Sometimes during the process of giving birth, a doctor or midwife may make a cut in a woman’s perineum (the area between the vagina and anus). The cut makes the opening of the vagina a bit wider, allowing the baby to come through it more easily.
In Bangladesh, episiotomies are carried out quite frequently. NICE (the National Institute for Health and Clinical Excellence) recommends that an episiotomy should be considered if the baby is in distress and needs to be born quickly, or if there is a clinical need, such as a delivery that needs forceps or ventouse.
In some women, the perineum may tear during childbirth as the baby comes out. If you have a tear or an episiotomy, you will probably need stitches to repair it, depending on the nature of the wound. If your doctor feels that you need an episiotomy when you’re in labour, they will discuss this with you.
The stitches used during an episiotomy should heal within one month. Usually, dissolving stitches are used so you won't need to go back to hospital to have them removed.
You’ll probably feel some pain around the episiotomy for two or three weeks after your baby is born. Sex can also be painful for the first few months after an episiotomy.
Why you might need an episiotomy
An episiotomy may be recommended if your baby develops a condition known as foetal distress. Foetal distress is where the baby’s heart rate significantly increases or decreases before birth. This means that the baby may not be getting enough oxygen and has to be delivered quickly to avoid the risk of birth defects or stillbirth.
This is also considered when there is a probability of perineal tear, i.e. tear in the area between the vagina and anus due to the pressure of delivery. In this case, a surgical incision is a safer option than allowing the perineum to get injured. The healing is quicker and safer and there is less chance of a recurring tear in the following pregnancy, a problem that is quite common in deliveries that take place at home, unattended.
If a caesarean section is not appropriate – for example, because the baby's head is already moving down the birth canal, an episiotomy can be the best way to speed up birth.
Another reason for carrying out an episiotomy is when it is necessary to widen your vagina so that instruments, such as forceps or ventouse suction, can be used to assist with the birth. This may be necessary if:
- You are having a breech birth (the baby is not head first).
- You have been trying to give birth for several hours and are now exhausted.
- You have a serious health condition, such as heart disease, and it is recommended that delivery should be as quick as possible to minimise any further health risk.
How an episiotomy is performed
An episiotomy is usually a simple operation. Local anaesthetic is used to numb the area around the vagina so you will not feel any pain.
Whenever possible, the doctor or midwife will make a small, diagonal cut from the back of the vagina and directed down and out to one side. Following the birth of your baby, the cut is stitched together using dissolvable stitches.
Recovering from an episiotomy
Episiotomy cuts are usually repaired within an hour of the baby's birth. The incision (cut) may bleed quite a lot initially, but with pressure and stitches this should soon stop.
Usually, dissolving stitches are used so you won't need to go back to hospital to have them removed. Stitches should heal within one month of the birth. Talk to your obstetrician about which activities you should avoid during the healing period. Your doctor should explain all these in details when you are about to be discharged from the hospital and usually what you can and can’t do is described in detail in your discharge card.
After having an episiotomy, it is normal to feel pain around the cut for two to three weeks after giving birth, particularly when walking or sitting. Passing urine can also cause the cut to sting.
Coping with pain
It’s common to feel mild to moderate pain after an episiotomy. Painkillers, such as paracetamol (Ace), can help to relieve pain and are safe to use if you are breastfeeding. Ibuprofen is safe to use as long as your baby was not premature (born before 37 weeks of pregnancy), was not a low birth weight and has no medical condition. Aspirin isn't recommended because it can be passed on to your baby via your breast milk.
Using a doughnut-shaped cushion or squeezing your buttocks together while you are sitting may also help to relieve the pressure and pain at the site of your cut.
Research suggests that, after an episiotomy, around one percent of women will feel severe pain that seriously affects their day-to-day activities and quality of life. If this happens, it may be necessary to treat the pain with stronger prescription-only painkillers, such as codeine. However, if you are prescribed prescription-only medication, it may affect your ability to breastfeed safely. Your obstetrician will be able to advise you further about this. It is unusual for post-operative pain to last for longer than two-to-three weeks.
Placing an ice pack or ice cubes wrapped in a towel on the incision can often help to relieve pain. Avoid placing ice directly onto your skin because this could damage it.
Exposing the stitches that were used to seal the incision to fresh air can 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.
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 to ease the discomfort. You may find that squatting over the toilet, rather than sitting on it, reduces the stinging sensation when passing urine.
When you are passing a stool, you may find it useful to place a clean pad at the site of the cut and press gently as you go. This can help to relieve pressure on the cut. Wipe after washing when you go to the bathroom. When wiping your bottom, make sure that you wipe gently from front to back because this will help to prevent bacteria in your anus infecting the cut and surrounding tissue.
If you find passing stools particularly painful, taking a short course of bulk-forming laxatives such as Isapghula husk (Isperghul) may help. This type of medication is usually used to treat constipation and makes stools softer and easier to pass.
Pain during sex
It is usually suggested that you avoid having sex for 6 weeks 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.
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. But you can also talk to your obstetrician, or go to a contraception clinic at any time.
If you’ve had a tear or an episiotomy, pain during sex is very common in the first few months. Studies have found that around 9 out of 10 women who had an episiotomy reported that resuming sex after the procedure was very painful, but that the pain improves over time.
If penetration is painful, say so. It’s not pleasant to have sex if it causes pain. If you pretend everything is alright when it isn’t, you may start to see sex as a nuisance rather than a pleasure, which won’t help either of you. You can still be close without having penetration (for example, mutual masturbation). Oral sex might not be the best idea if you have an episiotomy till until after 6 weeks.
Pain can sometimes be linked to vaginal dryness. You can try using a water-based lubricant (available at 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.
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, or persistent pain. Tell your obstetrician as soon as you can about any possible signs of infection, so that they can make sure you get any treatment you need.
Strengthening the muscles around the vagina and anus by doing pelvic floor exercises can help to promote healing and will reduce the pressure on the incision 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).
Preventing an episiotomy
There is no clear evidence that gently massaging your perineum in the last six weeks of pregnancy helps to prevent the tissue tearing or to avoid an episiotomy.
The only way to try to avoid a tear or episiotomy is 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 that 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. Sometimes, to avoid a tear or to speed up delivery, the obstetrician may quickly do an episiotomy.