What is it?
An episiotomy is a small surgical cut made in the perineum, the muscles between your vagina and your anus, to allow a baby to be born more easily or quickly once the head is crowning. The cut is done under a local anaesthetic and sewn up shortly after the birth. The most common types of episiotomy are the midline episiotomy, which runs directly towards the anus from the bottom of the vaginal opening, and the mediolateral episiotomy which runs from the bottom of vaginal opening at an angle to one side.
Why are episiotomies used?
Episiotomies have frequently been used to lessen the stress caused to the perineal area during childbirth, prevent perineal tearing and enlarge the vagina to give the baby more room to pass out of the birth canal and so speed up birth. Doctors used to believe that an episiotomy would not only make birth easier, but would also lessen post-partum problems such as incontinence and a painful healing period by reducing damage to the pelvic floor. As a result of this, in many areas episiotomies were considered almost a routine procedure and the episiotomy rate was consequently very high in the 1970s and eighties..
However, the tide has been turning against episiotomies since research has shown that they may worsen, rather than reduce post-partum problems and may, in fact, generally (but by no means always) heal less well (and more painfully) than natural tears. While some doctors do still favour episiotomies over tears, despite a lack of supporting evidence in their favour, it's no longer a routine part of a hospital childbirth.
These days you are most likely to be advised to have an episiotomy if your midwife or doctor has reason to believe that you would otherwise tear very badly during the birth, if your doctor is using forcepts for delivery and needs a little more room for manoeuvre or if your baby is in distress and needs to be delivered as quickly as possible.
Can I choose not to have an episiotomy?
You don't have to agree to an episiotomy. If the procedure is something that you would rather avoid, then make sure you make this clear in your birth plan and to your medical team in the run-up to the birth. Make sure too, that your birthing partner knows that this is something that is important to you. Different birthing places may have different approaches to episiotomies in that some may use episiotomies far more frequently than others: This is something that it's worth asking about when you go on your pre-natal visit. At the time when an episiotomy is suggested during labour your baby's head will be crowning, so it's not a time when you'll be likely to be able to give consent properly - that's why it's important that your birth partner knows how you feel about the episiotomy.
You can reduce the likelihood of an episiotomy by doing regular Kegel exercises in the weeks before labour to strengthen the muscles of the pelvic floor and by daily perineal massage in the last six weeks before birth. Done correctly and regularly, this massage helps to pre-stretch the muscles of the perineum so that they can more easily accommodate baby during birth.
Will an episiotomy be painful, and how will it heal?
As an episiotomy is carried out very quickly under local anaesthetic you're quite unlikely to feel any pain, besides which, there's already so much going on during the birth that you really have other things on your mind. The recovery period is, however, another matter, and you're quite likely to feel discomfort or pain as the wound heals, particularly in the first few days when your nether regions are quite swollen. You can help recovery and ease discomfort in the same way that you would for natural tearing:
- Pour warm water on your perineum as you wee - the water will dilute the urine so that it doesn’t sting the cut. It's a good idea to keep a bottle or measuring cup handy by the loo for this purpose. Find out more here.
- Support your perineum during first bowel movements - when you first go to the loo after labour you may be worried that the stitches will tear. They won't, but to ease your mind and help you go to the loo more easily you can use a clean sanitary pad to support your perineum (press lightly upwards) as you open your bowels.
- Be scrupulous about toilet hygiene - to reduce the risk of infection as far as possible. Take particular care to wipe from front to back, not vice versa. Pouring warm water over your genitals after you urinate or have a bowel movement will help.
- Take a warm bath - to relax and promote healing. Adding lavender essential oil may be soothing (dilute in milk first so it doesn’t just sit on top of the water. Keep bathing time relatively short as a long soak will make the perineal tissues soggy and could pose an infection risk.
- Change your maternity or sanitary pad frequently- at least every four hours, and ensure it’s firmly in place so that it doesn't rub against the stitches.
- Keep cool down below - Keeping maternity pads in the freezer will ensure they are cool and soothing when you put them on. You could also spray pads with cooled witch hazel from the fridge which will help heal as well as cool. Another idea is to use a cooled gel pad on the area to help reduce swelling, particularly in the first couple of days. But avoid ice packs as you may get ice burn.
- Pat yourself dry gently - don't rub your stitches as this will irritate the healing area, but do make sure that the area is dry before dressing.
- Exercise your pelvic floor - as soon as you can after the birth. Kegel exercises help speed up recovery by increasing blood flow to the area. Toning up the perineum will also help combat any post-natal problems you may have with incontinence. Aim to do 50 to 100 every day.
- Let the fresh air in - to speed up healing. Lie on the bed on an absorbent pad (the sort you use as a bed protector for toddlers is a good idea) or old towels and remove your sanitary pad and knickers for at least ten minutes daily, or as often as you can.
- Take pressure off the area - Avoid standing or sitting for longer periods. When you do need to sit for a while you could try a ‘valley cushion’ which is specially designed to ease pressure on your perineum. To find one, contact the National Childbirth Trust (NCT). Keep plenty of fibre in your diet to help avoid constipation and uncomfortable bowel movements.
- Take painkillers if you need to - there's no point in putting up with the pain unnecessarily. If you're breastfeeding then ask your doctor for painkillers that are safe to take while breastfeeding.
- Witch hazel or Arnica tablets - may help reduce the swelling and bruising and promote healing.
Your wound should heal within about two weeks, but the area may be uncomfortable even after superficial healing. The scar is usually fully healed by the time of your post-partum check six weeks after the birth, and is one of the things which your doctor will check on. If the wound continues to be very painful several days after the birth, if their is an unpleasant odour from the area, or if you have a fever, then you should contact your midwife or GP in case you have an infection.
How will an episiotomy affect my sex life?
As with any vaginal trauma from the birth, it's usual for an episiotomy scar to be fully healed after six weeks, and if so your doctor will give you the all-clear for resuming sex with your partner. However, even if the scar is healed, vaginal dryness is very common after birth, particularly where there is scar tissue and where libido (and hence natural lubrication) is reduced, as is common for new mums - particularly those breastfeeding. If vaginal dryness after your six-week check is a problem then you could use a water-based lubricant to reduce discomfort through intercourse.
Occasionally an episiotomy may have been stitched up too tightly after the birth, reducing the size of the vagina. If you think this may be a problem then ask your doctor to check - you may have to do special stretching exercises to widen the vagina before intercourse will be comfortable.
If your episiotomy is not fully healed after 6 weeks your doctor will be able to advise you on medication to best speed up recovery.
