When an episiotomy is needed and how to recover quickly

• An episiotomy is a cut in the perineum that used to be standard procedure during birthing.
• But recent research has advised against it expect in cases of fetal or maternal distress.
• To recover from an episiotomy, take sitz baths, use ice, and practice kegel exercises.

An episiotomy is a surgical cut into the perineum, the area between the vagina and anus, made during childbirth.

The procedure used to be commonplace, but these days episiotomies are only used when the parent or infant are in distress during childbirth.

"Episiotomies are used in emergency situations," says G. Thomas Ruiz, MD, the OB-GYN lead at MemorialCare Orange Coast Medical Center.

Still, roughly 5% of people will have an episiotomy during childbirth. Here's what you should know about episiotomies and how to recover quickly.

What is an episiotomy?

Doctors used to use episiotomies in up to a third of vaginal childbirths. They believed that episiotomies would speed up childbirth by making the vaginal opening larger, and that the surgical cut was easier to repair than natural tears.

But in 2006, the American College of Obstetricians and Gynecologists (ACOG) recommended against using episiotomies, except in instances of fetal or maternal distress. They changed the guidelines because newer research suggested that:

• Episiotomies increased the risk for third- and fourth-degree tears extending from the vagina toward the anus or rectum.
• People who had episiotomies were more likely to experience lasting pain and prolonged healing time because episiotomy cuts are generally deeper than natural tears.

Instead, the ACOG recommends allowing people to labor for longer, giving the perineum adequate time to stretch. The ACOG also suggests applying warm compresses or lubricant to the perineum to facilitate vaginal childbirth with less tearing.

But your doctors may decide that getting an episiotomy is in you and your baby's best interest if:

• An infant is near to vaginal delivery and suddenly experiences distress, like dropping heart rate.
• The baby is unexpectedly breeched (born feet first) or its shoulders become stuck.
• The mother is suddenly experiencing distress and the baby is already near vaginal birth.

What to expect

An episiotomy is performed during the second stage of labor, active pushing. If you haven't already had an epidural, doctors will provide a local anesthetic.

Most commonly, the doctor performs a median or midline episiotomy, where a cut is made straight from the vagina toward the anus. Less commonly, doctors will opt for a mediolateral episiotomy, where a cut is made at a 45-degree angle toward the labia.

Both have benefits and drawbacks: A midline episiotomy is generally easier to repair, but results in deeper tears.

After an episiotomy is performed and the baby is delivered, your doctor will stitch the incision. The stitches dissolve and will not need to be removed.

Risk factors

Some things may reduce your risk for episiotomy and manage concerns around the procedure, says Daniel Boyer, MD, a medical researcher with The Farr Institute.

• Be conscious of fetal size. People delivering babies that are above-average weight are more likely to need an episiotomy. Controlling your weight gain during pregnancy and managing conditions like diabetes can help you deliver an average-sized baby, Boyer says.
• Consider maternal age: Older parents are more likely to need an episiotomy; having a child before the age of 24 may reduce risk, Boyer says.
• Practice perineal massage. Doing perineal massage, or stretching the tissue of the perineum, before delivery can reduce your risk for needing an episiotomy. This is done at home, sometimes with the help of a partner.
• Research episiotomy rates. Most doctors publish their episiotomy rates. If they are higher than the national average of 5%, ask why and consider seeking a different care provider, says Ruiz.

Anyone who is concerned about an episiotomy should talk with their provider. Once an episiotomy is ordered, it's usually an emergency situation, so it's best to have your questions answered before delivery.

"Pregnant women can talk to their care providers before labor begins to enable them to have an open mind towards episiotomies if needed," says Boyer.

Recovery

Most doctors say that it takes six weeks to heal from an episiotomy, but for many people it takes longer, Ruiz says.

"Realistically, it may be twice that long before they feel comfortable," he says.

To help your episiotomy heal, you should:

• Ice your perineum. During the first 24 hours after giving birth, apply cold compresses frequently to help with pain and swelling. You'll likely be unable to do this yourself, so ask a nurse for help.
• Take sitz baths. A sitz bath is a warm, shallow bath, often with epsom salts, that you dip your vulva into. After the first 24 hours, use a sitz bath at least once a day, Ruiz says. You can purchase a sitz bath at a pharmacy, or simply fill a regular tub with four inches of water and 2 tablespoons of Epsom salts, he says.
• Use stool softeners. Straining during a bowel movement can put excess pressure on your stitches, so Ruiz recommends using stool softeners while healing.
• Spray with a peri bottle. Rather than wiping with toilet paper, spray stitches with warm water from a peri bottle after peeing. This will help minimize irritation and stinging.
• Practice good hygiene. Changing pads every two hours and patting stitches dry after bathing or showering can help prevent infection, Boyer says.
• Be gentle. Avoid sex, tampons, or vigorous exercise for at least six weeks, or until your doctor clears you to return to your normal routine.
• Kegel exercises. As you recover, use Kegel exercises to strengthen your pelvic floor and reduce the risk of incontinence, Ruiz says.

To manage pain, use over-the-counter pain relievers or the numbing spray Dermoplast, Ruiz says. Rarely, if someone has had a severe tear, doctors will prescribe narcotics.

If you plan to breastfeed, talk to your doctor about which drugs are safe.

Risks

The risks of an episiotomies include:

• Bleeding
• Large tears that extend into the anus or rectum
• Incontinence
• Pain during sex
• Infection

In general, your pain should be getting better, not worse with time, Ruiz says. You should see a doctor if you experience:

• Increased pain
• Redness or opening of the wound
• Foul smells
• Four days without a bowel movement
• Clots larger than a walnut

Insider's takeaway

Episiotomies used to be common, but the medical community now recognizes that for most people the risks outweigh the benefits.

"They're very outdated," Ruiz says.

However, about 5% of people will still need an episiotomy, so it's important to understand the procedure before birth.

"Nowadays, episiotomies are not part of routine birth; however, circumstances may require an episiotomy to lower the health risk of the mother or her baby," says Boyer.