Episiotomy

Episiotomy (perineal incision) is a surgical incision of the perineal tissues performed during the second stage of labor, intended to widen the vaginal opening and facilitate the birth of the baby. The procedure involves cutting the skin, subcutaneous tissue, and pelvic floor muscles. Modern medicine has moved away from the routine use of episiotomy in favor of a selective approach based on clinical indications. The decision to perform it results from an assessment of the obstetric situation, including fetal well-being and the risk of spontaneous, uncontrolled tearing of the perineal tissues.

Episiotomy - when is it performed

Contemporary guidelines (including WHO and obstetric societies) indicate that episiotomy should be performed only in justified clinical situations. The aim of the procedure is a controlled widening of the birth canal, which may reduce the risk of serious tissue damage or shorten the duration of labor in threatening situations.

The most common indications include:

threat of fetal hypoxia – the need to accelerate delivery,
operative delivery (e.g., using forceps or vacuum extraction),
rigidity or low elasticity of the perineal tissues, increasing the risk of uncontrolled tearing,
delivery of a large-for-gestational-age infant (macrosomia),
preterm delivery, when the delicate tissues of the fetus require reducing the resistance of the birth canal.

There are two main types of incision:

median – runs along the midline of the perineum,
mediolateral – directed obliquely to the side, reducing the risk of anal sphincter injury.

Currently, the mediolateral incision is preferred because it carries a lower risk of complications involving the anus and sphincter muscles. The technique used and the experience of the person conducting the delivery are also important.

Episiotomy - how healing progresses

The healing process after an episiotomy involves the classic stages of tissue regeneration and usually lasts from several weeks to several months, depending on the extent of the incision and individual bodily predispositions.

Phases of healing:

Inflammatory phase (0–3 days)

There is activation of the immune system, swelling, and increased blood flow. Symptoms such as pain or tenderness are a physiological reaction of the body.

Proliferative phase (3–21 days)

Tissue reconstruction occurs through proliferation of fibroblasts (cells that produce collagen) and the formation of new blood vessels (angiogenesis).

Remodeling phase (up to several months)

Collagen is reorganized, and the scar gradually increases its mechanical strength.

Factors affecting proper healing:

adequate perineal hygiene,
avoiding excessive tissue strain (e.g., during constipation),
proper wound care,
the general condition of the body (e.g., nutritional status, hormonal balance),
absence of infection.

The contemporary clinical approach emphasizes the importance of early urogynecological physiotherapy, which supports the healing process by:

improving tissue blood flow,
reducing muscle tension,
preventing adhesion formation and abnormal scarring.

Episiotomy - possible complications

Although episiotomy is a relatively safe procedure, it carries a risk of complications that can be both short-term and long-term.

Early complications:

pain and swelling in the perineal area,
hematomas and bleeding,
wound infection,
separation of sutures.

Late complications:

scar tenderness (so-called dyspareunia – pain during intercourse),
formation of adhesions and reduced tissue elasticity,
sensory disturbances in the perineal area,
chronic pelvic floor muscle tension,
urinary or fecal incontinence (in cases of damage to deep structures).

Complications associated with damage to the anal sphincter (so-called OASI – obstetric anal sphincter injuries) are of particular clinical importance, as they can lead to serious functional disorders.

It is worth emphasizing that an improperly healed scar can affect the biomechanics of the entire pelvis, causing compensatory muscle tension and even painful symptoms in the lumbar spine.

Episiotomy and pelvic floor muscles

Episiotomy directly interferes with the structures of the pelvic floor muscles, which play a key role in maintaining the function of the pelvic organs. The incision involves, among others, muscles such as the bulbospongiosus muscle, the superficial transverse perineal muscle and elements of the levator ani muscle complex.

The impact of episiotomy on pelvic floor function may include:

weakening of supportive function – increased risk of pelvic organ prolapse,
disorders of urinary and fecal control,
changes in muscle tone – both weakness and excessive tension,
sexual dysfunction.

From a physiotherapy perspective, restoring proper muscle function is important through:

manual scar therapy (mobilization, tissue work),
exercises activating the pelvic floor muscles,
breathing re-education (work on the diaphragm and intra-abdominal pressure),
fascial therapy.

The contemporary therapeutic approach treats the episiotomy scar as an element affecting the entire functional system of the body. For this reason, comprehensive rehabilitation includes not only local perineal therapy, but also work on body posture, movement patterns and the respiratory system.