What is an Episiotomy? Procedure, Benefits and Recovery

What Is an Episiotomy?

An episiotomy is a deliberate incision of the perineal body made with surgical scissors at the peak of a uterine contraction. The cut extends through skin, subcutaneous tissue, and superficial perineal muscles.

The procedure is performed under local anaesthetic if not already covered by regional analgesia like an epidural. In India, where epidural coverage in public sector deliveries is low, local infiltration with lignocaine is standard. The incision is repaired after delivery of the placenta using absorbable sutures.

Why an Episiotomy Is Performed During Childbirth

Restrictive episiotomy (the current evidence-based standard) reserves the procedure for specific clinical situations where avoiding it may increase risk. They are:

• Foetal distress: Abnormal foetal heart rate requiring rapid delivery; episiotomy may shorten the second stage when time is critical

• Instrumental delivery: Forceps and ventouse extractions increase perineal trauma risk; episiotomy provides controlled space for instrument placement

• Shoulder dystocia: when the baby has an impacted shoulder behind the pubic bone, an episiotomy improves access for internal manoeuvres

• Rigid or scarred perineum: Previous female genital mutilation (FGM) or extensive scarring may prevent adequate stretching

• Preterm birth: Reduced perineal resistance may benefit a very premature baby.

Episiotomy is not indicated for prolonged second stage alone, an estimated large baby size or a first time delivery without the above indications.

Types and Procedure of Episiotomy

Two incision types are used: 

• Mediolateral episiotomy: Directed at 45-60 degrees from the midline toward the right ischial tuberosity and is most widely recommended. It reduces the risk of extension into the anal sphincter (third- and fourth-degree tears) compared with the midline technique.

• Midline (median) episiotomy: Incision runs directly posteriorly along the perineal raphe. It heals with less postoperative pain and is technically simpler, but carries a substantially higher risk of sphincter and rectal extension. 

Procedure: The incision is made at the height of a contraction. After delivery of the baby and placenta, the wound is repaired in layers using absorbable sutures. Repair takes 15-30 minutes.

Benefits and Risks of Episiotomy

When used selectively, an episiotomy provides:

• A controlled incision easier to repair than a ragged spontaneous tear

• It reduces crowding in instrumental deliveries that increases severe perineal trauma risk. 

• It may meaningfully shorten the time to delivery in case of foetal distress

The risks of routine episiotomy are:

• It does not prevent severe perineal tears

• Mediolateral extension into the sphincter occurs in some cases 

• Risk of increased bleeding and wound infection

• Dyspareunia

• Wound dehiscence. 

Recovery and Healing After an Episiotomy

The suture line is tender for 1-2 weeks. Absorbable sutures dissolve within 3-6 weeks. Most women return to normal daily activities in 2-3 weeks; complete tissue healing takes 6-8 weeks.

During the recovery period care includes:

• Hygiene: Clean the perineum with warm water after every toilet visit and pat dry gently; avoid soap directly on the wound

• Sitz baths: Sitting in shallow warm water for 10-15 minutes 2-3 times daily reduces swelling and promotes healing

• Pain relief: Paracetamol is safe for postpartum pain and topical lignocaine gel reduces local stinging

• Positioning: A donut shaped cushion or folded towel reduces perineal pressure while sitting

• Diet: Fibre from dal, vegetables, whole grains (jowar, bajra, ragi) and fruit prevents constipation and straining that is the most common cause of wound disruption

• Pelvic floor exercises: Gentle Kegels can begin within 24-48 hours if pain allows; they improve circulation and help restore pelvic floor function.

Possible Complications of Episiotomy

After an episiotomy common complications are:

• Wound infection

• Haematoma

• Partial or complete separation of the sutured wound (dehiscence)

• Dyspareunia or pain during intercourse 

• Anal sphincter injury.

FAQs 

1. Is an episiotomy performed in every normal delivery?

No. Current evidence-based guidelines recommend restrictive use - only when a specific clinical indication exists like foetal distress, instrumental delivery or shoulder dystocia. Routine episiotomy in uncomplicated vaginal deliveries is not supported by evidence and is discouraged by WHO and FOGSI, though it remains more prevalent in India than standards justify.

2. How painful is recovery after an episiotomy?

Perineal soreness, stinging on urination and discomfort while sitting are typical in the first 1-2 weeks. This is manageable with paracetamol, sitz baths, and perineal cooling. Pain that worsens after the first 48 hours or is accompanied by fever suggests a complication and needs review rather than continued home management.

3. How long does an episiotomy take to heal completely?

Surface healing occurs within 2-3 weeks; absorbable sutures dissolve by 3-6 weeks; complete deep tissue healing takes 6-8 weeks. Resuming intercourse before the 6-week postnatal review is generally not advised.

4. Can sitting be uncomfortable after an episiotomy?

Yes perineal pressure while sitting is common in the first 1-2 weeks. A donut-shaped cushion or folded towel placed under the thighs so the perineum is not in direct contact with the seat significantly reduces discomfort. Sitz baths before prolonged sitting sessions help by reducing swelling.

5. Are stitches always required after an episiotomy?

Yes. An episiotomy cuts through multiple tissue layers and requires repair in every case using absorbable sutures that dissolve within weeks. A spontaneous superficial tear may sometimes be left without sutures if small and well-opposed but a surgical incision is always repaired.

6. Can an episiotomy affect future pregnancies or deliveries?

A well-healed episiotomy does not alter the future vaginal delivery prognosis. Scar tissue may reduce perineal elasticity and perineal massage in the final weeks of subsequent pregnancies helps soften it. Decisions about episiotomy in future deliveries are made on clinical grounds at the time, not based on prior episiotomy history alone.

7. What activities should be avoided during episiotomy recovery?

Avoid heavy lifting, strenuous exercise, swimming and sexual intercourse for 6 weeks or until healing is confirmed. Constipation must be prevented. Prolonged sitting without perineal offloading should be minimised in the first two weeks.

8. How can discomfort and swelling be managed after an episiotomy?

Sitz baths 2-3 times daily, pain reliever as directed, topical lignocaine gel, and a cold pack wrapped in cloth applied to the perineum in the first 24-48 hours reduce swelling. Gentle Kegel exercises improve circulation to the healing tissue. Keeping the wound clean and dry after each toilet visit is the most important single measure.

9. Are there ways to reduce the chance of needing an episiotomy?

Perineal massage from 34 weeks and applying firm pressure to the lower vaginal wall for 5-10 minutes daily using clean hands and a carrier oil improves elasticity and reduces episiotomy rates in first-time mothers. A hands-on approach by the midwife or obstetrician to support the perineum during crowning also reduces uncontrolled tearing and the perceived need for incision.

10. When should medical attention be sought after an episiotomy?

Consult a doctor if pain worsens after the initial 48 hours rather than improving, fever rises above 38°C, the wound area becomes increasingly swollen or red, there is purulent or malodorous discharge, or a gap appears in the sutured wound.