During vaginal delivery, birthing people are at risk for perineal tears. If the muscles and skin of the perineum — that fleshy area below the vaginal opening — aren’t prepared with the elasticity to stretch and accommodate the infant as they enter the world, the perineum can tear, causing pain in the moment and for weeks to come.
In an effort to make giving birth a more comfortable experience, obstetricians will perform an episiotomy, in which they surgically cut into the perineum in order to encourage the birthing process and allow for the assistance of surgical instruments. [2]
Whether the perineum tears on its own or an episiotomy is performed, the area is stitched up after the completion of delivery. However, surgery of any kind comes with its own risks and episiotomies are no exception.
When an episiotomy is performed during childbirth, it can cause complications after the fact. Patients are at risk for postpartum bleeding and difficulty caring for a newborn due to pain while sitting, walking, and nursing. [1] This in turn can affect the new parent’s emotional wellbeing, as caring for a newborn comes with a healthy level of stress. Feelings of being unable to care for their baby can leave a mother feeling distressed, further prolonging physical healing. [1]
Because an episiotomy is a surgical incision, the procedure comes with risk especially pertaining to infection and proper healing. Patients who undergo an episiotomy during childbirth are also at risk for OASIs: obstetric anal sphincter injuries, also known as 3rd and 4th degree tears. In these instances, the tissue tears from the vagina to the rectum and in some cases the mucous membrane lining of the rectum and can lead to fecal incontinence. [1]
With that being said, the best course of action for women who are expecting is to attempt to avoid perineal tears altogether, whether they happen naturally or surgically.
Episiotomy Prevention
An effective way to avoid an episiotomy is to prepare the pelvic muscles and perineum for childbirth. To do this, we recommend patients begin meeting with a pelvic floor physical therapist around the 28-week mark of their pregnancy. One of the best defenses against episiotomies and perineal tears is to perform a perineal massage on the area. Your physical therapist can do this during the treatment session as well as teach you how to do it at home between visits.
Studies have shown that perineal massage greatly reduces the need for episiotomies and can even encourage a faster birthing experience throughout the second stage of labor. [1] The massage is a simple practice anyone can do and it is recommended that in addition to preparatory measures, perineal massage and warm compresses are used during the crowning stage of labor to help the area stretch without tearing. [3]
In addition to digital massage of the area, pelvic PTs are able to assess the pelvic floor muscles and pelvic alignment and provide guidance and exercises that help prepare patients for childbirth, giving them the greatest chance at having a natural birth with minimal anatomical damage. [1]
In most cases, pelvic floor and perineal preparation will reduce or eradicate the need for an episiotomy and/or the extent of perineal tears, however, in certain cases such as fetal distress or other unavoidable birth complications, an episiotomy will be deemed medically necessary. In these circumstances, pelvic floor physical therapy is equally as important in guiding your postpartum care and recovery, which are of the utmost importance. [3]
Episiotomy Care & Recovery
If an episiotomy is necessary, proper action must be taken to support the healing process and minimize the chances of complications. There are three stages of healing after an episiotomy, and care techniques adapt and adjust for each stage.
Stage 1: Episiotomy Healing
The first stage of episiotomy healing is the acute phase 24-72 hours after the incision is made and stitched. Also known as the inflammatory/coagulation stage, this is a time to support perineal muscle tone and proper drainage of the area. [5]
Practitioners perform a technique known as deep fascial massage during this stage to facilitate tone and drainage, and treatment is based on the individual presentation of the pelvic tissue. And remember, this is a healing surgical site so traditional wound care is a must. [5]
Only cotton panty liners and pads should be used while healing, as other textured pads can aggravate the wound. [5]
Stage 2: Healing An Episiotomy
Stage 2 of episiotomy healing lasts anywhere from day 4 to day 21 after the surgery is performed. Also known as the proliferation stage, this is the time when the body builds new barriers between the wounds and the external environment, a process known as re-epithelization. Following this process, the extracellular matrix develops — a protein-based scaffolding the body creates to support cells — which leads to the formation of scar tissue. [5]
Physical exercise during this phase of episiotomy recovery is crucial to increase blood flow to the area and promote a strong, healthy recovery. [6] An experienced physical therapist will prescribe pelvic floor muscle exercises based on each patients’ individual needs.
It’s recommended that patients kickstart the pelvic floor healing process by doing a round of kegel exercises before delivering the fetal placenta, whether they’ve had an episiotomy or not. [5]
Stage 3: Extended Episiotomy Recovery
The third and final stage of recovery from perineal tears and/or an episiotomy is the remodeling phase, which lasts up to one year postpartum. By the time a patient enters this phase, treatment focused on surgical recovery ceases unless there are unresolved issues from the prior phases. [5]
However, pelvic floor PT is still recommended for all postpartum patients to support healthy pelvic floor muscle function and perineal wellness which most likely needs tending to beyond the 21-day mark. [5]
If episiotomy-related pelvic pain persists in stage 3 during sitting, using the bathroom, and/or sexual intercourse, continued treatment is recommended and can include exercises for both strengthening and relaxing as well as scar mobilization to improve mobility and normal function. [5]
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If at all possible, avoiding an episiotomy is the best chance patients have at avoiding perineal tears in later births and other episiotomy-related tears and pelvic pain. [4] For those expecting, remember to get in touch with a pelvic floor specialist during your second trimester to coordinate your preparatory and postpartum treatment plans.
With a new baby in the mix, it’s difficult to find the time to prioritize your own wellbeing, but assisting your body through the work of childbirth and recovery is going to serve you and your family more fully in the long run.
New Dimensions Physical Therapy is always available to patients in the NYC and Long Island areas. Contact us today to begin your pelvic floor wellness journey.
Akhlaghi, F., Sabeti Baygi, Z., Miri, M., & Najaf Najafi, M. (2019). Effect of Perineal Massage on the Rate of Episiotomy. Journal of family & reproductive health, 13(3), 160–166.
Dieb, A.S., Shoab, A.Y., Nabil, H. et al. Perineal massage and training reduce perineal trauma in pregnant women older than 35 years: a randomized controlled trial. Int Urogynecol J 31, 613–619 (2020). https://doi.org/10.1007/s00192-019-03937-6
Papadakis, K., & Myriknas, S. (n.d.). Standardizing indications for episiotomy: a narrative review of contemporary clinical evidence. Retrieved November 24, 2021, from https://www.csp.org.uk/system/files/documents/2020-01/04_papadakismyriknas.pdf.
CIECHOMSKI, J. A. R. O. S. Ł. A. W., & MALICKI, P. A. W. E. Ł. (2021). Case report: Treatment of episiotomy scars according to the concept of fascial manipulation®. Pelviperineology, 39(1), 27–33. https://doi.org/10.34057/ppj.2020.39.01.006
Thurston, L. A., Stone, J., Mileski, M., Abrams, D., & Huggins, W., 2nd (2018). An interprofessional approach to prevent recurrent obstetric anal sphincter injury (OASIS): A case report. Clinical case reports, 6(12), 2326–2332. https://doi.org/10.1002/ccr3.1834
Suhr, F. (2019). Extracellular matrix, proteases and physical exercise. Deutsche Zeitschrift Für Sportmedizin, 2019(4), 97–104. https://doi.org/10.5960/dzsm.2019.367