What is an episiotomy?
Episiotomy is a surgical incision made to the vagina to increase the size of the birth canal. Nowadays it is used during birth in very specific circumstances, but in the past it was used much more routinely. A baby’s head may have trouble getting through the birth canal if the vagina hasn’t stretched enough, in which case a medical professional may elect to make an incision (episiotomy) to widen the canal. It is a controversial procedure as the vagina has been shown to tear further upon being cut, which can lead to further damage of the surrounding muscles and anus. Since this realization, the use of the procedure has decreased substantially. (1,2)
However, in some countries, the prevalence of episiotomies has slightly increased on average over recent years. (3)
This article will inform mothers about all aspects of episiotomy—the pros and the cons—and help moms make up their own minds on the topic!
Controversy surrounding further tearing, painful recovery, and sexual discomfort
The controversy surrounding episiotomies stems from the additional tearing that can occur once the vaginal tissue has been cut.
Many complications can arise from episiotomies, and over the years the procedure has fallen out of favor with many medical professionals. (1)
Many women don’t seek treatment for pain and difficulties with sex after undergoing an episiotomy. Pain during sex is a valid concern, and without treatment, symptoms can persist in the long term. (4)
Further controversy surrounds episiotomies that the mother has not consented to and that were ultimately the result of a dosage mistake. It is important to note that these are very extreme circumstances that usually involve facilities or professionals that are negligent and far below standard. One extreme circumstance is when a mother is over-medicated by mistake, which can limit her ability to push the baby out of the birth canal. In this case, a medical professional might intervene and assist by widening the birth canal with an episiotomy without consulting the mother. Another instance of this negligence is accidentally under-medicating, which could also lead to an unconsented episiotomy if the birth is a difficult one. (5)
Episiotomy incision types
Although an episiotomy is a single cut, there are three different incision types:
A. Medial episiotomy: a midline incision of the perineum downward toward the anus (1,6)
B. Mediolateral episiotomy: an incision between 40-60 degrees left or right of the anus (1,6)
C. Lateral episiotomy: an incision even farther from the anus (4-5 o’clock or 7-8 o’clock) (1,6)
Because there is risk of further damage to the perineum due to tearing, the medial episiotomy (A) is considered the most risky. If torn all the way to the anus, a woman may experience lack of control of her anus while it is healing. On the other hand, mediolateral incisions cut through muscle and may involve short- or long-term pain during the healing process. (2,7,6)
The severity of the tear is classified on a scale from 1-4. There is a correlation between medial episiotomies and higher degrees (3rd and 4th) of tearing. For this reason, many hospitals have stopped performing episiotomies all together.
There are 4 degrees of tearing:
1st degree: tearing of the perineal skin and mucous membrane (1)
2nd degree: a deeper tear that reaches the perineal muscle (1)
3rd degree: tear that reaches the anal muscles (1)
4th degree: tear that reaches the anus membrane (1)
Recovery times and pain levels also tend to increase in the higher degree tears. These tears can also occur naturally, or via natural tearing, which is common in birth, particularly with first-time moms. (8)
Pros
Mothers who undergo an episiotomy often experience a particularly difficult and assisted birth. You can imagine a health professional might have to resort to an episiotomy if the baby is in distress, or the mother needs to get the baby out in a hurry. In this case, the vagina hasn’t had enough time to stretch naturally to allow the crowning head through. In assisted births, an episiotomy might be used to widen the birth canal and make room for tools like forceps and vacuums to help facilitate the birth. (8)
Cons
There are risks involved with episiotomies. If the perineal tissue is cut, there are some potential consequences:
Perineal tissue may tear farther along the incision (6,7)
Increased risk of 3rd and 4th degree tears (6,7)
Increased blood loss, increasing chances of a hematoma (6,7)
Increased costs (6,7)
More pain during recovery (particularly with the mediolateral incision) (6,7)
Postpartum pain and difficulty with sex (6,7)
Women who have had episiotomies often experience more pain than women who have natural tearing. Mediolateral episiotomies in particular are associated with short- or long-term pain. This incision type damages muscle, which leads to a more uncomfortable healing process than more superficial tears of the perineal skin. (2,7)
Another notable con is the increased risk of 3rd and 4th degree tears, which damage the anus and result in more painful and lengthy recoveries. (2,9)
It is important to monitor the incision area—episiotomy incisions take longer to heal than natural tears. Both episiotomies and natural tears use “dissolvable” stitches that are absorbed by your body. If the stitches begin to break down before the incision has closed, a medical professional will have to restitch the incision. Restitching is more common with episiotomy wounds than natural tears because of the longer healing time. (6,1,10)
Open or untreated perineum wounds can become infected. Infections are among the most serious postpartum conditions as they can lead to life-threatening sepsis or septic shock. Nonetheless, monitor your incision site closely—perhaps with a mirror—and keep an eye out for signs of infection: unusual-smelling discharge, additional pain and pressure surrounding the stitches (swelling), red or swollen skin around the incision (inflammation). (11)
Severity, pain, treatments, and healing times
As mentioned above, modern materials for stitches of the perineum are gradually absorbed by the body. In other cases, stitches are removed by a doctor or midwife. (10)
Keep an eye on the incision site! If there is swelling and inflammation, there is a chance the incision could reopen, in which case a medical professional will have to restitch it to promote healing and prevent infection. (6)
There are some long-term effects of episiotomies that may occur: prolonged pain, pain with sex, leaks or urges to urinate, some lack of anal control as it heals, and in more extreme cases, chronic infection. (6)
Some post-episiotomy treatment options to note are:
Far-infrared local thermal therapy (4)
Hypericum Perforatum herb (4)
Phenytoin cream (4)
Complementary or alternative medicine (4)
Far-infrared (FIR) local thermal therapy is a clinical treatment for episiotomy incisions and is more often used on first-time mothers. FIR local therapy aims to increase wound healing and reduce long-term pain. It also has shown to reduce discomfort and pain with sex. Studies have shown that FIR local thermal therapy can significantly improve healing, reduce pain and accelerate the return of sexual wellness and activity. (4)
Hypericum Perforatum (HP) herbs are used by midwives to reduce pain in the perineum. It is a noninvasive, effective topical formula that has been known to relieve episiotomy pain. (7)
Phenytoin cream has shown to help accelerate episiotomy repair. It is easy to use and inexpensive! It has been known to relieve inflammation and increase blood circulation. (12)
In developed countries, many women are supplied with complementary or alternative medicines after episiotomies to improve nausea and vomiting, back pain, anemia, perineal pain and postpartum depression. These medicines help mothers manage their own symptoms and improve their quality of life during recovery. (7)
Healing times, pain levels, and the return of sexual activity can vary depending on the severity of the incision and the quality of treatment. On average, perineal pain is usually resolved 3 months after the delivery. Some mothers may experience pain during sex for a longer period of time. (4)
Most women who’ve had episiotomies experience pain in the perineum immediately after birth, but this pain may persist in the short term and/or long term.
Pain in the perineum may occur following an episiotomy:
After 1 day: 9 in 10 women have pain (7)
After 10 days: 3 in 5 women have pain (7)
After 40 days: 1 in 4 women have pain (7)
Despite pain levels, it is important to stay on top of your perineal wound treatment, which can reduce pain and improve sexual activity. (4)(5)
Conversations before birth with medical professionals about episiotomy & stitch types
Stitching methods used by medical professionals may affect pain levels postpartum. For example, a continuous stitch has shown to be less painful during recovery. Stitching just underneath the skin may also decrease pain and often require less painkillers during recovery. Talk to your medical professionals before birth so that they understand your preferences. (13,14)
In some countries, catgut (an absorbable stitch material) is used as well as synthetic stitch materials. Some research has shown that women who’ve used synthetic stitches had less pain than those with catgut stitches the first 3 days after birth, and also required less painkillers. However, synthetic stitches take longer to absorb. More severe tears that require longer healing times should be stitched with synthetic material, or other longer lasting stitches. Ask your medical professional about their stitching materials and express your preference! (13)
When you arrive for delivery, share your opinion on episiotomies with your health professionals. In some facilities, protocol may not even include episiotomies, but it never hurts to talk about it and make your preferences known.
After birth, be sure you fully understand how to treat and tend to your perineal wound, if you experienced natural tears or an episiotomy. The better quality of treatment, the quicker you’ll recover, reduce pain and regain comfort with sex. (4)
Scar tissue of the vagina & what to expect
You may not notice a scar after an episiotomy incision has healed, or you might. Nonetheless, there are some aspects of scar tissue that at first may not seem related. Scar tissue may feel raised or even itchy. (15) Scar tissue may cause pain with penetration during sex. You might even notice pain from the scar tissue when sitting in particular chairs, or some discomfort with certain underwear.
Conclusion
At the end of the day, the mother should have conversations with her medical professional about episiotomies. It is within a mother’s right to have her own preferences when it comes to episiotomy. Know that episiotomy is an option during the later stages of labor, but also understand the potential consequences! Sharing your feelings and preferences with your medical professional is always comforting, so take a stand on your birth plan in regard to episiotomy!
References
Zaidan Asma, Hindi Muhab, Bishara Ahmed, Alolayan Samar, Abduljabbar Hassan, 2018. The Awareness Regarding the Episiotomy Procedure Among Women in Saudi Arabia. Materia-SocioMedica: Journal of the academy of medical sciences of Bosnia and Herzegovina, 30(3): 193–197, doi: 10.5455/msm.2018.30.193-197
Y. Ali-Masri Hadil, J. Hassan Sahar, M. Zimmo Kaled, W. Zimmo Mohammed, M. K. Ismail Khaled, Fosse Erik, Alsalman Hasan, Vikanes Ase, Laine Katariina, 2018. Evaluation of Accuracy of Episiotomy Incision in a Governmental Maternity Unit in Palestine: An Observational Study. Obstetrics and gynecology international, 6345497, doi: 10.1155/2018/6345497
Helena E Lindgren, Åsa Brink, and Marie Klinberg-Allvin, 2011. Fear causes tears - Perineal injuries in home birth settings. A Swedish interview study. BMC Pregnancy Childbirth; 11: 6, doi: 10.1186/1471-2393-11-6
Li-Hua Huang, Yu-Fen Lai, Gin-Den Chen, Maw-Sheng Lee, Soo-Cheen Ng, 2019. Effect of far-infrared radiation on perineal wound pain and sexual function in primiparous women undergoing an episiotomy. Taiwanese Journal of Obstetrics and Gynecology, Volume 58, Issue 1, Pages 68-71
Gaurav Sharma, Loveday Penn-Kekana, Kaveri Halder, Véronique Filippi, 2019. An investigation into mistreatment of women during labour and childbirth in maternity care facilities in Uttar Pradesh, India: a mixed methods study. Reproductive health, 16: 7, doi: 10.1186/s12978-019-0668-y
İsmet Gün, Bülent Doğan, Özkan Özdamar, 2016. Long- and short-term complications of episiotomy. Turkish Journal of Obstetrics and Gynecology, 13(3): 144–148, doi: 10.4274/tjod.00087
Farzaneh Vakili, Mandana Mirmohammadaliei, Ali Montazeri, Mina Farokhi, Mohammad Bagher Minaee, 2018. Impact of Hypericum Perforatum Ointment on Perineal Pain Intensity Following Episiotomy: a Randomized Placebo-Controlled Trial. Journal of caring sciences, 7(4): 205–211, doi: 10.15171/jcs.2018.031
María Teresa Sánchez-Ávila, Marisol Galván-Caudillo, Jaime Javier Cantú-Pompa, Natalia Vázquez-Romero, Jhanea Patricia Martínez-López, Víctor Manuel Matías-Barrios, Abryl Mariana Avitia-Herrera, Luis Alonso Morales-Garza, Claudia Eugenia Hernández-Escobar, Gonzalo Soto-Fuenzalida, María Teresa González-Garza, 2018. Prevalence of high-grade perineal tear during labor in Mexican adolescents. Colombia Medica (Cali), 49(4): pages 261–264, doi: 10.25100/cm.v49i4.3515
Golden WE, Sanchez N. 1996 The relationship of episiotomy to third and fourth degree lacerations, US National Library of Medicine, National Institute of Health, J Ark Med Soc. 92(9):447-8.
Kettle C, Dowswell T, Ismail KM, 2010. Absorbable suture materials for primary repair of episiotomy and second degree tears. Cochrane database of systemic review, (6):CD000006. doi: 10.1002/14651858.CD000006
L Dudley, C Kettle, P W Thomas, K M K Ismail, 2017. Perineal resuturing versus expectant management following vaginal delivery complicated by a dehisced wound (PREVIEW): a pilot and feasibility randomised controlled trial. BMJ Open, 7(2): e012766, doi: 10.1136/bmjopen-2016-012766
Hamideh Pakniat, Atyeh Bahman, Farideh Movahed, Niloofar Mohammadi, 2018. Effects of Topical Phenytoin Cream on Episiotomy Repair in Primiparous Women: A Double Blind Clinical Trial. Iranian Journal of Pharmaceutical Research, 17(4): 1563–1570
Kettle C, Dowswell T, Ismail KM, 2010. Absorbable suture materials for primary repair of episiotomy and second degree tears. Cochrane database of systemic review, (6):CD000006. doi: 10.1002/14651858.CD000006
Kettle C, Dowswell T, Ismail KM, 2012. Continuous and interrupted suturing techniques for repair of episiotomy or second degree tears. Cochrane database of systemic review, 11:CD000947, doi: 10.1002/14651858.CD000947
Episiotomy and perineal tears. NHS UK. https://www.nhs.uk/conditions/pregnancy-and-baby/episiotomy/