Episiotomy and perineal tears

Sometimes a doctor or midwife may need to make a cut in the area between the vagina and anus (the perineum) during childbirth.

This is called an episiotomy and makes the opening of the vagina a bit wider, allowing the baby to come through it more easily.

Sometimes a woman's perineum may tear as the baby comes out. An episiotomy can help to avoid a tear or speed up delivery.

Studies suggest that in first-time vaginal births, it's more common to have severe injuries involving the anal muscle if the perineum tears spontaneously rather than if an episiotomy is performed.

Why you might need an episiotomy

How it's performed

Recovering from an episiotomy

Preventing a perineal tear

The National Institute for Health and Care Excellence (NICE) recommends that an episiotomy should be considered if:

• the baby is in distress and needs to be born quickly, or
• there is a clinical need, such as a delivery that needs forceps or ventouse, or a risk of a tear to the anus

If your doctor or midwife feels you need an episiotomy when you're in labour, they will discuss this with you.

Around one in seven deliveries involves an episiotomy.

If you have a tear or an episiotomy, you'll probably need stitches to repair it. Dissolving stitches are used, so you won't need to return to hospital to have them removed.

Why you might need an episiotomy

An episiotomy may be recommended if your baby develops a condition known as foetal distress, where the baby's heart rate gets significantly faster or slower before birth.

This means the baby may not be getting enough oxygen and has to be delivered quickly to avoid the risk of birth defects or stillbirth.

Another reason for carrying out an episiotomy is when it's necessary to widen your vagina so instruments, such as forceps or ventouse suction, can be used to help with the birth.

This may be necessary if:

• you're having a breech birth, where the baby is not head-first
• you have been trying to give birth for several hours and are now tired after pushing
• you have a serious health condition, such as heart disease, and it's recommended that delivery should be as quick as possible to minimise any further health risks

Research shows that in some births, particularly with forceps deliveries, an episiotomy may prevent third-degree tears, where the tear affects the anal muscle.

How an episiotomy is performed

An episiotomy is usually a simple procedure. A local anaesthetic is used to numb the area around the vagina so you won't feel any pain. If you've already had an epidural, the dose can be topped up before the cut is made.

Whenever possible, the doctor or midwife will make a small diagonal cut from the back of the vagina, directed down and out to one side. The cut is stitched together using dissolvable stitches after the birth.

Recovering from an episiotomy

Episiotomy cuts are usually repaired within an hour of the baby's birth. The cut (incision) may bleed quite a lot initially, but this should stop with pressure and stitches.

Stitches should heal within one month of the birth. Talk to your midwife or obstetrician about which activities you should avoid during the healing period.

Coping with pain

It's common to feel some pain after an episiotomy. Painkillers such as paracetamol can help relieve pain and are safe to use if you're breastfeeding.

You shouldn't take ibuprofen if you're breastfeeding and your baby was born premature (before 37 weeks of pregnancy), had a low birth weight, or has a medical condition.

Aspirin also isn't recommended as it can be passed on to your baby through your breast milk. Your midwife will advise you if you're not sure what painkillers to take.

Research suggests around 1% of women (1 in 100) feel severe pain that seriously affects their day-to-day activities and quality of life after having an episiotomy.

If this happens, it may be necessary to treat the pain with stronger prescription-only painkillers, such as codeine.

However, prescription-only medicine may affect your ability to breastfeed safely. Your GP or midwife will be able to advise you about this.

To ease the pain, you can try:

• placing an ice pack or ice cubes wrapped in a towel on the incision – avoid placing ice directly on to your skin as this could cause damage
• using a doughnut-shaped cushion or squeezing your buttocks together while you're sitting to help relieve pressure and pain at the site of your cut

Exposing the stitches to fresh air can help encourage the healing process. Taking off your underwear and lying on a towel on your bed for around 10 minutes once or twice a day may help.

It's unusual for postoperative pain to last longer than two to three weeks. If the pain lasts longer than this, you should speak to a doctor, health visitor, or another health professional.

Going to the toilet

Keep the cut and the surrounding area clean to prevent infection. After going to the toilet, pour warm water over your vaginal area to rinse it.

Pouring warm water over the outer area of your vagina as you pee may also help ease the discomfort.

You may find squatting over the toilet, rather than sitting on it, reduces the stinging sensation when passing urine.

When you're passing a stool, you may find it useful to place a clean pad at the site of the cut and press gently as you poo. This can help relieve pressure on the cut.

When wiping your bottom, make sure you wipe gently from front to back. This will help prevent bacteria in your anus infecting the cut and surrounding tissue.

If you find passing stools particularly painful, taking laxatives may help. This type of medication is usually used to treat constipation and makes stools softer and easier to pass.

For more information, read about treating constipation.

Pain during sex

There are no rules about when to start having sex again after you've given birth.

In the weeks after giving birth, many women feel sore as well as tired, whether they've had an episiotomy or not. Don't rush into it. If sex hurts, it won't be pleasurable.

If you've had a tear or an episiotomy, pain during sex is very common in the first few months.

Studies have found around 9 out of 10 women who had an episiotomy reported resuming sex after the procedure was very painful, but pain improves over time.

If penetration is painful, say so. If you pretend everything is all right when it isn't, you may start to see sex as a nuisance rather than a pleasure, which won't help you or your partner.

You can still be close without having penetration – for example, through mutual masturbation.

Get tips on talking about sex.

Pain can sometimes be linked to vaginal dryness. You can try using a water-based lubricant available from pharmacies to help.

Don't use an oil-based lubricant, such as Vaseline or moisturising lotion, as this can irritate the vagina and damage latex condoms or diaphragms.

You can get pregnant as little as three weeks after the birth of a baby, even if you're breastfeeding and your periods haven't started again.

Use some kind of contraception every time you have sex after giving birth, including the first time (unless you want to get pregnant again).

You'll usually have an opportunity to discuss your contraceptive options before you leave hospital (if you've had your baby in hospital) and at the postnatal check.

You can also talk to your GP, midwife or health visitor, or go to a contraception clinic at any time.

Find sexual health services near you.

Infection

Look out for any signs that the cut or surrounding tissue has become infected, such as:

• 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 about any possible signs of infection so they can make sure you get any treatment you need.

Exercises

Strengthening the muscles around the vagina and anus by doing pelvic floor exercises can help promote healing, and will reduce the pressure on the cut and surrounding tissue.

Pelvic floor exercises involve squeezing the muscles around your vagina and anus as though to stop yourself from going to the loo or passing wind (farting).

Your midwife can show you how to perform the exercises correctly. You can also read pelvic floor exercises for women (PDF, 68kb) for advice.

Scar tissue

For a few women, excessive, raised or itchy scar tissue forms around the place where a tear happened or where an episiotomy was performed. If your scar tissue is causing problems for you, tell your doctor.

Scar tissue doesn't stretch, so you may need an episiotomy again if you have excessive scar tissue and you have another baby. You can talk to your midwife or doctor about this.

Preventing a perineal tear

A midwife can help you avoid a tear during labour when the baby's head becomes visible.

The midwife will ask you to stop pushing and to pant or puff a couple of quick short breaths, blowing out through your mouth.

This is so your baby's head can emerge slowly and gently, giving the skin and muscles of the perineum time to stretch without tearing.

The skin of the perineum usually stretches well, but it may tear, especially in women who are giving birth for the first time.

Research suggests massaging the perineum in the last few weeks of pregnancy can reduce the chances of having an episiotomy during birth.

A review of four trials showed massaging the perineum from 35 weeks of pregnancy reduced the likelihood of tears, needing an episiotomy, and pain in women who had not given birth vaginally before.

The type and frequency of massage varied across the trials. Most involved inserting one or two fingers into the vagina and applying downward or sweeping pressure towards the perineum.

The benefit was more marked among those women who carried out perineal sweeping twice a week.