If you’re pregnant for the first time, it’s very likely you’ve heard something about episiotomy and some alarm bells have rung. Don’t worry. We’re about to offer you all the information you need about episiotomy incisions, based on the latest research.

What is an episiotomy?

An episiotomy is a surgical procedure. It is an incision made in the vaginal opening when the baby’s head is crowning. The vaginal tissues are cut to make the vaginal opening larger.

Although routine episiotomies were performed in many western hospitals in the past, research done in the last few decades has been very consistent about how unnecessary a routine episiotomy is.

Let’s see why this procedure is done, and look at when and in which specific circumstances a woman might need an episiotomy to facilitate a vaginal birth.

Why is an episiotomy done?

You might wonder why such a procedure might be necessary.

Several decades ago, when birth was moved from home to the hospital, the power over the process also shifted from the woman in labor to the obstetricians and gynecologists who accompanied her.

When a woman leads her own labor, her pelvic floor muscles are doing precisely the job they’re meant to do. When a woman is placed on her back, anesthetized, told when to push, and has her perineal area manipulated, however, then there’s a much higher risk of perineal trauma.

Routine episiotomies were performed to avoid severe tears that were a consequence of these unnecessary interventions.

These days, the only reasons an episiotomy should be done is when an operative procedure takes place or if there is fetal distress. A local anesthetic should always be applied before carrying out any perineal techniques, especially an episiotomy incision.

Episiotomy incision for operative vaginal delivery

An operative vaginal birth is when the healthcare provider performs maneuvers from the outside that might cause extensive perineal tears. A surgical incision is performed with the intention of reducing perineal trauma.

These operative procedures include instrumental deliveries, such as the use of forceps or a ventouse (vacuum cup) or times when the baby’s shoulders are stuck, in what is known as shoulder dystocia. Although an episiotomy won’t help with the birth of the baby, it allows more room to maneuver to prevent worse tearing from occurring.

Episiotomy incision for fetal distress

The other reason an episiotomy might be necessary is when a baby is in severe distress and the baby’s birth needs to be speeded up.

The baby needs to be born straight away and there isn’t time to wait for the perineal skin to stretch naturally. This is the only circumstance when a baby might ‘need an episiotomy’.

You can find out more in our article When Is An Episiotomy Necessary?

Can you give birth without episiotomy?

Yes, absolutely. Your body is prepared to give birth. The vaginal opening can stretch, allowing your baby’s head to pass without tearing. Believe it or not, one of the most important missions of labor pain is to avoid tearing of the perineum.

When a woman in labor follows her pain and moves, pushes, and acts as her body tells her, tearing of the perineum becomes minimal. Women who go through normal labor following their bodies’ natural cues will usually give birth without having perineal tears.

Why are routine episiotomies no longer done?

As we mentioned at the beginning of the article, routine episiotomies are a thing of the past. There was a time when doctors would perform an episiotomy on every single woman who had a vaginal birth in their presence. There was also a time even when the American College of Obstetricians and Gynecologists (ACOG) recommended the performance of this surgical procedure.

Research has been consistent in stating that the use of episiotomies should be restricted to cases when it’s absolutely necessary. As this randomized controlled trial shows, there are no better perinatal outcomes when episiotomies are performed.

Episiotomy vs tearing

The main reason why episiotomy was invented was to avoid severe tearing – especially third and fourth degree tears (tears that affect the anal sphincter).

Some women tore their perineum quite severely. The episiotomy was therefore used, with the intention of preventing a severe perineal tear. It was thought that a surgical cut would not only prevent the tearing but would also heal more easily as a surgical incision was much easier to suture than a natural tear.

You can read more about tears in our articles:

Third Degree Perineal Tears – What You Need To Know

Fourth Degree Tear – Severe Tearing During Childbirth.

Is it better to tear or have an episiotomy?

Doctors then started to perform episiotomies routinely. Most women had one, even though the vast majority would have ended up with an intact perineum if it wasn’t for the episiotomy.

It was soon discovered that many episiotomies were, in fact, the cause of third and fourth degree tears.

The perineum, like everything else in our bodies, was perfectly designed to avoid tearing and, if tearing did happen, it would be minimal. An intentional cut in the perineum, however, would sometimes continue and become an uncontrolled tear.

Imagine a piece of cloth grabbed tightly and pulled from both sides. It’s very taut but also very strong. It would take a great amount of force to rip it. Now, imagine what would happen if you took a pair of scissors and cut it in the middle. A tear would easily follow that first cut.

That’s exactly what happens with a surgical cut and it’s the main reason why a tear is better than a episiotomy. If you took that same piece of cloth we were talking about and exerted so much pressure that you finally started to rip it, it would be a minimal tear, as each fiber would offer resistance to being ripped.

A tear will do the least possible damage. It will happen at the weakest parts and it will avoid vessels and nerves. When it hits a strong fiber it will stop or change direction. A tear is better than an episiotomy in every way and an episiotomy should only be performed in the circumstances mentioned above.

Read more about this in Episiotomy vs Tearing – Which One Is Better?

What degree tear is an episiotomy equivalent to?

A first degree tear involves just the skin. A second degree tear also involves the vaginal muscle. A third degree tear involves the vagina and anus, up to the border of the anal sphincter. A fourth degree tear extends from the woman’s vagina into her rectum. A fourth degree tear is iatrogenic (caused by medical treatment). This means that is very unlikely that a woman who tears naturally will end up with a fourth degree tear.

The incision site of an episiotomy covers the skin and the vaginal muscle so, in terms of the tissues affected, it’s considered equivalent to a second degree tear. However, the severe pain in the genital area, the pelvic floor dysfunction, and the length of the healing period is much greater with an episiotomy than with a natural second degree tear.

Can an episiotomy cause problems later in life?

Some women suffer lifelong consequences from an episiotomy. If you’ve had an episiotomy make sure you find a pelvic floor specialist to minimize the repercussions. A specialist healthcare provider will be able to assess your case, relieve pressure, and teach you the most convenient pelvic floor exercises and perineal massage techniques.

If your perineal recovery is giving you trouble, immediately find the right healthcare provider to provide your follow-up care. It might help you heal faster, avoid later complications – such as urinary incontinence and problems with your bowel movements –and will minimize the impact of the episiotomy on future pregnancies.

How to avoid episiotomy

This advice is very clear: look for a healthcare provider who will listen to your requests. You can write a birth plan stating you want to avoid an episiotomy at all costs.

If you see hesitation or hear vague answers like ‘This decision cannot be made now’, that healthcare provider is not the right one for you. Find one who makes you feel heard and respects your decisions.

Can I say no to episiotomy?

Absolutely. Body autonomy is a basic human right. That means you have the last word about what’s done to your body. If you say ‘No’ to episiotomy, the healthcare provider must respect your decision, by law.

Does episiotomy make you tighter?

Absolutely not. The tightness of your vagina depends mainly on the condition of your pelvic floor muscles. Hypopressive pelvic floor exercises will help you regain any lost tightness in your vagina.

Episiotomy recovery

There are plenty of natural remedies that will help with the care of your perineum after birth. Washing the area daily with just warm water and changing sanitary pads frequently will help keep the area clean. A daily sitz bath will reduce swelling. If the swelling is bad, you can apply witch hazel pads or warm compresses to ease the soreness.

How do you poop after an episiotomy?

This is one of the main questions – and one of the main fears – the vast majority of women have after childbirth. How do I poop? If you have stitches in your vaginal area your first poop is a big worry.

As a general rule, don’t delay your first poop. Go the very moment you feel the need. We’ll never get tired of saying this: your body knows what’s best. Listen to it and if it’s telling you ‘Now is the time to poop’, then you’d better listen.

Stool softeners might help you deal with the first poop with more confidence. Even if you haven’t taken a stool softener, though, and your body tells you to poop, then do yourself a favor and go. Many people are embarrassed to go to the toilet if there are people in their house, so this is also a good reason to have fewest possible visitors during the first few weeks postpartum.