Episiotomy Complications and Side Effects

An episiotomy is a surgical incision made in the perineum (the area between the vaginal opening and the anus) during childbirth. While once routine, current guidelines strongly recommend a restrictive approach because episiotomy does not reliably prevent severe tears and can increase certain complications.

Common Complications and Side Effects

Common short- and long-term complications include:

Pain and discomfort: Perineal pain, especially when sitting, walking, or having sex (dyspareunia), which can last weeks to months.

Infection: Redness, swelling, pus, fever, or foul odor at the incision site.

Wound problems: Wound dehiscence (the incision reopening), hematoma (blood collection), or poor healing.

Severe tears: Midline episiotomy increases the risk of third- and fourth-degree tears (extending into the anal sphincter and rectal lining), which can lead to fecal and flatus incontinence.

Long-term pelvic floor issues: Increased risk of anal incontinence, pelvic organ prolapse, and chronic pelvic pain, especially after severe tears.

When to Seek Care

Seek prompt medical evaluation if there is:

• Increasing or severe perineal pain, especially with fever or chills
• Signs of infection: redness, swelling, pus, foul odor, or fever
• Wound separation, gaping, or bleeding from the incision
• Inability to control gas or stool (suggesting anal sphincter injury)

When It May Be Malpractice

An episiotomy may support a medical malpractice claim if:

• It was performed without a valid clinical indication (e.g., no fetal distress, no operative delivery, no clear risk of severe tear)
• It was done without proper informed consent, especially if the patient had clearly refused or the risks were not explained
• The technique was improper (e.g., midline episiotomy in high-risk situations, excessive force, poor repair) leading to a severe tear or other injury
• Complications (infection, dehiscence, severe tear) were not recognized or treated in a timely way

What Is an Episiotomy

An episiotomy is a surgical incision made in the perineum at the end of the second stage of labor to enlarge the vaginal opening and facilitate delivery. It is not a spontaneous tear, but a deliberate cut made by the obstetrician or midwife.

The use of episiotomy in the US has dropped significantly over the last century (from 63% in 1979 down to 12% in 2021). Still, the usage rate of this procedure varies from hospital to hospital, ranging from less than 1% up to 40%. This suggests that some doctors prefer to do the procedure even when unnecessary.

The two main types are:

Midline (median) episiotomy: A straight cut downward from the posterior fourchette toward the anus, commonly used in the U.S., but associated with higher risk of extension into the anal sphincter.

Mediolateral episiotomy: A diagonal cut from the posterior fourchette toward the ischial tuberosity, more common in Europe and associated with lower risk of anal sphincter injury in some studies, though it may cause more perineal pain and dyspareunia.

Current guidelines from the American College of Obstetricians and Gynecologists (ACOG) and World Health Organization (WHO) note that there are no specific situations in which episiotomy is absolutely essential. Instead, the decision should be based on clinical judgment and a restrictive approach is recommended over routine use. If your OB-GYN insisted on an unnecessary procedure, or did so without properly informing you of the risks and potential side effects, you may have a malpractice case against them.

Why Is an Episiotomy Performed

Episiotomy is considered when clinical factors suggest that a controlled incision may be safer than an uncontrolled tear. While experts once believed that episiotomy offers a better trajectory than natural tearing, various studies have since disputed this belief. Doctors exercise great caution in balancing out potential courses of action, because preventing birth injuries should also not come at the expense of the mother's health.

In the following scenarios, doctors and midwives may opt to do the procedure as a means to address any severe distress the mother or child may be experiencing, or to mitigate any further injuries a mother may contract:

Operative vaginal delivery: Forceps or vacuum extraction, especially in first-time mothers, where a mediolateral episiotomy may reduce the risk of obstetric anal sphincter injuries (OASIS).

Nonreassuring fetal status: When expedited delivery is needed due to fetal heart rate abnormalities.

Shoulder dystocia: Some guidelines suggest episiotomy may provide more room for maneuvers, though evidence of benefit is limited and it may increase the risk of severe tears.

Large baby or difficult delivery: When there is concern that the perineum will tear severely if not cut, or in cases of cephalopelvic disproportion.

Breech presentation: To facilitate a smoother delivery in some breech cases.

Prolonged second stage: To expedite delivery when pushing has been ineffective.

Premature birth: To reduce pressure on the baby's head during delivery.

Maternal exhaustion: To shorten the pushing stage when the mother is extremely fatigued.

Previous scarring: In cases where previous scarring might lead to more severe tearing.

However, ACOG and WHO emphasize that routine episiotomy for "prophylaxis" is not supported by evidence and should be avoided. It should only be used selectively based on individual clinical circumstances.

How Is an Episiotomy Done

An episiotomy is performed at the end of the second stage of labor, just before the baby's head is about to crown.

Typical steps include:

Positioning: The patient is usually in the lithotomy or semi-reclining position, with adequate lighting and exposure.

Anesthesia: Local anesthetic is injected into the perineum to numb the area, unless the patient already has an epidural. With proper anesthesia, mothers shouldn't feel pain during the procedure. They may still feel pressure or tugging sensations, of course.

Incision: Using sterile scissors, the provider makes a controlled cut:

• Midline: straight down from the posterior fourchette, usually 2-3 cm long
• Mediolateral: angled laterally at about 60 degrees from the midline toward the ischial tuberosity

Delivery: The baby is delivered through the enlarged opening.

Repair: After delivery of the placenta, the incision is repaired in layers (vaginal mucosa, perineal muscles, subcutaneous tissue, and skin) using absorbable sutures.

ACOG recommends that repair be done by a trained provider with good visualization, adequate analgesia, and proper technique to minimize complications.

What Are the Risks of Episiotomy

Despite its potentially life-saving upsides, episiotomy carries both short-term and long-term risks, many of which are similar to or worse than those of spontaneous tears.

Short-Term Risks

Increased perineal trauma: The incision may extend into a third- or fourth-degree tear, especially with midline episiotomy combined with forceps.

More blood loss and hematoma: Compared with no episiotomy, episiotomy is associated with greater blood loss and higher risk of perineal hematoma.

Pain and discomfort: More intense and prolonged perineal pain, especially with sitting, walking, and urination. Pain is natural as the anesthetic wears off post-procedure.

Infection and wound complications: Risk of wound infection, dehiscence (reopening), and delayed healing.

Urinary retention: Difficulty urinating due to pain or swelling.

Perineal edema: Swelling in the perineal area.

Difficulty with bowel movements: Due to pain or fear of tearing.

Temporary loss of perineal muscle strength: Affecting the pelvic floor muscles.

Long-Term Risks

Anal incontinence: Women with episiotomy, especially those with OASIS, have higher rates of fecal and flatus incontinence compared with those without episiotomy or with intact perineum.

Dyspareunia and sexual dysfunction: Increased risk of pain with intercourse and reduced sexual satisfaction, particularly after mediolateral episiotomy. This can also include decreased libido.

Pelvic floor dysfunction: Higher risk of pelvic organ prolapse and urinary incontinence, especially after multiple vaginal deliveries with perineal trauma.

Rectovaginal fistula: Rare but potentially life-threatening complication.

Chronic perineal pain: Persistent pain that can interfere with daily activities.

Altered sensation: Changes in feeling in the perineal area.

Psychological stress: Emotional impact from the procedure and its aftermath.

Scarring: Poorly healed wounds can lead to painful scars.

Increased risk in future deliveries: This procedure also increases the risk of episiotomy and perineal trauma in future deliveries.

Mothers (and their partners) may also take some time to recover from this procedure. Even after leaving the hospital, mothers who underwent this procedure would require special physical and emotional care.

Signs Your Episiotomy Is Not Healing Properly

Even with good care, some episiotomies do not heal as expected. Recognizing warning signs early can prevent serious complications.

Infection Symptoms

Signs of infection at the episiotomy site include:

• Redness, warmth, and swelling around the incision
• Pus or foul-smelling discharge from the wound
• Increasing pain, throbbing, or burning, especially with urination
• Fever (temperature of 100.4°F or 38°C or higher) or chills

Wound Separation and Severe Pain

Warning signs of wound dehiscence or poor healing include:

• The incision opening up, with visible gaps or broken stitches
• New or worsening bleeding from the perineum
• Severe, sharp, or tearing pain that does not improve with pain medication
• Inability to control gas or stool, which may indicate an undiagnosed third- or fourth-degree tear

When to Seek Urgent Medical Care

Seek urgent evaluation if any of the following occur:

• Fever, chills, or signs of systemic infection
• Heavy bleeding (soaking more than one pad per hour) or large clots
• Wound that is gaping, draining pus, or clearly separating
• New or worsening inability to control gas or stool
• Severe pain that is not relieved by prescribed pain medication

Prompt treatment (antibiotics, wound care, or surgical revision) can prevent chronic problems like fistula, chronic pain, or permanent incontinence.

How Can Episiotomy Be Avoided

Several medical strategies could help mothers prepare for the delivery. While good nutrition and proper exercise is a good starting point, mothers can take extra measures to prepare themselves for delivery.

When looking to avoid episiotomy, your doctor may do/recommend the following:

Recommend perineal massages: Regular massage during late pregnancy increases tissue elasticity.

Recommend Kegel exercises: This strengthens pelvic floor muscles before and during pregnancy.

Patient counseling and education: Understanding the process can help mothers work with their bodies.

Warm compresses: Applied to the perineum during labor to increase flexibility.

Upright or side-lying positions: These can reduce perineal pressure during delivery.

Skilled midwifery support: Hands-on techniques to support the perineum.

Controlled pushing: Slow, guided pushing during delivery to allow gradual stretching.

Avoiding unnecessary interventions: Induction or forceps when not medically necessary.

For expecting pregnant mothers, we suggest that you discuss your options and preferences with your doctor to avoid any adverse incidents during pregnancy.

When Episiotomy Complications May Be Medical Negligence

Complications from an episiotomy may rise to medical negligence (malpractice) if the care fell below the accepted standard and caused harm.

Common scenarios that may support a claim include:

Unnecessary episiotomy: Performing an episiotomy without a valid clinical indication (e.g., no fetal distress, no operative delivery, no clear risk of severe tear) when a restrictive approach was appropriate.

Failure to obtain informed consent: Not adequately explaining the risks, benefits, and alternatives of episiotomy, or performing it over the patient's clear refusal. Doctors should properly inform and get consent from their patients before doing this procedure. Even in emergency situations, verbal consent (if time allows for a brief explanation of this procedure's goals and risks) is preferred over implied consent.

Improper technique: Using a midline episiotomy in a high-risk situation where it substantially increases the risk of OASIS, or using excessive force during delivery. Doctors and midwives must use their best judgment to ensure that the laceration is necessary, minimal, and effective.

Failure to recognize or repair severe tears: Missing a third- or fourth-degree tear at the time of delivery or repairing it inadequately, leading to incontinence or chronic pain.

Failure to monitor and treat complications: Not recognizing signs of infection, dehiscence, or hematoma and failing to intervene promptly. Doctors should always provide counseling and proper post-procedure care instructions to their patients.

To establish malpractice, it must be shown that the provider's actions (or inactions) were below the standard of care in obstetrics and directly caused the injury. Any complications that may arise due to substandard execution of this procedure constitute medical malpractice. Failing to fulfill these responsibilities could potentially warrant a medical malpractice claim against negligent healthcare providers.

What to Do If You Suspect Negligent Care

If you believe an episiotomy was performed negligently and caused serious harm, consider the following steps:

Seek medical care: Continue follow-up with an OB/GYN, urogynecologist, or pelvic floor specialist to document and treat ongoing problems (incontinence, pain, wound issues).

Preserve records: Obtain and keep copies of:

• Prenatal and labor records
• Delivery notes, including the episiotomy description and repair
• Postpartum notes, imaging (e.g., endoanal ultrasound), and specialist evaluations

Consult a medical malpractice attorney: An experienced attorney can:

• Review the medical records to determine if the standard of care was breached
• Identify whether the complications were foreseeable and preventable
• Advise on deadlines (statute of limitations) and whether a claim is viable

There are strict time limits for filing a medical malpractice claim, so early consultation is important.

FAQ

When Is an Episiotomy Necessary?

There is no single situation where episiotomy is absolutely required, but it may be considered when clinical judgment indicates that a controlled incision is safer than an uncontrolled tear. Common scenarios include:

• Operative vaginal delivery (forceps or vacuum), especially in first-time mothers
• Nonreassuring fetal heart tones requiring expedited delivery
• Shoulder dystocia or other difficult deliveries where more space is needed
• Known risk factors for severe perineal trauma (e.g., large baby, occiput posterior position)

ACOG and WHO recommend a restrictive approach: episiotomy should be used selectively, not routinely, and only when there is a clear clinical benefit.

Is It Better to Tear or Have an Episiotomy?

For most women, a spontaneous tear is preferable to a routine episiotomy. Evidence shows that:

• Restrictive episiotomy (only when clearly indicated) is associated with less severe perineal trauma, fewer healing complications, and lower rates of anal incontinence than routine episiotomy
• Midline episiotomy increases the risk of third- and fourth-degree tears compared with no episiotomy
• Mediolateral episiotomy may reduce OASIS in some settings but is associated with more perineal pain and dyspareunia

The goal is to avoid both severe tears and unnecessary surgical cuts. Techniques like warm compresses, perineal support, and delayed pushing can help reduce trauma without routine episiotomy.

Can You Refuse an Episiotomy?

Yes, a patient has the right to refuse an episiotomy, except in a true emergency where immediate action is needed to save life or prevent serious harm. Key points:

• Episiotomy requires informed consent; the provider must explain the reason, risks, benefits, and alternatives
• A patient can state a preference against episiotomy in a birth plan and withdraw consent at any time
• In non-emergency situations, performing an episiotomy over a patient's refusal may constitute battery or negligence

If an episiotomy is done without proper consent, that can be a basis for a malpractice claim.

How Long Does It Take to Heal After an Episiotomy?

Healing time varies, but most women notice improvement within a few weeks:

• Initial pain and discomfort usually peak in the first few days and gradually improve over 2-4 weeks
• Most sutures are absorbable and dissolve on their own over several weeks
• Full healing of the perineum and return to normal sensation may take 6-12 weeks or longer, especially if there was a severe tear or complications like infection

Persistent pain, dyspareunia, or incontinence beyond a few months should be evaluated by a specialist.

What Are Long Term Complications of an Episiotomy?

Long-term complications are more common after severe tears (third- and fourth-degree) but can occur even with a simple episiotomy. They include:

• Anal incontinence: Difficulty controlling gas or stool, especially after OASIS
• Dyspareunia and sexual dysfunction: Pain with intercourse and reduced sexual satisfaction
• Pelvic organ prolapse: Increased risk of bladder, uterus, or rectal prolapse, particularly after multiple vaginal deliveries with perineal trauma
• Chronic pelvic pain: Persistent perineal or pelvic pain that interferes with daily activities
• Scarring and fistula: Poorly healed wounds can lead to painful scars or abnormal connections (fistulas) between the vagina and rectum

Women with ongoing symptoms should be referred to a urogynecologist or pelvic floor specialist for evaluation and management.

Speak to a Medical Malpractice Attorney Today

At the Porter Law Group, our team of proven medical malpractice lawyers delivers ideal results. We take pride in helping families rebuild after unfavorable circumstances. We operate on a contingency basis, meaning you do not need to pay us anything unless we win your case. Through this approach, we can better support families during their times of need.

If you or a loved one has been a victim of medical malpractice, please reach out to us for a non-obligatory free case evaluation. You can also contact us at 833-PORTER9 or info@porterlawteam.com to schedule a consultation.