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For many years, doctors delivering babies routinely performed episiotomies. Nowadays, this procedure — an intentional, small cut made in a woman’s perineum — is not regularly done during childbirth.

But there are still times when an episiotomy is necessary. Here’s what you need to know about episiotomies and why they are sometimes still done.

What Is an Episiotomy?

An episiotomy is a minor surgery during childbirth. The doctor cuts the perineum — the skin and muscles between the vaginal opening and the anus. The idea is that the cut widens the vaginal opening, allowing the baby’s head through.

The idea of episiotomy is that it may help avoid serious perineum tears during delivery. It was also thought to allow for an easier delivery of the baby.

Doctors would make one of two types of cuts for an episiotomy:

• Medial. A vertical cut at the vaginal opening, going toward the anus. It heals faster but is more likely to tear through to the anus, causing more damage during delivery.
• Mediolateral. An incision at an angle. It takes longer to heal than a median cut but is less likely to tear into the anus.

When doctors make an episiotomy cut, they either numb the area around the perineum or rely on your epidural for pain control.

Changing Attitudes Toward Episiotomies

Episiotomies became increasingly popular during the 20^th century. In the late 1970s, more than 60% of vaginal births involved an episiotomy, according to an Obstetrical & Gynecological Survey study. Doctors thought healing from an episiotomy, a straight cut, was safer than recovering from a ragged tear.

There were no studies to back up such claims, however. In 2006, the American College of Obstetricians and Gynecologists recommended against routine episiotomies. They currently recommend episiotomies only when absolutely necessary.

What Are the Risks of Episiotomies?

Risks of episiotomies include:

• The cut could tear, become larger during delivery, and even reach the rectum or muscles of the pelvis.
• Infection around the cut and stitches.
• Injury to the anal area.
• Longer recovery from childbirth.
• Loss of blood.
• Painful sex in the months after birth.
• Urinary incontinence after childbirth.

Tearing Vs. Episiotomy

The skin of the vagina and vulva have an amazing ability to stretch during childbirth. But sometimes, the baby’s head is simply too big.

If the skin doesn’t stretch enough, a tear might happen. This might happen if labor comes on quickly before the tissue has had a chance to thin. Tearing can also happen in births where doctors use forceps or vacuums to deliver the baby.

While a vaginal tear sounds horrible, tearing is common — it happens in about 80% of first-time vaginal deliveries. That’s according to a study in BMC Pregnancy and Childbirth. Many of these are low-grade tears that usually heal quickly without lasting complications.

But an episiotomy incision is usually deeper than a natural tear. This also means that episiotomies don’t heal better than tears. They often take longer to heal.

Why Would Someone Need an Episiotomy?

Although doctors today try to avoid unnecessary episiotomies, they are sometimes needed during childbirth. And usually, the decision needs to happen quickly. Here are some reasons your doctor may do an episiotomy.

• The baby is breech, with its feet and buttocks coming out first. A breech baby may get stuck in the birth canal.
• The baby is in distress. If the baby’s heart rate is too slow or fast, your doctor may need to deliver the baby quickly. In that case, performing an episiotomy may help.
• The baby’s head or shoulders are too big for the vaginal opening.
• You have another health condition. If you have a serious problem such as heart disease, your doctor may need to shorten labor and delivery.
• You’ve been pushing for hours and are too exhausted to keep going.

Caring for an Episiotomy or Tear

A doctor will stitch up your tear or episiotomy within an hour after you give birth. If you have an epidural, you may not even notice.

You’ll need to care for a tear or an episiotomy in the days and weeks after giving birth. Expect some pain and soreness on top of the existing swelling and pain you’re feeling. You don’t need to remove your stitches — they will dissolve on their own.

During recovery, your doctor may suggest that you:

• Apply ice packs, especially right after the birth. Ice packs on the perineum in the first 24 hours after delivery will decrease swelling and ease pain.
• Change sanitary pads every few hours.
• Don’t have sex or use tampons for at least six weeks following a tear or episiotomy.
• Drink lots of water to keep hydrated and prevent constipation. Likewise, eat high-fiber foods or take stool softeners. Doing so will help bowel movements pass easily and feel less painful.
• Keep the perineum clean and dry. Use a spray bottle to clean the area after using the bathroom. Pat (don’t rub) it dry with a clean towel after washing.
• Take ibuprofen for pain relief. It’s safe to take if you are breastfeeding.
• Take sitz baths, which are shallow baths to soak and soothe the perineum. You can use a few inches of water in a regular bathtub. Or, you can buy a sitz bath that fits onto the rim of the toilet.

When You Should Call the Doctor: Episiotomy Complications

Most people heal from an episiotomy or vaginal tearing in about a month. You should expect some discomfort as you heal. However, you should call your doctor if:

• The skin around the stitches looks red and swollen.
• The wound feels like it’s broken open.
• You go four or more days without a bowel movement.
• You have a foul-smelling discharge.
• Your pain gets worse.
• You pass a blood clot bigger than a walnut.

How to Prevent Tearing or an Episiotomy

You can’t always prevent vaginal tearing during delivery. And if your baby is in distress, your doctor may quickly decide to perform an episiotomy. But there are some steps you can take during your pregnancy to lessen the chances of a tear or cut.

• Massage the perineum with oil during your pregnancy, especially in the last four to six weeks before your due date.
• Practice Kegel exercises to strengthen the pelvic floor and aid in pushing.
• Ask your doctor how often they do episiotomies. Make it clear to them and in your birth plan if you would like to avoid it if possible.
• Work breathing and stress relief techniques from childbirth class. These can help you control your breathing and the urge to push once you’re in labor.
• If medically appropriate, try “laboring down,” — a method to give your vaginal tissues and perineum time to stretch. Delaying pushing once intense contractions begin can let your body prepare to deliver the baby. This may reduce tearing.
• Adjust your pushing position. Avoid laying flat on your back and try side-laying or hands-and-feet. These positions may pull less on the perineum, opening the vaginal outlet.
• The use of warm compresses on the perineum during labor has been shown to decrease tears.

These steps won’t guarantee that you won’t tear or need an episiotomy. But they will give you the best odds of avoiding either.