Everything You Need to Know About Episiotomy Repair

Giving birth is one of the most extraordinary experiences life offers. But while you’re putting together your birth plan, it’s worth thinking through some of the less glamorous parts too, including the possibility of an episiotomy and what the repair and recovery actually involve.

Nobody wants to picture stitches when they’re imagining meeting their baby for the first time. But understanding what an episiotomy is, when it’s actually needed, and how you can lower your own risk of one, can make a real difference to how confident you feel heading into labour. This guide walks through all of it, from the procedure itself to postpartum care and healing afterwards.

WHAT IS AN EPISIOTOMY?

An episiotomy is a small surgical cut made in the perineum (the area of skin and muscle between the vaginal opening and the anus) during the pushing stage of labour. The idea is to widen the vaginal opening slightly so the baby can be born more quickly, or to make room for instruments like forceps.

There are two main types of incision your doctor or midwife might use if an episiotomy is genuinely needed:

• Midline incision: a straight vertical cut from the bottom of the vaginal opening towards the anus.
• Mediolateral incision: starts in the same place but angles off to one side at roughly 45 degrees, away from the anus.

The mediolateral cut is generally considered to carry a lower risk of extending into the anal sphincter, which is why it tends to be preferred in many units, though the midline cut heals with less bleeding and less pain in some cases. Your doctor will choose based on your individual anatomy and the situation in the room at the time. (source)

Why episiotomies used to be routine, and why that’s changed

For much of the 20th century, episiotomies were performed almost automatically for first time mothers, on the theory that a clean surgical cut would heal better than a natural tear and would help protect the pelvic floor. It became so standard that many women never even had a conversation about it beforehand.

That thinking has shifted a lot. A widely cited 2005 review in the Journal of the American Medical Association concluded that routine episiotomy doesn’t actually deliver the benefits it was long assumed to have:

“Evidence does not support maternal benefits traditionally ascribed to routine episiotomy. In fact, outcomes with episiotomy can be considered worse since some proportion of women who would have had lesser injury instead had a surgical incision.” (source)

A later Cochrane review reached a similar conclusion, finding that natural tears tend to heal at least as well as, and often better than, surgical incisions (Carroli and Mignini, 2009). As a result, routine use of the procedure has dropped sharply over the past couple of decades, and most guidelines now recommend it only when there’s a clear medical reason, not as standard practice.

When an episiotomy is still recommended

Today, most care providers reserve episiotomy for situations where it genuinely helps, such as:

• The baby is showing signs of distress and needs to be born quickly.
• The baby is large or in a position that’s making the birth canal exit particularly difficult.
• A forceps or vacuum assisted delivery is needed.
• The baby is preterm and more fragile.

If you’re worried about this, it’s a completely reasonable thing to bring up at an antenatal appointment. Ask your midwife or obstetrician how often they perform episiotomies and under what circumstances, so you know roughly what to expect.

EPISIOTOMY REPAIR AND DEGREES OF TEARING

Whether you have an episiotomy or a natural tear, the wound is stitched closed shortly after your baby (and placenta) is delivered, usually under local anaesthetic if you don’t already have an epidural in place. Tears and episiotomy wounds are classified by degree, depending on how deep and how far they extend:

• First degree: a shallow tear affecting only the skin.
• Second degree: extends into the underlying perineal muscle. This is the most common type requiring stitches.
• Third degree: extends into the muscle that controls the anus (the anal sphincter).
• Fourth degree: extends through the anal sphincter and into the lining of the rectum.

Third and fourth degree tears are more serious and are usually repaired in an operating theatre by a doctor rather than a midwife, so that the repair can be done carefully layer by layer. If you’ve had one of these, your team should give you a clear aftercare plan and follow up appointment, since these need closer monitoring for healing and bowel function.

Most first and second degree repairs heal within four to six weeks, though full comfort, including with sex, can sometimes take a bit longer. Everyone heals at a slightly different pace, so try not to compare your recovery to anyone else’s. Signs that something isn’t healing as it should include increasing pain rather than gradual improvement, a bad smell from the wound, fever, or the stitches coming apart. If you notice any of these, contact your midwife, GP or maternity unit promptly rather than waiting it out.

HOW THE REPAIR IS STITCHED

A good repair matters, both for comfort during healing and for reducing longer term issues, so it’s fair to expect your doctor or midwife to explain what they’re doing and why. There are several stitching methods in use, including the continuous suture and the interrupted (lock) suture, which are the two most commonly discussed.

• Continuous suture: one long stitch runs the length of the wound, tied off at the end. There’s no need for the stitches to be removed afterwards, since dissolvable thread is generally used.
• Interrupted (lock) suture: each stitch is placed and knotted individually along the wound.

A Cochrane review comparing the two found that the continuous technique was associated with less short term pain and less need for pain relief:

“The continuous suturing techniques for perineal closure, compared with interrupted methods, are associated with less short-term pain, need for analgesia and suture removal.”

This doesn’t mean the interrupted method is wrong or that something has gone badly if that’s what’s used on you. The choice often depends on the type and extent of the tear and what your doctor judges will give the best result. Even with a technically excellent repair, healing isn’t guaranteed to go perfectly. Wound infection, minor breakdown of the stitch line, and ongoing discomfort during sex are all recognised possibilities, and in rare cases a deep tear can lead to a rectovaginal fistula (an abnormal connection between the vagina and rectum that allows stool or gas to pass through the vagina). This is uncommon but worth knowing about, and it’s something your doctor can assess and treat if it happens.

AFTERCARE THAT ACTUALLY HELPS

The first week or two after stitches can feel uncomfortable, especially sitting down or using the bathroom. A few things genuinely help:

• Sitz baths: shallow, warm (not hot) baths a few times a day can soothe the area and support healing. Ask your midwife how often is right for you.
• Keeping the area clean and dry: pat rather than rub after washing or using the toilet, and change sanitary pads regularly.
• A high fibre diet and plenty of water: constipation puts strain on stitches, so this is one of the most practical things you can do for yourself in the first weeks.
• Pelvic floor (Kegel) exercises: gentle pelvic floor work, once you feel ready, supports healing and helps restore strength. Ask your midwife or physiotherapist when it’s safe to start.
• Ice packs: wrapped in a cloth, not applied directly to skin, for short periods can reduce swelling in the first day or two.

Paracetamol or ibuprofen (if you’re able to take it and your doctor has given the go ahead) can help with pain, and a squeeze bottle of warm water used while urinating can ease stinging. Avoid tampons, sex, heavy lifting or any strenuous activity until you’ve had the all clear at your postnatal check, usually around six weeks, and your stitches have fully healed.

CAN YOU LOWER YOUR RISK OF AN EPISIOTOMY OR SEVERE TEARING?

There’s no guarantee, since so much depends on how labour actually unfolds. But there are a few things research and clinical experience suggest can help:

• Perineal massage: practised regularly in the last weeks of pregnancy, this can improve the stretchiness of the perineal tissue and has been linked to a reduced chance of tearing or needing an episiotomy for first time mothers. See our step by step guide on how to do a perineal massage safely.
• Pelvic floor exercises: beyond general strength, these help you learn to consciously relax the muscles, which is genuinely useful during the pushing stage.
• Warm water immersion during labour: some midwives find that labouring, or giving birth, in warm water helps the perineum relax and stretch more gradually.
• Upright or side lying birthing positions: positions like kneeling, side lying or being upright can sometimes reduce pressure on the perineum compared to lying flat on your back, though squatting itself doesn’t suit everyone and isn’t automatically better. Talk it through with your midwife rather than committing to one position in advance.
• Slow, guided pushing: letting contractions do more of the work and pushing gently as your midwife guides you, rather than forceful pushing on command, is thought to give tissue more time to stretch.
• Choosing a care provider you trust on this: talk to your midwife or obstetrician early about your preferences around episiotomy, and ask how they support women in avoiding one where it’s safe to do so. A good provider will listen to this without dismissing it, while still being honest that sometimes it becomes necessary for the baby’s safety.

TRUSTING YOUR BODY, WHILE STAYING REALISTIC

Your body is genuinely capable of extraordinary things during birth, and it’s worth learning what to expect during the pushing stage so you feel less caught off guard on the day. Read up on positions, breathing and pushing techniques, and talk to your midwife about what’s realistic for your particular pregnancy and birth plan.

At the same time, it helps to hold that knowledge loosely. Most episiotomies today happen because they’re needed in the moment, not because anyone failed to prepare properly. If you do end up needing one, it doesn’t mean anything went wrong with your birth. It simply means your care team made a call to keep you and your baby safe. Ask questions, follow the aftercare advice you’re given, and don’t hesitate to contact your midwife, GP or maternity unit if healing doesn’t feel right. Looking after your own recovery is just as much a part of caring for your baby as anything else in those early weeks.