baby passes through the vagina. Injury to the perineum can be:
➪ when the surface is nicked, but may not need stitches for repair
➪ when the lining of the vagina and some connective tissue is torn
➪ a tear that goes through the muscle around the anus
➪ a tear that goes through the vagina and into the rectum
Stretching of the skin and small tears may not need repair. An episiotomy or tears that need repair will be repaired with stitches while you are on the delivery table.
Advantages of an Episiotomy
Although there is pain and discomfort after an episiotomy, there are advantages to having one.
- An episiotomy can make the process of delivery much easier and the mother doesn’t need to put in much effort in pushing to deliver the baby.
- Your baby can be delivered quickly in certain emergency situations.
- There is less trauma to the vaginal tissues. If the skin is allowed to tear, the tear can be jagged and much harder to repair than a clean cut made with scissors. You can also tear in a place that could cause more serious injury in the rectum or anus. Preventing tearing of the muscle ring around the anus is very important as this could lead to later trouble with bowel movements or fecal incontinence.
- Tears can take longer to heal than an episiotomy.
Possible Complications of an Episiotomy
An episiotomy can cause pain, bleeding, swelling, bruising or get infected. It can also have complications if the incision extends into the rectum or the episiotomy wound isn’t sewn back together well. Avoid intimate relations for several weeks until the episiotomy is completely healed. In some cases, there may be painful relations even after the episiotomy incision has completely healed.
How to Care for an Episiotomy
An episiotomy takes about 4—6 weeks to heal depending on the size of the incision, material used for the stitches and the lifestyle of the mother after delivery. By the time the stitches are absorbed, the skin is strong and the edges should not separate. If you see stitches on your sanitary pad, check your episiotomy with a mirror to make sure the skin is still closed and looks healed.
Most mothers don’t feel any pain while episiotomy is being done because of anesthesia. However, the recovery period can be painful and the stitches uncomfortable for the mother, especially when sitting. The following tips can help relieve pain and discomfort:
- Cold therapy—using ice packs—on the stitches numbs the area and reduces pain and swelling. Ice can be used during the first 24 hours. Don’t apply the ice directly to the skin. Ice should be applied 20 minutes on and 10 minutes off several times a day. Swelling of the skin can cause pulling of the stitches.
- Ring cushions inflated with air, water or made of foam can make sitting more comfortable.
- The incision site should be cleaned with warm water and plain, unscented soap when you use the bathroom. The hospital may give you a peri-bottle for spraying water on the area.
- A warm bath or sitting in a tub of warm water for 20 minutes several times a day can help relieve pain. After the bath, the incision site should be patted dry with a soft towel.
- Expose the stitches to the air at least twice everyday for 10 minutes or so.
- Witch hazel can be applied to the site to sooth the soreness (Tucks Pads, Tucks Clear Gel) or a topical anesthetic (Americaine, Dermoplast). You can make witch hazel pads with soft 2” x 2” non-sterile gauze pads and witch hazel. Always apply the witch hazel to a clean gauze pad so you will not get germs into the witch hazel. To make cold witch hazel pads, keep the bottle of witch hazel or some pre-soaked witch hazel pads in the refrigerator.
- Over-the-counter medications like acetaminophen may be taken to relive the pain. However, don’t take any medicine without talking with your doctor, especially if you’re breastfeeding.
- Take the sting out when you urinate by pouring warm water over your perineum while you pee
- Straining with constipation puts pressure on the stitches during bowel movements. Drinking plenty of fluids and eating a balanced diet with plenty of fiber helps prevent constipation. Ask your doctor about using a stool softener (Colace) to make stool easier to pass without straining. If you are breastfeeding, taking a stool softener may cause loose stools in your baby, too. Holding a pad of toilet paper against your stitches during a bowel movement can help relieve pain from the stitches. After a bowel movement, wipe from front to back with toilet paper. Then gently wipe or pat, again from front to back, with witch hazel pads to reduce minor itching or burning. Use a clean piece of toilet paper or witch hazel pad for each wipe. Drop used toilet paper and pads into the toilet after each wipe.
- Squeeze your buttocks together while sitting or getting up from a seated position to help ease discomfort from your stitches.
- If you can’t relieve the pain or if you have a fever above 104.5° F, call your doctor right away as these could be signs of an infection which needs to be treated.
- It is very important to prevent infection of your stitches that can infect the vagina. Read here for hygiene information about perineal care after vaginal birth.
After you get home, call your doctor:
- If you have any signs of infection such as fever and chills, redness, pain or swelling at the incision site that does not get better every day, or you have a foul-smelling discharge or bleeding from the episiotomy site
- If your pain isn’t controlled with the medicines your doctor prescribes
- If you have problems controlling your bowels or bladder that does not go away.
Always wash your hands thoroughly before and after going to the bathroom or changing a sanitary pad. Proper handwashing is the best thing you can do for yourself and your baby to prevent infection. This link will tell you more about proper handwashing, when to use soap and when it’s OK to use gel sanitizers.
Hemorrhoids are swollen veins of the rectum. Hemorrhoids can be caused by pressure from your baby’s head or your pushing during the final stage of labor. It’s easy to confuse pain from stitches for pain from hemorrhoids. Read here for more on how to care for the perineum and hemorrhoids.
Long-term Effects of Episiotomy
Because of the good blood supply to the area, episiotomies heal quickly and usually without problems. Episiotomy stitches are absorbed by the body and do not need to be removed. The pain and discomfort can be relieved by medications and by using ice packs within 24 hours followed by warm baths. You can walk as soon as you feel able. Everyday activities can be resumed shortly after the procedure, though the stitches might take some time to heal completely.
Ways to Avoid an Episiotomy
It’s a good idea to talk to your doctor about your feelings about an episiotomy. Include your thoughts, as well as your doctor’s thoughts in your birth plan.
There are times when an episiotomy is unavoidable. However, there are ways which can help prevent it. The following methods can be tried to deliver your baby easily and without having an episiotomy.
Massaging the perineal and vaginal area helps in stretching the tissues and aids in childbirth without episiotomy or tearing of the skin and muscles. Massage should be done for at least 5—10 minutes everyday beginning with week 34 until delivery. Lubricants like KY jelly, olive oil, vitamin E oil, almond oil or pure vegetable oil should be used for massage. Make sure your fingernails are trimmed and your hands are clean before doing the massage. Also, talk with your doctor before starting the massages, especially if you have a history of vaginal infections or are at risk for preterm birth.
To do perineal massage: apply a water soluble lubricant like vitamin E to the thumb or index finger, and insert the finger or thumb into the vagina about an inch. Slide the finger with pressure in a semicircular motion, starting at the side of the vagina and moving down toward the anus, and back up to the other side of the vagina. Do the massage for a 5 minutes every day. Clean off the excess oil when you finish so you won’t get it on your clothes. When you go into labor, tell your obstetrician that you have done perineal massage. There is no guarantee you won’t need an episiotomy, but by doing the massage you may reduce trauma to the perineum during delivery.
Do Kegel Exercises
You were probably doing Kegels while you were pregnant and you should keep doing them after your baby is born. Pelvic muscles are just like any other muscle—exercise makes them stronger. Kegel exercises include tightening and relaxing of the pelvic muscles. Kegels can help strengthen the perineum muscles which support the organs in the pelvis (uterus, bowel, bladder).
First you have to figure out which muscles to exercise. To find these muscles, alternately start and stop urinating while using the toilet. However, when you do Kegel exercises, don’t do them while you’re urinating. Do Kegel exercises lying, sitting, standing, walking, and driving to make the pelvic muscles the strongest.
Kegel Exercise: Tighten the perineal muscles slowly a small amount at a time, like an elevator going up 10 floors. The release the muscles slowly—one “floor” at a time. Repeat. Start off with 5-10 times and then work up to 20-30 each time. Do the exercises 3 times a day—morning, afternoon and evening. Try to keep up a regular schedule each day such as after meals, in the shower, or just before bedtime.
Try not to squeeze your buttocks or abdomen while you tighten up as this puts pressure on the pelvic floor muscles. Keep the muscles of your abdomen, thighs and hips relaxed.
Think about your perineal muscles when you are lifting, sneezing, coughing or laughing and do Kegels then, too. After a while it will become a habit and you won’t have to think about it.
Correct Breathing and Pushing During Labor
Controlled breathing, along with proper pushing, helps you have a non-emergency vaginal delivery and avoid an episiotomy. Not pushing when you’re told too can give your perineum time to stretch and avoid tears.