Episiotomy: Indication, Recovery & Complications

Episiotomy is a surgical procedure in which a cut is made in the perineum to widen the opening between the vagina and the anus, making it easier for the baby to pass through during a vaginal birth.

It may be recommended by an OB-GYN only in selected and limited situations, such as a forceps-assisted delivery, a very high risk of severe perineal tearing, or prolonged labor with fetal distress.

However, according to the World Health Organization (WHO) and American College of Obstetricians and Gynecologists (ACOG), episiotomy should be used selectively, as there is insufficient evidence to support its routine use.

Main indications

Episiotomy may be recommended by a doctor in cases such as:

• Very high risk of severe perineal tears

• Prolonged vaginal labor with fetal distress

• History of anal sphincter injury

• Failure of labor to progress

This procedure should only be done with the woman’s informed consent. She should be told, preferably before the pushing stage of labor, why an episiotomy might be recommended and what the possible risks are.

If an episiotomy is needed, the provider should still ask for consent again right before performing it. When it is done without prior explanation, without consent, and without a clear medical reason, an episiotomy is considered a form of obstetric violence.

According to the World Health Organization, routine episiotomy is not recommended and the procedure should be reserved for selected clinical situations rather than used regularly.

How it is performed

The most commonly recommended technique is the mediolateral episiotomy, in which the cut is made at an angle in the perineal area. According to ACOG, a mediolateral incision is associated with a lower risk of extending into the anal sphincter than a midline incision.

Another technique, although not recommended, is the median episiotomy, in which a straight vertical cut is made in the perineum toward the anus. It is easier to repair, but it carries a higher risk of extending to the anus and causing complications such as anal sphincter injury and fecal incontinence.

Care instructions

Recovery after an episiotomy begins in the hospital, usually during the first day after delivery, with monitoring by the obstetrician, anesthesiologist, and nursing team. During this time, the doctor may prescribe pain relievers such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs).

Some important steps to take to support proper healing include:

• Keeping the area clean and dry at all times

• Changing the sanitary pad whenever it becomes soiled

• Maintaining good genital hygiene

• Avoiding tight pants or underwear to help prevent moisture buildup

• Doing Kegel exercises, as recommended by a doctor, to help reduce the risk of some complications

Applying ice to the area may also help reduce pain and support healing.

The stitches used for an episiotomy are usually dissolvable, meaning the body absorbs them or they fall out on their own. Because of this, it is generally not necessary to return to the hospital to have them removed.

Recovery time

Healing time after an episiotomy varies, but it usually takes about 6 weeks after delivery for the area to heal. During this time, you can generally return to daily activities gradually, as long as you avoid strenuous effort and follow your doctor’s advice.

Sexual activity should only be resumed once healing is complete. Because the area can stay sore for a while, taking a warm bath before having sex again may help relax the muscles and reduce discomfort.

Possible complications

The main complications that may occur after an episiotomy include:

• Wound reopening

• Injury to the muscles in the pelvic area

• Hemorrhage or bleeding at the incision site

• Localized pain or swelling

• Urethral injury or urinary incontinence

• Infection at the incision site

• Longer postpartum recovery time

• Rectovaginal fistula

• Injury to the anal sphincter or anal mucosa

• Fecal incontinence

• Chronic pain

• Pelvic organ prolapse

In addition, the woman may experience emotional trauma, difficulty carrying out daily activities, pain during sex (dyspareunia), and ongoing discomfort in the months after the procedure.

Red flags

People recovering from an episiotomy should contact their OB-GYN or go to the nearest emergency room if they develop fever, chills, bleeding, pus at the incision site, or foul-smelling discharge. These symptoms may indicate an infection and need immediate medical attention.