What Is an Episiotomy?
An episiotomy is typically performed during the pushing stage of labor. After numbing medication (if not already under epidural), a provider makes a small incision in the perineal tissue just before the baby’s head crowns.
There are two main types:
Midline (median) – A straight incision toward the anus
Mediolateral – An angled incision away from the anus
Each has different risks, particularly concerning the possibility of extension into deeper tissues.
Why Were Episiotomies Once Routine?
Historically, providers believed episiotomies would:
- Prevent severe tearing
- Protect pelvic floor muscles
- Reduce long-term incontinence
- Speed up delivery
- Protect the baby from distress
However, large studies over time showed that routine episiotomy often caused more severe tearing, not less.
Current Medical Guidelines
The American College of Obstetricians and Gynecologists (ACOG) and other global medical organizations now recommend restrictive use rather than routine use.
Episiotomies may be considered in specific situations such as:
- Fetal distress requiring expedited delivery
- Shoulder dystocia
- Instrument-assisted births (forceps or vacuum)
- Extremely rigid perineal tissue obstructing birth
Even in these situations, the decision should be individualized.
Risks and Complications
An episiotomy is a surgical cut, and like all surgical procedures, it carries risks:
1. Extension into Severe Tears
The incision can extend into third- or fourth-degree tears involving the anal sphincter or rectum.
2. Increased Pain
Surgical incisions often cause more postpartum pain than natural tears.
3. Infection
As with any wound, infection is possible.
4. Longer Healing Time
Healing may take several weeks, sometimes longer depending on severity.
5. Pain During Intercourse
Some women experience discomfort during intimacy for months.
6. Pelvic Floor Dysfunction
Although once believed to prevent it, episiotomy does not reliably prevent pelvic floor damage.
Recovery After an Episiotomy
Healing typically takes several weeks. Recovery may include:
- Ice packs in the first 24 hours
- Sitz baths
- Perineal cleansing with warm water
- Stool softeners
- Pain medication if prescribed
Proper wound care is important to prevent infection. Any signs of increased pain, swelling, fever, or foul odor should be reported to a provider.
Natural Tearing vs. Episiotomy
It may seem counterintuitive, but research shows that natural tears are often smaller and heal better than surgical incisions.
Natural tears:
- Tend to follow natural tissue lines
- Are often less severe
- Usually heal with fewer complications
A surgical cut does not guarantee protection from deeper tearing.
Can Episiotomies Be Prevented?
While no one can completely control how their body responds in labor, several strategies may reduce the likelihood of episiotomy:
- Perineal massage in late pregnancy
- Upright or side-lying birth positions
- Slow, controlled pushing
- Warm compresses on the perineum during crowning
- Continuous labor support (such as a doula)
One preparation method that supports perineal massage is the use of perineum oil in the final weeks of pregnancy.
When applied regularly beginning around 34–35 weeks (with provider approval), perineum oil can help improve tissue flexibility and hydration. The perineum must stretch significantly during crowning. Tissue that is dry or rigid may resist gradual stretching, which can increase the likelihood that a provider feels intervention is necessary.
Perineal massage with oil may:
- Improve elasticity of the perineal tissue
- Increase circulation to the area
- Reduce dryness and tension
- Help women become familiar with the stretching sensation of birth
While it does not eliminate all risk, conditioning the tissue may reduce the perceived need for a surgical incision in some cases.
Open communication with your provider before labor is key. Ask about their episiotomy rate and under what circumstances they use it.
Informed Consent Matters
An episiotomy should not be performed without consent unless there is an emergency where immediate action is required to protect life.
Women have the right to:
- Ask questions
- Understand risks and benefits
- Decline non-emergency procedures
- Include preferences in a birth plan
Labor can move quickly, so discussing preferences before delivery is wise.
Questions to Ask Your Provider
- What is your episiotomy rate?
- In what situations do you recommend one?
- How do you support the perineum during birth?
- What alternatives do you try first?
These conversations create clarity and reduce unexpected interventions.
The Bottom Line
Episiotomies are no longer considered routine best practice. While they may be medically necessary in certain cases, most women can safely give birth without one.
Preparation — including perineal massage, supportive positioning, and thoughtful communication — can influence outcomes. Education and advocacy remain powerful tools.
Understanding your options helps you enter labor informed—not fearful—and better equipped to participate in decisions about your body.
If you are preparing for birth, take time to learn about interventions that may arise. Knowledge transforms uncertainty into confidence.
