Episiotomy in India: How to Reduce Your Risk

• Routine episiotomy is not evidence-based — it does not reduce severe (third or fourth degree) tears and is linked to more pain and slower recovery.
• International guidelines (WHO, ACOG, RCOG, NICE, FOGSI) support selective episiotomy — only for a clear medical reason — with overall rates of roughly 10-30 percent.
• WHO and Indian studies suggest 60-70 percent of Indian hospital births involve episiotomy, rising to 80-90 percent for first-time mothers in many facilities.
• Perineal massage from 34-35 weeks, upright and spontaneous pushing, slow delivery of the head, and warm compresses all reduce perineal trauma.
• Asking your OB about their episiotomy rate and writing your preference into your birth plan are reasonable, powerful steps.
• When episiotomy is genuinely indicated — instrumental delivery, fetal distress, an uncontrollable severe tear — it is the right decision and recovery is similar to a natural tear.

An episiotomy is a surgical incision in the perineum, made when the baby's head is crowning (visible at the vaginal opening). It is usually 2-4 cm long. The two main types are mediolateral (angled to one side, common in India and Europe) and midline (straight down toward the anus, common in the US but with a higher chance of extending into the anal sphincter). The cut is stitched after the baby and placenta are delivered.

From the early-to-mid 1900s through the 1980s, episiotomy was performed in most vaginal births. The belief was that a clean surgical cut would heal better than a 'jagged' tear, prevent severe tears into the anal sphincter, protect the baby's head, and protect the pelvic floor.

Decades of research have thoroughly disproven this. Large randomised trials and Cochrane systematic reviews show that routine episiotomy does not reduce severe perineal tears and does not improve maternal or infant outcomes. Instead it is associated with more pain, slower healing, more stitches, more painful intercourse, and more pelvic floor symptoms compared with selective use or letting the perineum tear or stay intact naturally.

By the 1990s and 2000s, international guidelines (ACOG, RCOG, NICE, WHO and FOGSI) had moved from routine to selective episiotomy. Selective use means the cut is made only for a specific medical reason — such as an instrumental (vacuum or forceps) delivery, fetal distress requiring rapid birth, or a severe imminent tear that cannot be controlled. Under selective practice, overall episiotomy rates fall to about 10-30 percent.

Selective episiotomy does not mean 'never'. It means appropriate use only when genuinely indicated, recognising that routine use causes more harm than good. The shift away from routine practice has been faster in some health systems than others — and India is one where it has been particularly slow, partly because many obstetricians were trained in the routine era and the practice is embedded in labour-room culture.

The Indian episiotomy rate is far above the evidence-based selective benchmark. WHO data and several Indian hospital studies suggest 60-70 percent of hospital vaginal births involve episiotomy, with some facilities exceeding 80-90 percent. For first-time mothers the rate is often 80-90 percent or higher. Compare this with the international ideal of 10-30 percent and the over-use is clear.

Several factors drive these numbers:

None of this is offset by benefit. Because routine episiotomy does not reduce severe tears or improve outcomes, the extra surgical wound simply means more pain, more stitches, longer recovery, more risk of infection or wound breakdown, and more chance of painful intercourse — without anything gained.

This pattern is part of a wider over-medicalisation of Indian childbirth, alongside high caesarean rates in private hospitals (often 40-60 percent versus the WHO-suggested 10-15 percent) and frequent induction of labour. It reflects systemic factors far more than anything an individual woman did or did not do.

Change is happening, slowly. FOGSI endorses selective episiotomy in line with international guidelines, some Indian obstetricians and hospitals explicitly practise it, and India's growing birth-autonomy movement actively advocates for it. But in a typical Indian labour room, routine episiotomy remains the default unless you raise the question — which is exactly why informed advocacy, written into your birth plan, matters.

Perineal massage in the final weeks of pregnancy is the most evidence-based way to reduce both episiotomy and severe tears. The Cochrane systematic review on perineal massage found that women who massage regularly from around 34-35 weeks have less perineal trauma at birth — fewer episiotomies and fewer tears needing stitches — with the benefit clearest in first-time mothers.

It works by gradually stretching and softening the perineal tissue so it can accommodate the baby's head more easily, improving blood flow to the area, and helping you become familiar with the stretching sensation so you can consciously relax during pushing.

When to start: around 34-35 weeks. Earlier than 32 weeks adds little; starting after 36-37 weeks leaves less time to practise. A 34-week start gives 4-6 weeks of regular massage before your due date. If you are already past that point, starting now is still worthwhile — late is better than never.

How often: ideally daily, 5-10 minutes a session. Some studies show benefit with 3-4 times a week, but consistency over the weeks matters more than any single session.

Technique (in brief — see the full guide): wash your hands, use a clean plain oil (coconut, sweet almond or vitamin E oil — avoid heavily scented products), get comfortable (sitting propped up with knees bent, or in the shower), insert your thumbs about 2-3 cm into the vagina, press gently downward and outward toward the rectum until you feel a mild stretch or burning, hold 1-2 minutes, then release and repeat with slow rhythmic strokes. Stop if it is painful. Either you or your partner can do it — many couples find partner-massage more practical in late pregnancy.

Is it safe? Yes, when done gently with clean hands in a pregnancy without contraindications such as placenta praevia, vaginal bleeding, infection, or waters that have broken. It does not stimulate the cervix and there is no evidence it triggers preterm labour. Mild Braxton Hicks afterwards is normal. It substantially reduces — but does not guarantee against — tears, because some tears happen regardless of preparation.

Perineal massage works best combined with the other strategies below: upright pushing, spontaneous pushing, slow delivery of the head, warm compresses, and selective episiotomy practice.

How you push, and how fast the head is delivered, strongly affect perineal trauma. Several evidence-based approaches reduce risk compared with the traditional supine lithotomy position (lying on your back with legs in stirrups) and directed, counted pushing.

Upright pushing positions. International evidence supports upright positions — supported squatting, kneeling, sitting on a birth stool, side-lying, or hands-and-knees — over lithotomy. Upright positions open the pelvic outlet slightly, let gravity assist descent, and reduce direct downward pressure on the perineum. The Cochrane review on positions in the second stage links upright posture to a shorter pushing stage and fewer operative deliveries. Lithotomy remains the Indian default mainly because it is convenient for the team, not because it is best for you.

Spontaneous pushing. Evidence favours pushing in response to your own urges over directed pushing (coached counting and prolonged breath-holding). Spontaneous pushing respects your body's rhythm, is less tiring, and is gentler on the baby's oxygen supply. If you do not have a heavy Epidural for Labour in India: Cost, Decision & Myths, your body will usually give clear urges to push once you reach the pushing stage of labour — follow those rather than waiting to be told.

Slow delivery of the head. Crowning is the highest-risk moment for tearing. Allowing the head to ease out gradually — by breathing through contractions rather than forcefully pushing at the final moment, while the midwife or OB gently controls the speed — significantly lowers tear risk compared with rapid expulsion.

Warm compresses. Applying warm, wet compresses to the perineum during the second stage (especially at crowning) has Cochrane evidence for reducing trauma. Many Indian hospitals do not do this routinely, so it is worth requesting.

Hands-on versus hands-off support. Some clinicians gently support the perineum during crowning; others use a hands-off approach. The evidence is mixed, and either can give good results when combined with slow pacing and tissue stretching.

Used together, these strategies plus perineal massage and selective episiotomy practice substantially reduce perineal trauma compared with the routine supine-lithotomy, directed-pushing, episiotomy approach. To use them in an Indian hospital, raise them at antenatal visits and at admission — ask which positions the labour room supports. Birth-autonomy supportive facilities tend to be more flexible than standard chain hospitals.

Lowering your episiotomy risk comes down to a few interlocking steps: prepare your body, choose the right provider and facility, write a clear birth plan, and arrange advocacy for labour.

Prepare antenatally. Do perineal massage daily from 34-35 weeks. Practise pelvic floor exercises through pregnancy. Take a childbirth class that covers second-stage management, pushing positions and selective episiotomy so you are informed for the conversations ahead.

Choose your OB and hospital with care. Ask directly: 'What is your typical episiotomy rate, especially for first-time mothers?' A low rate (20 percent or less) signals selective practice; 50 percent or more signals routine practice. Ask which pushing positions the hospital supports and how they manage crowning. If your OB is committed to routine episiotomy and switching is feasible, a more aligned provider or a lower-intervention facility is worth considering.

Write it into your birth plan. A collaborative phrasing invites discussion rather than confrontation: 'I would prefer to birth without an episiotomy unless there is a clear medical indication — instrumental delivery, fetal distress requiring rapid birth, or a severe imminent tear — with a brief discussion if time allows.' See the birth plan template. Share it at antenatal visits and bring printed copies.

Arrange advocacy. A Doulas in India: What They Do, Cost (Rs 15,000-50,000) and How to Find One or your partner can speak for your second-stage preferences when you cannot. Brief them clearly. At the moment of crowning, if episiotomy is suggested, a calm 'is there an immediate medical reason, or can I push slowly and try without?' engages shared decision-making at the critical moment.

During labour, change positions freely, use upright and side-lying postures, and follow your body's pushing urges. If episiotomy is genuinely indicated, accept it — but if it is being done as routine, asking for a moment may change the outcome.

Accept what you cannot control. Despite good preparation, you may still have an episiotomy depending on the OB on duty, the labour-room culture, and the clinical situation. 'I did what I could to reduce my risk' is an empowering frame even when the outcome is not what you hoped. Many women who had an episiotomy in one birth go on to avoid it in the next with the same preparation and advocacy.

Effective conversations get past general reassurance and into actual practice. Use direct questions and listen for direct answers.

About practice. 'What is your episiotomy rate for first-time mothers?' (the single most useful question — low suggests selective, high suggests routine). 'Do you do episiotomy routinely or selectively?' 'In which specific situations would you do one?' A clear list — instrumental delivery, fetal distress, severe imminent tear — signals selective practice. 'First-time mother' or 'as I usually do' signals routine practice.

About second-stage management. 'Which pushing positions do you support?' 'Do you use spontaneous or directed pushing?' 'How do you manage crowning — slow controlled delivery or rapid?' 'Do you use warm compresses?' These reveal whether the OB's technique is perineum-preserving.

About your situation. 'Are there factors in my pregnancy that make episiotomy more likely?' 'What can I do in pregnancy to lower my risk?' If perineal massage is not mentioned, it suggests the OB is not engaging with evidence-based prevention.

Signal that you are informed. Referring to 'international evidence', 'FOGSI guidelines' or 'WHO recommendations' and asking about specific scenarios tends to get more substantive answers. Be respectful but persistent — this is your care, and you are entitled to clear answers.

If the OB is dismissive — 'we do what's needed', 'don't worry, trust me', 'every birth is different so I can't say' — that response is itself informative. It is reasonable to ask again for a specific answer, and reasonable to consider a different provider. This episiotomy conversation is one part of the broader birth-planning discussion that also covers monitoring, mobility, pain relief and partner presence.

Arguing against routine use is not the same as 'never'. Selective episiotomy means appropriate use for a clear reason. Knowing the genuine indications helps you accept the procedure when it is truly needed and question it when it is not.

Instrumental delivery. A vacuum or forceps birth often needs extra room for safe instrument placement; an episiotomy here is generally appropriate because an uncontrolled tear during instrumental delivery is more likely to be severe. See more on assisted delivery.

Fetal distress requiring rapid birth. If the baby's heart rate is concerning and birth must be hastened, the extra space can shorten the second stage.

A severe imminent tear that cannot be controlled. Occasionally, despite good technique, the perineum is about to tear severely; a controlled episiotomy may then be the lesser harm.

Shoulder dystocia — episiotomy may give room for manoeuvres when the shoulders are stuck after the head delivers. See shoulder dystocia management.

Other specific situations — certain breech vaginal births, severe maternal exhaustion with the head visible, or a maternal condition where a prolonged second stage is dangerous (such as severe pre-eclampsia in the second stage).

What is NOT a clear indication: being a first-time mother, a suspected large baby, a long second stage, or general tightness at crowning — most of these resolve with patience and slow pacing. 'Just in case' is routine practice, not selective use.

If an episiotomy is done for a clear reason, it was the correct decision and the outcome is the best the situation allowed; recovery is similar to a natural tear. If it was done without an evident indication, it is reasonable to debrief with your OB afterwards to understand the decision — useful both for processing the experience and for any future pregnancy.

Whether the cut was clearly indicated or routine, good wound care matters for your recovery. Healing is similar to recovery from a natural perineal tear — for a full timeline see episiotomy and perineal tear healing.

First 24-48 hours. The wound is closed with absorbable stitches that do not need removal. Pain is at its peak now: use ice packs through a cloth (10-15 minutes at a time), regular paracetamol and ibuprofen (both safe with breastfeeding), and a numbing spray or gel if provided. A ring or shaped cushion makes sitting easier, and pouring warm water over the area while you pass urine eases the sting.

First week. Pain reduces steadily. Sitz baths (sitting in warm water 10-15 minutes, two to three times a day) soothe and aid healing. Wash with warm water after using the toilet and pat dry. Avoid intercourse and tampons for about six weeks. Postpartum bleeding (lochia) continues separately and is normal. Piles are common alongside perineal pain — see postpartum haemorrhoid relief.

Weeks 2-6. Discomfort fades and the stitches dissolve over two to six weeks; mild itching as it heals is normal. Begin gentle pelvic floor exercises once acute pain settles, building up gradually. Most women are comfortable by 4-6 weeks, confirmed at the six-week postnatal check.

Sex and intimacy. Resume when you feel comfortable rather than by the calendar. Lubricant helps, as postpartum and breastfeeding hormones cause vaginal dryness. Painful intercourse is somewhat more common after episiotomy than after a natural tear — for a gentle, realistic approach see intimacy after childbirth.

Longer term. Most scars heal well with no lasting effect. A few women have persistent scar sensitivity, ongoing painful sex, or pelvic floor symptoms such as urinary leaking or a sense of prolapse — these are treatable, often with postpartum pelvic floor rehabilitation. Pelvic floor physiotherapy is available in major Indian cities (roughly Rs 500-2000 per session).

Emotional recovery. Feeling 'cut', unheard, or shaken by the surgical aspect of birth is valid. Talking it through, journaling, or counselling all help — and if the experience was particularly distressing, naming and processing birth trauma can be an important part of healing. Having had an episiotomy once does not mean you will need one again.

Most episiotomy wounds heal without trouble, but some signs need prompt assessment by your OB. Contact your doctor — or go to the hospital — if you notice any of the following while healing:

The high Indian episiotomy rate is sustained by cultural narratives as well as clinical habit. Individual women advocating for selective use contribute to change, but cannot single-handedly shift the system.

Common narratives that get in the way include 'doctor knows best' (so questioning feels inappropriate), 'just trust the process', 'this is what is done here', 'first-time mothers always need it', and 'episiotomy heals better than a tear'. The last two are simply not supported by evidence.

The counter-narrative is grounded in evidence: routine episiotomy does not improve outcomes and adds harm; selective use for clear indications is the standard of care; and Indian women deserve the same evidence-based care offered elsewhere. A well-prepared and supported perineum can often deliver a baby without a cut.

What individual women can do: advocate with their own OB and hospital; choose providers and facilities aligned with selective practice; share both good and poor experiences with other women; and give feedback to facilities through formal channels. What clinicians and institutions can do: update practice to current FOGSI and international guidance, audit and address high episiotomy rates, and build selective practice into training and continuing education.

Change is real but slow. India's episiotomy rate has sat at 60-70 percent for many years and is declining at some facilities while remaining high at others. The shift from routine to selective episiotomy took decades in other health systems and is still ongoing — India is in the early phase. Your informed choices, conversations and shared experiences are part of that larger story, even as you prepare realistically for your own birth.

Episiotomy is one part of the bigger picture of perineal and pelvic floor health through pregnancy, birth and the postpartum period.

The pelvic floor is a hammock of muscles and ligaments supporting your bladder, uterus and rectum. It governs continence, sexual function and core support. Pregnancy stretches it, the hormone relaxin loosens its ligaments, and vaginal birth stretches it further — so attention to it pays off long term.

In pregnancy, regular Kegel and pelvic floor exercises maintain muscle strength and support recovery: tighten the muscles you would use to stop the flow of urine (don't actually do this on the toilet), hold 3-10 seconds, release, and repeat 10-15 times, three times a day, making sure you are not clenching your tummy, buttocks or thighs.

After birth, common pelvic floor issues include urinary leaking with a cough, sneeze or laugh, a feeling of vaginal heaviness or bulge, perineal pain, and reduced sexual sensation or comfort. Begin gentle pelvic floor exercises one to two weeks postpartum once acute pain has settled, avoid heavy lifting for six or more weeks, and manage postpartum constipation and piles so you are not straining.

Seek help if urinary leaking persists beyond three to six months, if you have any faecal incontinence, if you feel a vaginal bulge, or if sex stays painful. Postpartum pelvic floor rehabilitation with a trained physiotherapist can assess and treat these — increasingly available in Indian cities, though still under-used.

Indian conversation about pelvic floor health is limited, and many women endure symptoms thinking they are just 'part of being a mother'. They are not — they are treatable. Your willingness to seek care and talk about it openly helps shift that silence for everyone.

• WHO recommendations: Intrapartum care for a positive childbirth experience (restrictive episiotomy policy)
• Cochrane Review: Selective versus routine use of episiotomy for vaginal birth
• Cochrane Review: Antenatal perineal massage for reducing perineal trauma
• ACOG Practice Bulletin: Prevention and Management of Obstetric Lacerations at Vaginal Delivery
• RCOG Green-top Guideline No. 29: Management of Third- and Fourth-degree Perineal Tears
• NICE Guideline NG235: Intrapartum care