PREGNANCY

Episiotomy: what is it and will I need one?

Last modified on Friday 15 January 2021

While the thought of an episiotomy – a cut made 'down there' just before the baby is ready to come out – isn't pleasant, it can help get the baby out quickly, and without you tearing. From why you may need one, to how long it takes to heal, here's what you need to know about having an episiotomy.

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What's an episiotomy?

An episiotomy is a cut that your midwife may need to make in your perineum (the stretch of skin between your vagina and anus). This is to help create more room for the baby to come out.

When will I need an episiotomy?

These days, only one in every seven births requires an episiotomy to help get the baby out, which means there's a good chance you won't need to have one.

However, if you do need one, your episiotomy will be performed in the second stage of labour, once you've started pushing the baby out and are very close to giving birth.

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Episiotomies used to be a routine part of labour and birth, but now the Royal College of Midwives (RCM) only recommends them in specific cases.

The National Institute for Health and Clinical Excellence (NICE) says that ‘a routine episiotomy should not be carried out during spontaneous vaginal birth’.

These days, it should only be considered necessary if:

  • the baby appears to be in foetal distress (ie has a significantly increased or decreased heart rate, and there is a real risk to the baby’s life or wellbeing if he is not born quickly)
  • the midwife needs to deliver the baby using assistance via forceps or ventouse, and more space is required to do so
  • the baby is not being born head first (ie breech or face presentation)
  • you’ve had a long labour and are exhausted
  • the baby is large
  • you have a serious health condition and not getting the baby out quickly could jeopardise your health.

Having an episiotomy: will it hurt?

An episiotomy is a fairly straightforward procedure that your midwife will be used to doing.

She may need your legs in stirrups to perform it. Then you won't feel a thing as she makes the quick cut because you'll either have your epidural (topped up if necessary) as pain relief – or she'll apply a numbing local anaesthetic to the area first.

The cut is usually 4-5cm long and is done at a 45 degree angle to avoid doing any damage to your anal sphincter (your bottom!).

What's the difference between an episiotomy and a tear?

Your vagina will naturally stretch with childbirth to accommodate the baby's head to come out. Most women (about 90%) will suffer first or second degree tears during this process – something that midwives don't worry too much about these days as natural tears are found to heal pretty well.

An episiotomy is a cut that your midwife will make to your perineum, if the skin doesn't seem to be stretching well enough on its own. She'll only do this if she thinks it's absolutely necessary to help labour progress quickly and get the baby out.

Illustration to show where and how an episiotomy is done.

How do I avoid needing one?

Your midwife may mention the benefits of perineal massage in your antenatal appointments. This is a way to help gently stretch and soften your perineum ready to cope with childbirth.

Research has found that massaging the perineum in the last five or six weeks of pregnancy reduced the likelihood of tears, needing an episiotomy, and pain in women who have not given birth vaginally before.

Here's how to perform perineal massage.

During labour, it's important to stay as relaxed as possible to push the baby out, without the need for intervention. Trying different breathing techniques and birthing positions can help with this.

Can I refuse to have one?

As with any surgical procedure, consent is required before an episiotomy is carried out.

If you really don't want one, discuss it with your midwife beforehand and make sure it's written in your birth plan so that your midwife will know in advance.

If this is the case, make sure you carry out your perineal massage regularly to help soften the area (see above).

While you have the right to refuse one, midwives these days aren't likely to suggest an episiotomy unless they feel it absolutely necessary.

For instance, it could help avoid intervention, an emergency C-section or something more serious.

Foetal distress can lead to stillbirth or increase the chance of birth defects if not dealt with swiftly and decisively, so do bear this in mind before you reject the suggestion.

Will I have an episiotomy scar?

It's likely that you'll have a scar after an episiotomy – although you'll be pretty unaware of it once it's healed. In some cases, scar tissue can form and some women may find it irritating or itchy. If your scar causes any problems, speak to your GP.

Will I need an episiotomy next time?

No. Just because you have had an episiotomy before, doesn't mean you'll need to have one every time you give birth.

If you're concerned about this, discuss it with your midwife in your antenatal appointments.

Having an episiotomy: the pros

  • To get the baby out quickly
  • To avoid the risk of stillbirth or birth defects
  • Can help avoid severe third-degree tears
  • Will only be performed if deemed necessary

Having an episiotomy: the cons

  • It can be a traumatic procedure to come to terms with afterwards
  • It takes a good a month to heal
  • It can make the first few days and weeks of being a mum particularly uncomfortable (sitting down, going to the toilet etc).

Episiotomy: what happens afterwards

Once you've had the baby, your episiotomy cut will be stitched up by your midwife. Although it's not particularly pleasant, you'll be nicely distracted by your newborn while she does this. You shouldn't feel anything as she'll apply a local anaesthetic to make sure the area is still numb.

Then you'll have to keep your stitches clean to avoid infection. Your midwives will check these regularly while you're in hospital and in the first week when they visit you at home. They've seen it all a million times before, so if you're worried or just want reassurance that everything's OK down there, make sure you ask them to check.

Signs of infection include:

  • red, swollen skin
  • discharge of pus or liquid from the cut
  • persistent pain
  • a smell that isn't usual for you.

Tell your GP, midwife or health visitor as soon as you can if you notice any of these, as you may need a course of antibiotics to treat the infection.

How long does it take to heal?

You may wonder if you'll ever be able to sit comfortably again, following an episiotomy. Although it takes time to heal, your stitches should dissolve and the pain should improve within a month.

By your six-week check, you should be sitting a lot more comfortably. Your GP can check the area at this appointment if you have any worries.

How to cope after an episiotomy

Some women say that they barely noticed or remember having an episiotomy, thanks to pain relief as well as being nicely distracted by the euphoria of giving birth.

However, once you're stitched up and the pain relief starts to wear off, it can be a shock to the system.

Firstly, the thought of what's happened down there is traumatic to deal with. But also the pain and discomfort can take some getting used to.

Luckily, there are some ways you can help yourself while your episiotomy heals. Here's how:

  • Take painkillers – midwives on the postnatal team can provide regular pain relief. Paracetamol is fine to take and so is ibuprofen if your baby is healthy and wasn't born prematurely. You can't take aspirin though.
  • Keep it clean – you'll be wearing maternity pads for up to the next six weeks or so, but make sure you change them regularly to avoid infection.
  • Let the air get to it – after a shower, or when possible, lay on a towel and let the air get to the area to help with healing.
  • Sit on an ice pack – wrap a freezer pack in a clean cloth or tea towel and then apply to the area or sit on it for a bit to help reduce swelling and pain.
  • Get padding – maternity pads can help protect the area when you're sitting down. Use double pads (one on top of the other) if you're feeling particularly tender in the first few days or weeks.
  • Start your pelvic floor exercises – it may be the last thing you feel like doing but squeezing the muscles down there can help get oxygen to the area and help with healing and tightening things up post birth.

Post episiotomy: will it sting when I go to the toilet?

The thought of going to the toilet once you've had an episiotomy isn't easy to get your head around. You'll most probably be dreading doing that first wee, once you've been stitched up – and who could blame you.

Sadly, it will sting at first but there are some tips for helping:

  • Take a deep breath in and then exhale as you wee
  • Pour some clean, warm water over the outer area of your vagina as you wee to help with the sting
  • Squatting rather than sitting on the toilet can help change the angle of your wee so that it doesn't come into contact with your stitches
  • Some midwives even recommend weeing in a warm shower to make it more comfortable.

How to do a poo after an episiotomy

If the thought of doing a wee after an episiotomy is bad, how on earth will you ever manage to do a poo?

The most common thing to worry about is that pushing will somehow rip your stitches. This isn't actually possible, so with that in mind, here are some handy tips to help with the process:

  • If you're doing a wee first, squat before you sit down so it doesn't surprise you by stinging while you're concentrating on doing a poo
  • Take a maternity pad, fold it in half and (with no sticky part showing) use it to apply gentle pressure and protect your stitches while you poo
  • Be gentle when you wipe your bottom to avoid transferring bacteria
  • If you get constipated and really struggle to do a poo, ask your midwife about using a laxative to make stools softer and easier to pass.

Having sex after an episiotomy

Remember that most women feel a bit sore if they rush into having sex after having had a baby – and that's without having had an episiotomy. It's a good idea to wait until your six-week check, so that your GP can make sure she's happy with how it's healed.

When you are ready to have sex, it may feel a bit tender or uncomfortable but this should get better with time. There shouldn't be any long-term pain associated with an episiotomy.