What Are the Complications of Episiotomy During Childbirth?

An episiotomy is a surgical incision made in the perineum (the area between the vagina and rectum) during vaginal delivery. For decades, this procedure was performed routinely, but research has revealed significant complications that have changed medical practice. Today, major medical organizations recommend using episiotomy only when medically necessary, not as a routine part of delivery.

Understanding the potential complications helps expectant parents have informed conversations with their healthcare providers about birth plans and interventions.

How Common Are Episiotomy Complications?

Complications from episiotomy affect a substantial number of women. Research shows that when episiotomy was used routinely rather than selectively, long-term complications occurred at notably higher rates. Between 26% and 32% of women experienced urinary incontinence, 6% to 8% dealt with persistent perineal pain, and 18% to 21% reported ongoing sexual dysfunction.

The good news is that episiotomy rates in the United States have dropped dramatically as medical understanding has improved. The procedure declined from 25% of vaginal deliveries in 2004 to less than 5% in recent years, following updated guidelines from the American College of Obstetricians and Gynecologists (ACOG) and international health organizations.

Bleeding and Blood Collection After Episiotomy

Excessive bleeding at the incision site ranks among the most frequent immediate complications. The perineal area has a rich blood supply, and the surgical cut can sometimes lead to more bleeding than expected.

Hematomas, which are collections of blood that pool under the skin, can also develop at the episiotomy site. These swollen, bruised areas cause pain and can significantly extend recovery time. In some cases, hematomas require medical intervention to drain the collected blood and prevent further complications.

Infection Risks at the Episiotomy Site

Like any surgical wound, an episiotomy creates an opening where bacteria can enter. Infection rates at episiotomy sites range from 0.5% to 7% according to CDC surveillance data, with rates varying based on delivery circumstances and wound care practices.

Episiotomy infections can manifest in several ways:

• Redness, warmth, and swelling around the incision
• Increased pain that worsens rather than improves
• Unusual discharge or foul odor from the wound
• Fever or general feeling of illness
• Abscess formation (a pocket of pus that may require drainage)
• Wound dehiscence (separation of the incision edges)

The location of episiotomy wounds makes them particularly vulnerable to infection. The proximity to both vaginal and rectal bacteria, combined with postpartum bleeding and the challenges of keeping the area clean while caring for a newborn, creates conditions where infections can develop.

Pain and Discomfort in the Weeks After Delivery

Perineal pain following episiotomy is nearly universal in the immediate postpartum period, but the intensity and duration vary considerably. Many women report that sitting, walking, and using the bathroom become painful activities.

Up to 30% of women experience significant sitting pain that interferes with daily activities and newborn care. This pain typically peaks in the first week after delivery but can persist for several weeks as the incision heals. The discomfort often makes it difficult to sit while breastfeeding, hold the baby comfortably, or perform basic self-care tasks.

Pain management becomes an important part of postpartum recovery, yet many women feel they must simply endure it as a normal part of childbirth. While some discomfort is expected, severe or worsening pain deserves medical attention.

Problems with Wound Healing and Scarring

The episiotomy wound must heal in a challenging environment. Several factors can interfere with normal healing:

Delayed healing occurs when the incision takes longer than expected to close and repair. This extended timeline leaves the wound vulnerable to infection and increases the duration of pain and limitations.

Wound separation (dehiscence) happens when the stitches don’t hold and the incision edges pull apart. This complication may require resuturing or, in some cases, healing by secondary intention (allowing the wound to heal gradually on its own from the inside out).

Abnormal scarring can develop as the episiotomy heals. Excessive scar tissue may form, creating hardened areas, raised scars, or tissue that pulls and causes ongoing discomfort. Some women develop keloid scars, which extend beyond the original wound area.

Swelling (edema) around the incision is common initially but should gradually resolve. Persistent swelling may indicate infection, hematoma, or healing complications.

Urinary Problems Following Episiotomy

Short-term urinary retention affects some women after episiotomy, particularly when the procedure was part of an instrumental delivery using forceps or vacuum extraction. The combination of perineal trauma, swelling, and pain can make it difficult or impossible to urinate normally.

Urinary tract infections also occur at higher rates following episiotomy. The proximity of the incision to the urethra, combined with the challenges of maintaining hygiene with a painful perineal wound, creates increased infection risk.

Some women experience temporary urinary incontinence (involuntary leaking of urine) in the weeks after delivery. While postpartum incontinence has multiple causes, episiotomy contributes to pelvic floor disruption that can affect bladder control.

Sexual Pain and Dysfunction After Episiotomy

Dyspareunia (painful intercourse) represents one of the most distressing long-term complications of episiotomy. Pain during sex can persist for months or even longer after delivery, affecting intimacy, relationships, and quality of life.

Research shows that up to 40% of women who have had an episiotomy report sexual dissatisfaction and reduced sexual desire. The physical pain combines with psychological factors; fear of pain, anxiety about the scar tissue, and changes in body image, which combine to create complex sexual dysfunction.

The reasons for ongoing sexual pain include:

• Scar tissue that lacks the flexibility of normal tissue
• Nerve damage from the incision or repair
• Psychological association between penetration and pain
• Pelvic floor muscle tension or dysfunction
• Inadequate healing or infection that wasn’t properly resolved

Many women don’t discuss these problems with healthcare providers, either because they feel embarrassed or because they assume sexual difficulties are a normal consequence of childbirth. However, persistent pain during intercourse is not something women should accept as inevitable, and treatments are available.

Pelvic Floor Damage and Incontinence Issues

The pelvic floor is a complex system of muscles, ligaments, and connective tissue that supports the bladder, uterus, and rectum. Episiotomy can damage these structures, leading to long-term dysfunction.

Urinary incontinence persists long-term in a significant percentage of women who underwent episiotomy. Studies show rates of 26% to 32% when episiotomy was used routinely, compared to lower rates with restricted use. Stress incontinence (leaking with coughing, sneezing, or exercise) is the most common type.

Anal incontinence (inability to control gas or stool) is one of the most devastating complications. Rates of 10% to 16% have been documented in the short term, and these problems can persist or worsen over time. Even occasional loss of bowel control significantly impacts daily life, social activities, and emotional wellbeing.

Pelvic organ prolapse occurs when the pelvic organs drop from their normal position, sometimes bulging into the vaginal canal. While multiple factors contribute to prolapse, episiotomy (especially when complicated by infection or extension) increases risk by weakening the support structures.

Extension into the Anal Sphincter and Rectum

One of the most serious complications occurs when the episiotomy extends beyond the intended incision into the anal sphincter or rectum. This is particularly common with midline episiotomies (cuts made straight down toward the rectum).

Large population studies have found that episiotomy increases the risk of severe perineal tearing with an odds ratio greater than 3. In other words, having an episiotomy more than triples the risk of the worst degree of tearing compared to delivering without one.

These extended tears are classified as third-degree (extending into the anal sphincter muscle) or fourth-degree (extending through the sphincter into the rectal lining). The consequences of sphincter injury include:

• Immediate surgical repair requiring specialized techniques
• Extended recovery time with significant activity restrictions
• High rates of fecal incontinence and inability to control gas
• Potential for rectovaginal fistula (abnormal connection between rectum and vagina)
• Increased risk of complications in future deliveries
• Long-term impact on quality of life and daily functioning

This complication occurs more frequently with midline episiotomies than with mediolateral incisions (cuts made at an angle away from the rectum). When episiotomy is truly necessary, mediolateral technique may offer some protection against the most severe extensions, though it comes with its own set of complications.

Chronic Pain That Persists After Healing

Some women continue experiencing perineal pain long after the episiotomy wound has visibly healed. This chronic pain can take several forms:

• Constant aching or burning in the perineal area
• Sharp pains with certain movements or positions
• Pain that increases throughout the day or with activity
• Tenderness where the episiotomy scar tissue has formed
• Nerve pain (neuropathic pain) that may feel like shooting, electric, or stabbing sensations

Chronic pain often results from nerve damage during the incision or repair process. Nerves in the perineal area are small and difficult to visualize during the procedure, making them vulnerable to being cut, compressed, or caught in sutures.

Scar tissue that forms abnormally can also create ongoing pain by:

• Pulling on surrounding tissues
• Restricting normal movement and flexibility
• Creating adhesions (areas where tissues stick together abnormally)
• Entrapping nerve endings

The psychological toll of chronic perineal pain shouldn’t be underestimated. Living with persistent pain in such an intimate area affects self-image, relationships, physical activity, and emotional health.

Increased Risk of Severe Tears in Future Deliveries

Women who have had an episiotomy face three times the risk of severe perineal tears in subsequent births. This statistic is particularly concerning for women planning multiple children.

The scar tissue from the previous episiotomy changes how the perineum responds during future deliveries. Scar tissue is less elastic than normal tissue, doesn’t stretch as well, and tends to tear along the same line as the original incision. Rather than protecting the perineum, the previous episiotomy creates a weak point where more severe damage can occur.

This increased risk affects birth planning for future pregnancies. Women may need to:

• Discuss their episiotomy history with new care providers
• Consider additional perineal support techniques during labor
• Be prepared for potentially longer recovery if tearing occurs
• Understand that episiotomy is not recommended to prevent tears when there’s a history of previous episiotomy

Why Medical Guidelines Now Recommend Against Routine Episiotomy

The shift away from routine episiotomy represents one of the clearest examples of evidence-based medicine changing clinical practice. For many years, episiotomy was performed on the majority of first-time mothers and many experienced mothers, based on the belief that it prevented more severe tears and protected the baby.

Rigorous research has proven these assumptions wrong. Studies comparing routine use (performed on most or all deliveries) to restrictive use (performed only when medically necessary) have consistently shown that routine episiotomy:

• Does not prevent severe perineal tears; it actually increases the risk
• Does not protect babies from birth injuries or improve outcomes
• Causes more complications than spontaneous tears
• Extends recovery time and increases pain
• Leads to higher rates of long-term problems

Current evidence supports that spontaneous tears, when they occur, generally heal better than surgical incisions. Natural tears tend to follow the body’s natural tissue planes and often affect less tissue than an episiotomy.

Medical Situations Where Episiotomy May Still Be Necessary

While routine episiotomy is no longer recommended, specific medical situations may warrant the procedure. These include:

• Fetal distress requiring immediate delivery when the baby needs to be born urgently and the perineum is limiting progress
• Shoulder dystocia when the baby’s shoulder is stuck and additional room is needed for emergency maneuvers
• Breech delivery where precise control of the delivery is critical
• Need for operative vaginal delivery with forceps when space limitations prevent safe application

Even in these situations, the decision should be individualized based on the specific circumstances, and the potential benefits must outweigh the known risks.

Techniques That May Reduce Episiotomy Necessity

Several evidence-based techniques can reduce both the need for episiotomy and the risk of spontaneous tears:

Perineal massage during pregnancy (typically starting around 34-35 weeks) involves gentle stretching of the perineal tissues. Studies show this practice can reduce the likelihood of episiotomy and severe tears, particularly for first-time mothers.

Warm compresses applied to the perineum during the second stage of labor increase blood flow and tissue elasticity, potentially reducing trauma.

Perineal support provided by the healthcare provider during delivery involves gentle counter-pressure and controlled delivery of the baby’s head, allowing tissues to stretch gradually.

Position changes during labor and delivery affect how force is distributed across the perineum. Upright positions and those that reduce pressure on the perineum may lower injury risk.

Controlled pushing techniques that avoid forceful, prolonged pushing efforts allow tissues to stretch more gradually.

Important Differences Between Midline and Mediolateral Episiotomy

The type of episiotomy cut matters significantly for complication rates. Two main techniques exist:

Midline episiotomy involves a straight incision from the vaginal opening toward the rectum. This approach:

• Is easier to repair with cleaner wound edges
• Generally causes less initial pain
• Carries much higher risk of extending into the anal sphincter and rectum
• Is associated with more severe long-term complications
• Has largely fallen out of favor due to extension risk

Mediolateral episiotomy involves an angled cut away from the rectum (typically at a 45-60 degree angle). This technique:

• Reduces the risk of anal sphincter injury
• May cause more initial pain and bleeding
• Creates a more complex wound to repair
• May result in more asymmetric scarring
• Is preferred in settings where episiotomy is deemed necessary

The dramatic difference in sphincter injury risk has led most practitioners to favor mediolateral technique when episiotomy cannot be avoided, despite the potentially more challenging recovery.

What Questions Should You Ask Your Healthcare Provider About Episiotomy?

Having clear conversations with your healthcare team about episiotomy before labor begins helps ensure your preferences are known and respected. Consider asking:

• What is your episiotomy rate or philosophy about using episiotomy?
• Under what specific circumstances would you consider an episiotomy necessary?
• What techniques do you use to reduce the need for episiotomy?
• If episiotomy becomes necessary, which type would you perform and why?
• What alternative approaches might be available in situations where episiotomy is traditionally done?

These conversations also provide an opportunity to discuss your birth plan, your concerns about interventions, and how decisions will be made during labor when things may be moving quickly.

Moving Forward After Understanding These Complications

The substantial body of research on episiotomy complications has fundamentally changed obstetric care. The dramatic reduction in episiotomy rates over the past two decades reflects medicine’s commitment to evidence-based practice and avoiding unnecessary interventions.

For expectant parents, this research provides important information for informed decision-making. Understanding that episiotomy is no longer routine, that it carries significant risks, and that it should only be used when medically necessary helps you advocate effectively for your care. Most deliveries do not require episiotomy, and when tears occur naturally, they typically heal well with proper care and repair.