An episiotomy is a surgical incision made in the perineum, the tissue located between the vaginal opening and the anus, performed during the second stage of labor to enlarge the birth canal. This procedure, which is closed with stitches after delivery, was once a standard part of childbirth but is no longer routine practice. Episiotomies are still performed, but only in specific, medically indicated situations. Current medical guidelines strongly favor a restrictive use of the procedure over the widespread, routine approach of past decades.
Why Routine Episiotomies Ended
For much of the 20th century, the procedure was performed routinely for nearly all first-time mothers in the United States, with rates reaching over 60% in the late 1970s. The long-held belief was that a clean, straight surgical incision would heal better than a natural tear, preventing severe lacerations and preserving the strength of the pelvic floor muscles. It was also thought to protect the baby’s head and speed up the final moments of delivery.
Starting in the 1970s, medical research began to challenge these assumptions, leading to a major shift in clinical practice. Studies demonstrated that routine episiotomies did not prevent severe tears; in fact, the procedure often extended into a larger third or fourth-degree laceration involving the anal sphincter. A systematic review showed that a restrictive approach led to lower risks of posterior perineal trauma, less need for suturing, and fewer healing complications. The American College of Obstetricians and Gynecologists (ACOG) formally recommended against routine use, advocating for the procedure only when medically indicated.
Specific Indications for Current Use
Despite the shift away from routine use, the episiotomy remains a tool reserved for specific scenarios where the benefits outweigh the risks. These indications are generally emergency situations that require the rapid delivery of the baby. One situation is fetal distress, where an abnormal heart rate pattern signals the baby is not tolerating labor well, and the second stage must be expedited to prevent serious harm.
The procedure is also necessary to facilitate operative vaginal delivery, which involves the use of forceps or a vacuum extractor to assist the birth. An incision may be required to create enough space to safely apply these instruments and avoid extensive tearing. Another indication is shoulder dystocia, a rare event where the baby’s shoulder gets stuck behind the mother’s pelvic bone after the head has been delivered. In these time-sensitive emergencies, the episiotomy provides the necessary room to perform maneuvers to free the baby and prevent injury.
Recovery and Potential Long-Term Complications
An episiotomy creates a surgical wound that requires careful repair and results in significant short-term pain and discomfort during the postpartum recovery period. The initial healing phase involves managing pain, swelling, and the site of the stitches, which typically takes several weeks to resolve. Activities like sitting, walking, and having a bowel movement can be painful, and most providers recommend avoiding sexual intercourse until the six-week postpartum checkup.
The type of incision performed affects the complication risk. The mediolateral approach (angled away from the rectum) is preferred over the midline approach (straight toward the rectum) due to the latter’s high risk of extending into a severe third or fourth-degree tear. Long-term complications can include dyspareunia, or pain during sexual intercourse, which can persist for months or years. The procedure has also been associated with an increased risk of long-term pelvic floor issues, such as urinary or fecal incontinence and chronic perineal pain, particularly when the incision damages the anal sphincter.
Reducing the Need for the Procedure
Since episiotomies are no longer considered necessary, several non-surgical techniques can be employed to minimize the risk of needing the procedure. Perineal massage, which can be started during the later weeks of pregnancy, involves manually stretching the perineal tissues to increase their elasticity and pliability. Research suggests this technique can reduce the risk of tearing that requires stitches, especially for first-time mothers.
During labor, the use of warm compresses applied to the perineum during the second stage helps the tissue stretch and reduces the likelihood of a severe laceration. Controlled or delayed pushing, where the birthing person is guided to push more gently or wait for a strong urge, allows the perineum more time to adapt to the baby’s head. Choosing an upright or side-lying birthing position, instead of the traditional lithotomy position (lying on the back with legs in stirrups), also reduces tension on the perineum and promotes a smoother delivery.