An episiotomy is a surgical cut made from the bottom of your vagina toward your rectum; this area is called your perineum. This incision is made to enlarge the opening of your vagina during a difficult vaginal delivery.  Most women will have some type of tearing in this area during a vaginal delivery. The tearing is called a laceration.  Most lacerations are minor and easily repaired. Serious lacerations are deeper and may involve the muscles of the perineum. 
It was once believed that doing an episiotomy prevented severe lacerations and made vaginal delivery safer for both the mother and the baby. The episiotomy procedure was first introduced in 1742. By 1920, it was a common part of childbirth in America. The American Gynecological Society recommended episiotomy for all women having their first vaginal delivery. 
Up until the late 1970s, about 60 percent of American women received episiotomy. Since then the number of episiotomies has fallen dramatically. Large reviews of studies found that routine use of episiotomy actually increased the risk of more severe lacerations and had no benefits for moms or babies.  Today episiotomies are only done for some difficult deliveries. You may need an episiotomy if: [1,3]
- You have a long and difficult delivery.
- You have a large baby.
- Your baby is a breach birth.
- Your baby’s shoulder can’t be delivered.
- Your baby has low oxygen levels during delivery.
- You need forceps or vacuum assistance during delivery.
What to Expect if You Need Episiotomy
You will need to sign a consent for episiotomy. You should talk about the reasons why you might need an episiotomy and the possible risks before you start your labor. Most obstetricians will no longer do an episiotomy unless it is really needed.  Possible risks include: [1,3]
- Serious laceration
- Opening of the incision during healing
- Pain during sexual intercourse after healing
If you need episiotomy, this is what happens: [1,3]
- Episiotomy is done during the second stage of labor when your baby’s head is crowning.
- If you have not had an epidural, your surgeon will inject a local anesthetic into your perineal area.
- Your surgeon will place his or her fingers through your vagina and under your stretched perineum to protect your baby’s head.
- A scissors or scalpel will be used to make the incision. The incision may extend from the bottom of you vagina toward your rectum or at a slight angle away from your rectum.
- After you deliver your placenta, your surgeon will repair the incision and any other laceration with an absorbable suture.
Home Care After Episiotomy
You may have pain after an episiotomy. You may need a prescription strength pain medication. If your surgeon feels there is a risk of infection, you may also need an antibiotic. Home care instructions may include: [3,4]
- Change your vaginal pad every few hours.
- Use an ice pack to reduce pain and swelling.
- Take warm sitz baths to reduce pain and swelling.
- Clean your perineal area with warm water spray after passing urine or having a bowel movement. Pat dry with a soft towel (not toilet paper).
- Drink plenty of fluids and use a stool softener to prevent constipation.
- Avoid douching, sexual intercourse, tampons, and heavy lifting until your surgeon says it is safe.
Call your surgeon if you have: [3,4]
- Vaginal bleeding or blood clots
- Discolored or bad smelling vaginal discharge
- Chills or fever
- No bowel movement in over three days
- Pain that is not controlled by your pain medication
The key takeaway is that episiotomy should not be a routine part of a vaginal delivery. Talk to your surgeon about when an episiotomy might be needed. Ask about prevention of perineal laceration.  Some recent studies suggest that perineal lacerations may be reduced by using heat and massage on the perineum during the second stage of labor. Lying on your side during this stage of labor may also reduce lacerations. 
- Medscape, Episiotomy and Repair.
- Medscape, ACOG: New Recommendations on Obstetric Lacerations.
- Johns Hopkins Medicine Health Library, Episiotomy.
- NIH, Episiotomy- aftercare.