When might a doctor recommend an episiotomy?

It may be recommended in cases like prolonged labour, foetal distress, use of forceps or vacuum, large baby, breech birth, or if there’s a high risk of severe tearing.

What are the risks or side effects of an episiotomy?

Risks may include pain, infection, bleeding, discomfort during healing, or complications if the incision extends too far. Recovery can vary based on the type and severity.

What is an Episiotomy? Procedure, Types, Risks & When It's Needed

An episiotomy is a medical procedure sometimes used during childbirth to help make delivery safer for you and your baby. It’s not as common as it used to be, but understanding what an episiotomy involves, why it might be necessary, and the different types can help you feel more prepared for labour.

What is an Episiotomy?

An episiotomy is a small surgical cut made in the perineum (area between your vaginal opening and anus) during childbirth. The purpose is to widen the vaginal opening and allow your baby to pass through more easily. This procedure is typically performed during the second stage of labour when your baby’s head is visible and pushing against the perineum. It’s not a routine practice anymore, as natural tearing is often preferred.

However, your healthcare professional might recommend an episiotomy in specific situations to reduce the risk of complications.

Why Might You Need an Episiotomy?

Your doctor will only suggest an episiotomy if it’s medically necessary, based on their assessment during prenatal visits or labour. These are the main situations where an episiotomy might be recommended:

Foetal distress: An episiotomy can speed up delivery if your baby’s heart rate shows signs of distress, such as being too fast or slow, indicating a lack of oxygen.
Large baby (macrosomia): When a larger-than-average baby may require more space to exit the vagina.
Breech position: If your baby is positioned feet or buttocks first.
Shoulder dystocia: When your baby’s shoulders get stuck behind your pelvic bone.
Prolonged labour: If you’re exhausted from pushing for a long time or can’t control your pushing.
Assisted delivery: The use of forceps or a vacuum device may require a wider vaginal opening.
Preterm delivery: Babies born before term may need a quicker delivery to avoid complications.
Risk of severe perineal tears: If your perineum is short or at risk of extensive tearing, an episiotomy may prevent more serious damage.

These situations are carefully evaluated by your healthcare professional to make sure the procedure is only performed when it benefits you or your baby.

How is an Episiotomy Performed?

The episiotomy procedure is done carefully to keep you as comfortable as possible. This is what happens during the process:

Anaesthesia: If you haven’t had an epidural, your healthcare professional will inject a local anaesthetic into the perineal area to numb it. Additional anaesthesia may not be needed if you’ve already had an epidural.
Timing of the incision: The cut is made during the second stage of labour, when your baby’s head is crowning and stretching the vaginal opening.
Making the incision: Your doctor makes a precise incision in the perineum using surgical scissors or a scalpel. The size and type of cut depend on your specific situation.
Delivery: After the incision, your baby and the placenta are delivered.
Stitching: Once the delivery is complete, the incision is closed with dissolvable stitches.

Types of Episiotomy Incisions

There are three main types of episiotomy incisions. Your healthcare professional will choose the most appropriate type based on your anatomy, your baby’s position, and the progress of labour. These are:

Midline (Median) Incision

A vertical cut from the vaginal opening towards the anus.
Easier and faster for your healthcare professional to perform and repair.
Less bleeding compared to other types.
Higher risk of extending into the anal sphincter or rectum, which could lead to complications like bowel incontinence.

Mediolateral Incision

An angled cut (usually 45 to 60 degrees) from the vaginal opening towards the buttock.
Less likely to tear into the anal sphincter or rectum, making it safer in some cases.
May cause more blood loss and discomfort during recovery.
More challenging to repair, which can extend the procedure time.

Lateral Incision

A rare type of incision starting about 1 cm from the vaginal opening.
Avoided in most cases due to the risk of damaging underlying muscles.
Used only in specific situations where other incisions aren’t suitable.

Degrees of Episiotomy

Episiotomies are classified by severity based on how deep the incision or tear extends. These degrees help your healthcare professional assess the extent of the procedure and plan your recovery:

First-degree: A small tear affecting only the vaginal lining. It heals quickly with minimal complications.
Second-degree: A deeper tear involving the vaginal lining and underlying perineal muscles. This is the most common type of episiotomy.
Third-degree: A tear that extends through the vaginal lining, perineal muscles, and into the anal sphincter.
Fourth-degree: The most severe, affecting the vaginal lining, perineal muscles, anal sphincter, and rectum. This type carries the highest risk of complications.

Why Are Episiotomies Less Common Now?

In the past, episiotomies were routine, with doctors believing they prevented severe tears and complications like urinary incontinence or pelvic floor damage. The World Health Organization (WHO) advises against routine episiotomies, suggesting the rate should stay below 10 per cent. As a result, healthcare professionals now prefer natural tearing unless an episiotomy is medically necessary.
However, the episiotomy rate exceeds global recommendations in most regions of India.

Can You Refuse an Episiotomy?

You have the right to refuse an episiotomy as long as you’re capable of giving informed consent. Discuss your preferences with your doctor during prenatal visits to include them in your birth plan. Ask questions like:

When might an episiotomy be necessary for me?
What type of incision is most likely?
What are the benefits and risks?
Are there alternatives to an episiotomy?

Can You Prevent an Episiotomy?

Some factors are beyond your control, but there are steps you can take to reduce the need for an episiotomy:

Perineal massage: Massaging the perineum in the weeks leading up to delivery may increase its elasticity. Though research on its effectiveness is mixed.
Warm compress: Applying a warm compress to the perineum during the second stage of labour can make the tissue more flexible.
Breathing and pelvic floor exercises: Practising exercises like Kegels during pregnancy can strengthen your pelvic muscles.
Labour positions: Positions like kneeling on all fours may reduce pressure on the perineum.

Always check with your healthcare professional before trying any of these techniques.
An episiotomy is only used when there’s a medical need, like a complicated delivery or foetal distress. In most cases, natural tearing is safer and heals better. You have the right to discuss this with your doctor and include your preferences in your birth plan. Knowing when it might be needed can help you stay informed and confident.

FAQs on What is Episiotomy? Procedure, Types and When It’s Needed

When might a doctor recommend an episiotomy?
It may be recommended in cases like prolonged labour, foetal distress, use of forceps or vacuum, large baby, breech birth, or if there’s a high risk of severe tearing.
What are the risks or side effects of an episiotomy?
Risks may include pain, infection, bleeding, discomfort during healing, or complications if the incision extends too far. Recovery can vary based on the type and severity.