An episiotomy is a surgical cut made in the tissue between the vagina and anus (called the perineum) during childbirth to widen the vaginal opening. Once performed routinely in the United States, episiotomy rates have dropped sharply over the past two decades. Both the American College of Obstetricians and Gynecologists (ACOG) and the World Health Organization now recommend against routine use, favoring a selective approach based on specific circumstances during delivery.
Why Episiotomy Rates Have Dropped
For most of the 20th century, doctors performed episiotomies on the majority of women giving birth vaginally, believing the clean surgical cut would heal better than a natural tear. That thinking changed in 2006, when ACOG issued a formal recommendation against routine episiotomy, citing adverse effects including perineal pain, painful sex, and sexual dysfunction. The evidence simply didn’t support the idea that a planned incision was better than letting the body tear naturally, which often results in smaller, more superficial injuries.
The shift has been dramatic. In France, where detailed national surveys track the procedure, episiotomy rates fell from about 26% of vaginal births in 2010 to just 8% in 2021. Similar declines have occurred across the U.S. and other high-income countries. Today, no definitive list of required indications exists. Instead, clinicians make case-by-case decisions during labor.
When It May Still Be Performed
Current guidelines recommend what’s called “restrictive” episiotomy, meaning the procedure is reserved for situations where the clinical picture calls for it rather than done as a default. The most common scenarios include concerning changes in the baby’s heart rate that suggest the baby needs to be delivered quickly, and assisted vaginal births using vacuum or forceps. First-time mothers undergoing assisted delivery are the group most likely to receive one.
That said, ACOG has been clear that no absolute indications have been established. The decision comes down to the delivering clinician’s judgment in the moment, weighing the baby’s condition, the mother’s anatomy, and how the delivery is progressing.
Two Types of Incision
There are two main approaches. A midline episiotomy cuts straight down from the vaginal opening toward the anus. A mediolateral episiotomy angles off to one side, typically at about 45 to 60 degrees.
Midline incisions tend to bleed less because the cut stays within the area where perineal muscles from both sides connect. However, they carry a significantly higher risk of extending into a severe tear. In one study comparing the two, deep tears (reaching into or through the anal sphincter) occurred in about 15% of midline episiotomies versus 7% of mediolateral ones. For this reason, mediolateral episiotomy is generally preferred in many countries, particularly when forceps are being used or the risk of a severe tear is already elevated.
Risks and Complications
The primary concern with episiotomy is that the incision can extend further than intended during delivery, turning into a third- or fourth-degree tear that reaches the muscle or lining of the anal sphincter. Research from a hospital following a restrictive episiotomy policy found that third-degree tears occurred in 3.3% of women who received an episiotomy compared to 0.8% of those who did not, a roughly fourfold increase in risk. Risk factors for severe tearing include the use of forceps, a baby weighing over about 7.7 pounds, the mother being shorter than about 4 feet 9 inches, and it being a first delivery.
Short-term complications include perineal pain, bleeding, and infection. Painful intercourse in the weeks and months after delivery is also more common with episiotomy than with spontaneous tears.
One reassuring finding: large studies looking at long-term pelvic floor health have found no significant association between episiotomy and lasting pelvic floor disorders. Rates of stress urinary incontinence, overactive bladder, anal incontinence, and pelvic organ prolapse were similar whether women had no episiotomies, one, or multiple across different deliveries.
How Repair Works
After delivery of the baby and placenta, the incision is stitched closed in layers. The vaginal lining, perineal muscles, and skin are each repaired, typically using absorbable synthetic sutures that your body breaks down on its own. You won’t need to have stitches removed.
Evidence favors a continuous, non-locking suture technique over the older method of placing individual interrupted stitches, because it results in less postpartum pain. Some clinicians use a two-stage approach where the vaginal lining and muscle are sutured but the outermost skin layer is left to close on its own. This technique is associated with less pain and less painful sex in the first three months after delivery.
Recovery and Aftercare
Most women heal without complications, though full recovery takes several weeks. You can return to light activities like housework or office work when you feel ready, but the general recommendation is to wait six weeks before using tampons, having sex, or doing anything that could stress the stitches.
For pain relief and healing in those early weeks, several approaches help. Cold packs applied to the perineum reduce swelling and numb the area. Sitz baths, where you sit in a few inches of warm water, promote healing through moist heat. Kegel exercises (gently squeezing the pelvic floor muscles) improve blood flow to the area and support recovery. Keeping the wound clean and dry is essential. Some research suggests that dry heat, even from something as simple as a hair dryer on a low, warm setting held at a safe distance, may be more effective at reducing episiotomy discomfort than a sitz bath because it penetrates deeper into the tissue without causing moisture buildup.
Pain during sex is common in the first few months after an episiotomy. For most women this resolves gradually, though it can take longer with more extensive repairs. Using a water-based lubricant and waiting until the area feels fully healed before resuming intercourse can make a significant difference in comfort.