Episiotomy During Childbirth: What It Is, When It Happens, and Recovery

Episiotomy — a surgical cut made to enlarge the vaginal opening during the second stage of labour — was once performed routinely in most hospital births, based on the belief that a controlled cut healed better than a natural tear and prevented the pelvic floor damage of uncontrolled tearing. The evidence no longer supports routine episiotomy, and the current recommendation from the WHO and most obstetric bodies is selective use — only when there is a specific clinical indication.

In practice in India, episiotomy rates remain high in many hospitals, and many women receive episiotomies without fully understanding what the procedure involves or whether it was clinically necessary. This guide explains what episiotomy is, when it is and is not appropriate, and how recovery works.

What an episiotomy is

An episiotomy is a cut made with surgical scissors into the perineum (the tissue between the vaginal opening and the anus) during the second stage of labour, just before or as the baby’s head is crowning. It is performed under local anaesthesia (an injection to numb the area) if the woman does not already have an epidural.

The most common type performed in India is the mediolateral episiotomy — a cut angled diagonally from the vaginal opening. The alternative, a median (midline) cut, is more common in some other countries but is associated with higher risk of extension into the anal sphincter.

The cut is repaired with dissolvable sutures after the birth of the baby and the placenta.

When episiotomy is medically indicated

The evidence supports episiotomy in specific circumstances:

• Shoulder dystocia — when the baby’s shoulder is stuck behind the pubic bone and rapid delivery is required, an episiotomy creates additional space.
• Instrumental delivery — when forceps or vacuum are used, an episiotomy is usually performed to create sufficient room for the instrument and reduce the risk of severe tearing.
• Fetal distress requiring immediate delivery — when the baby’s wellbeing is compromised and rapid delivery is needed.
• Imminent severe tear — where the tissue is clearly about to tear in a way that extends toward the anal sphincter, a directed episiotomy may redirect the tear.

What does not constitute a medical indication for routine episiotomy: a large baby, a first birth, tight perineal tissue, or simply to “prevent tearing.” The evidence does not support episiotomy for these reasons, and routine episiotomy is associated with more complications than selective episiotomy.

Asking about your hospital’s practice

Episiotomy rates vary significantly between facilities and between individual practitioners. If avoiding an episiotomy unless clinically necessary is important to you, include this in your birth plan: “I would prefer to avoid episiotomy unless there is a specific medical indication. I understand that some circumstances may make it necessary.”

Discuss this with your doctor antenatally. Ask what their episiotomy rate is. A provider whose answer is “we do it in all first deliveries” is practising differently from current evidence-based guidance.

Perineal massage from approximately 34–36 weeks (gently massaging the perineum with oil to increase tissue elasticity) has modest evidence for reducing the risk of severe perineal tears and may reduce the likelihood of episiotomy — worth discussing with your midwife.

Recovery from episiotomy

Immediate discomfort: The first days after an episiotomy are the most uncomfortable. The area is swollen, tender, and the sutures create additional discomfort. Sitting, walking, and using the toilet are all affected.

Ice packs in the first 24 hours reduce swelling and provide pain relief. After 24 hours, warmth (sitz baths) promotes healing and comfort.

Sitz baths — sitting in a shallow warm bath with the perineal area submerged — for 10–15 minutes several times daily promote healing, relieve discomfort, and keep the area clean.

Pain relief — paracetamol and ibuprofen (if tolerated) are safe postpartum and breastfeeding-compatible, and should be taken regularly rather than only when pain is severe.

Hygiene — keep the area clean with water after using the toilet. Pat rather than wipe. Change pads frequently.

Sutures — the dissolvable sutures typically dissolve within 2–4 weeks. You do not need them to be removed.

Return of comfort — most women find perineal pain from episiotomy significantly improved within 2–3 weeks, with the area largely healed by 6 weeks. Some women experience longer healing times, particularly if the wound was deeper or if there were complications.

Seek medical attention for: increasing pain after the first week (rather than decreasing), signs of infection (redness spreading beyond the wound edges, fever, foul-smelling discharge), wound opening, or persistent pain beyond 6 weeks.

Pelvic floor recovery — an episiotomy does not in itself cause permanent pelvic floor damage, but the area needs time to heal before resuming pelvic floor exercises. Gentle pelvic floor activation (Kegel exercises) can typically be restarted within a few days of birth, increasing gradually as comfort allows.

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This article is for general educational purposes only. If you have concerns about episiotomy or perineal recovery after birth, speak with your doctor or midwife.