An episiotomy is a surgery that widens the vaginal opening during childbirth. In the past, it was common for doctors to perform routine episiotomies during vaginal births. However, experts now only recommend it in certain situations.

An episiotomy involves a doctor or midwife making an incision in the perineum, which is the area between the vagina and anus. Doing this can make delivery easier in situations where the fetus or parent is in distress, if the fetus is large, or if there are other complications with labor.

This article covers the uses, benefits, and risks of episiotomy, as well as what people can expect before, during, and after the procedure.

A note about sex and gender

Sex and gender exist on spectrums. This article will use the terms “male,” “female,” or both to refer to sex assigned at birth. Click here to learn more.

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A woman having skin-to-skin contact with her newborn baby following an episiotomy.Share on Pinterest
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In females, the perineum is a diamond-shaped structure consisting of a network of nerves and muscles that impact urinary, reproductive, and digestive functions. It extends from the posterior end of the vulva to the anus.

During childbirth, the perineum should stretch to its elastic limit to accommodate the passage of the baby. However, there are times when it does not expand enough.

In these situations, the perineum tissue can tear due to the internal force of pushing and the fetus’s head. Alternatively, a doctor or midwife may perform an episiotomy. Medical professionals perform the procedure in the second stage of labor once the fetus’s head is in view, just before delivery.

In the past, doctors routinely performed episiotomies during delivery. However, healthcare professionals no longer recommend it.

The procedure may still be necessary if:

  • the perineum does not expand fully
  • the fetus is large (macrosomia)
  • there is shoulder dystocia, which is where the parent cannot deliver the fetus’s shoulders
  • a fetus is breech, which is when the buttocks or feet point down instead of the head
  • the fetus or the parent is in distress
  • doctors need to use forceps or a ventouse, which is a vacuum-like device, to assist delivery
  • the umbilical cord has become compressed

In the past, doctors thought that episiotomies were preferable to natural tearing. Healthcare professionals began using the procedure routinely during deliveries in 1918. This frequent use continued until the 1970s.

However, clinical trials on the benefits of routine episiotomies called this idea into question. So far, no scientific studies have proven that routine episiotomies are better than tearing for infant or maternal health.

For example, a 2017 study in northeastern Brazil looked at whether having a selective episiotomy was better for maternal or infant health than not having one. The researchers found no difference in health outcomes between the 122 participants who had an episiotomy and the 115 who did not.

As a result of these and other findings, the American College of Obstetricians and Gynecologists (ACOG) recommends that healthcare professionals only perform an episiotomy when it is medically necessary.

The World Health Organization (WHO) also does not recommend routine episiotomies for people having spontaneous vaginal births.

Episiotomies are becoming less common. A 2018 study in France found that between 2007–2014, rates declined from 26.7–19.9% for vaginal deliveries.

However, rates vary based on location. A 2021 study in Ethiopia found that of 410 participants, 44% underwent episiotomies. This is significantly higher than the WHO recommendation of 10%.

Yes – any adult capable of giving informed consent can refuse any surgical procedure they do not want.

If a person wants to avoid this procedure during delivery, it is a good idea to discuss it with an obstetrician or midwife when making a birth plan. This lets the medical team know what is and is not approved, and gives them a chance to talk a person through the potential benefits and risks of their decision.

A person may want to ask their doctor or midwife:

  • When is an episiotomy necessary?
  • Which type is most likely?
  • What are the benefits and risks of the procedure?
  • Are there alternatives?
  • What are the risks of not having an episiotomy if the situation arises?

There are several types of episiotomy, each with a slightly different procedure. Generally, each type involves the following:

  • Anesthetic: If a doctor feels a person requires an episiotomy and the person consents, the doctor will begin by administering anesthetic. If a person has already had an epidural, they may not need this. If they have not had an epidural, the doctor will inject local anesthetic into the perineum.
  • Incision: Next, a doctor will use scissors or a scalpel to make an incision. For median and mediolateral episiotomies, this begins at the posterior fourchette, which is the very bottom of the vaginal opening. Median episiotomies run downward toward the anus, while mediolateral incisions run right or left at a 45–60 degree angle.
  • Examination: After delivery is over, the doctor will use a metal retractor to examine the vagina, cervix, and surrounding tissues to assess the degree of trauma. They will also perform a rectal exam.
  • Stitches: If the lining of the rectum has injuries, the doctor will use a thin suture to close it. They will use stronger sutures for the deeper anal sphincters. The doctor will then repair the incision itself within an hour of childbirth. For this, they will use a surgical thread or stitch that absorbs quickly into the body and will not require removal.

It is common for people to experience pain and discomfort for 2–3 weeks after an episiotomy. The incision should heal within 1 month after delivery.

To help relieve pain, a person can try the following:

  • Place ice packs on the perineum.
  • Talk with a pharmacist about which over-the-counter pain medications, such as acetaminophen or ibuprofen, are safe for them to take during breastfeeding.
  • Allow the wound to get fresh air.
  • Pour water over the wound while urinating to help prevent stinging.
  • Eat a fiber-rich diet, drink lots of water, and take stool softeners to help prevent constipation. A person can talk with a healthcare professional about stool softeners that are appropriate for them.
  • Avoid penetrative sex until the pain is gone.

To reduce the risk of infection, it is important to clean the genitals from front to back. To bathe, a person may wish to try sitting in warm, shallow baths rather than hot ones.

A person must follow postoperative care instructions carefully. If any signs of infection develop, such as swelling, pus, or an unusual odor, they must seek medical care as soon as possible.

As with every surgery, an episiotomy has risks and complications. These include:

If pain or any other symptoms continue for longer than 3 weeks after an episiotomy, a person should speak with a doctor. The doctor will evaluate the person and create a treatment plan.

An episiotomy is a surgical procedure that involves cutting the perineum. It was common practice in childbirth in the past, until researchers found that routine episiotomies have no benefits compared with natural tearing. However, doctors and midwives may still perform the procedure in line with regulated guidelines when necessary.

If a person does not want an episiotomy during childbirth, they do not have to have one. They can speak with their obstetrician or midwife. However, in certain situations, an episiotomy may speed up delivery and help medical professionals respond to complications during labor, such as a breech birth.