What an episiotomy is

The NHS defines it as a cut "in the area between the vagina and anus (perineum) during childbirth" which "makes the opening of the vagina a bit wider, allowing the baby to come through it more easily." In some births, it adds, "an episiotomy can help to prevent a severe tear or speed up delivery if the baby needs to be born quickly."

The first thing to know is that it is not standard practice. The NHS states: "In England, episiotomies are not done routinely." NICE says the same thing as an instruction to clinicians: "Do not carry out a routine episiotomy during spontaneous vaginal birth."

When one is indicated

NICE's positive recommendation is narrow: "Perform an episiotomy if there is a clinical need, such as birth with forceps or ventouse or suspected fetal compromise."

The NHS lists the same triggers in patient language — an episiotomy might be done if the baby is in distress and needs to be born quickly, if forceps or ventouse are needed, or if there is a risk of a tear to the anus. It expands on the second: widening the vagina may be necessary so instruments can be used, which may apply if you are having a breech birth, if you have been pushing for several hours and are tired, or if you have a serious health condition such as heart disease that makes a quick birth safer.

The HSE describes fetal distress as the main reason, and notes an episiotomy may be needed to allow instruments to be used.

The two things NICE tells teams not to do

Both concern women who have had a severe tear before. NICE says: "Do not offer episiotomy routinely at vaginal birth after previous third- or fourth-degree trauma." And it asks that women with a history of severe perineal trauma be informed "that her risk of repeat severe perineal trauma is not increased in a subsequent birth, compared with women having their first baby."

If you have had a third- or fourth-degree tear, NICE expects a proper conversation about mode of birth covering current urgency or incontinence symptoms, the degree of previous trauma, the risk of recurrence, how well the repair worked, the psychological effect, and how your labour would be managed.

How it is done

The procedure has three parts, as the HSE sets them out: pain relief, the incision, and the repair.

Pain relief first

NICE is explicit: "Provide tested, effective analgesia before carrying out an episiotomy, except in an emergency because of acute fetal compromise." The NHS describes a local anaesthetic used "to numb the area around the vagina so you do not feel any pain", and notes that if you already have an epidural, "the dose can be topped up before the cut is made." The HSE says the same. If you already have working regional anaesthesia, that counts.

The cut

This is one of the few places where a guideline specifies geometry, and it is worth quoting in full. NICE: "If an episiotomy is performed, the recommended technique is a mediolateral episiotomy originating at the vaginal fourchette and usually directed to the right side. The angle to the vertical axis should be between 45 and 60 degrees at the time of the episiotomy."

In plain terms: a diagonal cut, angled away from the anus, not straight down. The NHS describes the same thing without the numbers — "a small diagonal cut from the back of the vagina, directed down and out to one side" — as does the HSE.

The angle matters because a mediolateral cut is what keeps the incision away from the anal sphincter. A midline cut heads straight for it.

The repair

The cut is stitched with dissolvable stitches, so there is nothing to have removed. The NHS says episiotomy cuts "are usually repaired within an hour of your baby's birth", and that the cut "may bleed quite a lot at first, but this should stop with pressure and stitches." The HSE gives the same one-hour figure.

You do not have to hand over your baby for this. The NHS notes that if you need stitches, "you should be able to carry on cuddling your baby while this is being done." UNICEF UK's Baby Friendly guidance agrees that many mothers can stay in skin-to-skin contact during perineal suturing "providing they have adequate pain relief", with the caveat that a mother in pain may not be able to hold her baby safely, and that babies should not be in skin-to-skin contact while she is receiving Entonox or other analgesics that affect consciousness.

Episiotomy and assisted birth

These two go together more often than not. The NHS says of forceps and ventouse births that "it is likely a cut (episiotomy) will be needed to make the vaginal opening bigger." RCOG says birth with either instrument "does mean a higher chance of you needing to have an episiotomy or having a vaginal tear."

The NHS also notes the rationale: "Research shows that in some births, particularly with forceps deliveries, an episiotomy may prevent tears that affect the anal muscle (third-degree tears)."

How often it happens

Rates vary sharply by setting. NICE's tables of planned place of birth give episiotomy rates per 1,000 low-risk women: for a first baby, 165 planning a freestanding midwifery unit, 216 alongside and 242 in an obstetric unit; for a later baby, 23, 35 and 56 respectively.

The NHS gives the broader context on perineal trauma of any kind: "Up to 9 in 10 first-time mothers who have a vaginal birth will have some sort of tear, graze or episiotomy."

What can reduce the chance of needing one

NICE asks teams to "discuss the woman's preferences for techniques to reduce perineal trauma during birth and support her choices", and makes two specific offers for the second stage. Once the baby's head is stretching the perineum, teams should "offer to apply a warm wet compress to the perineum and continue this until birth", checking the temperature is comfortable. Perineal massage with a water-soluble lubricant can be considered instead if you prefer it. Neither applies to births in water.

NICE also tells teams not to offer lidocaine spray to reduce pain in the second stage.

The NHS describes the slow-crowning technique: 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", giving the perineum time to stretch. And on antenatal perineal massage, it says massaging in the last few weeks of pregnancy "can reduce the chances of having an episiotomy during birth", noting that the technique and frequency vary between studies, that most involve inserting one or two fingers into the vagina with downward or sweeping pressure, and that "the most benefit was in women who repeated this every day."

One more thing NICE flags: women with infibulated female genital mutilation should be told about the risks of difficulty with vaginal examination, catheterisation and fetal scalp electrodes, the risks of delay in the second stage and spontaneous laceration, and the possible need for defibulation in labour.

Signs to report afterwards

The NHS asks you to contact your midwife or GP if your stitches get more painful, there is smelly discharge, or the skin around the cut or tear is red and swollen — any of which may mean an infection.

Episiotomy