An episiotomy is a small surgical cut made in the perineum — the stretch of skin and muscle between the vagina and the anus — at the moment of crowning, when the baby's head is about to deliver. It is performed by the obstetrician or midwife using surgical scissors after local anaesthetic is injected into the perineum, or with no extra anaesthetic if an epidural is already in place. In India the cut is almost always mediolateral, meaning it goes downward and outward at an angle away from the anus, because this direction reduces the risk of the cut extending into the anal sphincter compared with a midline (straight down) cut.

A perineal tear is the same kind of injury — a split in the skin and tissue of the perineum — except that it happens naturally as the baby is born rather than being made with scissors. Tears are graded by depth. A first degree tear involves the skin only and is very common, often only needing one or two stitches or sometimes none at all. A second degree tear extends into the muscle layer beneath the skin and is the most common tear that needs proper suturing — it is also similar in depth to what a standard episiotomy creates. A third degree tear extends down to the anal sphincter muscle, and a fourth degree tear extends all the way through the anal sphincter into the lining of the rectum. Third and fourth degree tears are far less common (around three to six percent of vaginal deliveries) and need specialised suturing and follow up.

Both an episiotomy and a tear are closed with dissolvable stitches that absorb on their own over two to six weeks. The healing process is similar for both — a controlled surgical cut and a clean natural tear of equivalent depth heal at roughly the same pace, and the long term outcome depends much more on the depth of the injury, the quality of the repair and the home care over the next six weeks than on whether the injury was a cut or a tear. The old belief that an episiotomy heals better than a tear is one of the most stubborn myths in obstetrics and has been disproven by decades of evidence — in fact small first degree tears heal best of all because they involve the least tissue.

Both injuries are also extremely common. Roughly eighty to ninety percent of first-time mothers having a vaginal birth will have either an episiotomy or some degree of perineal tear, and around forty to sixty percent of subsequent vaginal births involve one or the other. What changes between hospitals and between mothers is whether the injury was a surgical cut made by the doctor's choice, a natural tear that the body would have created anyway, or something that could have been avoided entirely with better birth-room practice.

• First degree tear. A shallow split of the skin of the perineum or the vaginal opening only, not extending into the underlying muscle. These tears are very common, often heal with no stitches or only one or two, cause minimal pain after the first few days, and rarely lead to any long term problem. Many first time mothers have a first degree tear and recover within ten to fourteen days.
• Second degree tear. A deeper tear that extends through the skin and into the perineal muscle layer underneath. This is the most common tear that needs proper suturing in layers and is approximately the same depth as a standard mediolateral episiotomy. Healing takes around three to six weeks for the external skin and up to eight weeks for the deeper muscle layer to feel fully comfortable. With good wound care most women are back to normal daily activity by week three to four.
• Third degree tear. The tear extends down through the perineal muscle and into the anal sphincter — the ring of muscle that controls the anus. Third degree tears are subclassified as 3a (less than fifty percent of the external sphincter torn), 3b (more than fifty percent of the external sphincter torn) and 3c (both external and internal sphincter torn). They are uncommon (around three percent of vaginal births) but more likely with forceps, vacuum, a large baby, an occiput posterior position or a previous third degree tear. They need a specialist repair done in operating theatre conditions, a longer course of antibiotics, stool softeners for several weeks and follow up with a pelvic floor physiotherapist.
• Fourth degree tear. The deepest tear, extending through the perineal muscle, the full anal sphincter and into the lining of the rectum. Fourth degree tears are rare (under one percent of vaginal births) but need a careful theatre repair, antibiotics, stool softeners for six to eight weeks, and structured follow up with both an obstetrician and a pelvic floor physiotherapist. With a good repair and proper rehabilitation, around ninety percent of women have no long term symptoms — the remaining ten percent may have some degree of urgency, leakage or wind incontinence that needs ongoing pelvic floor work or in some cases a further procedure.
• How the grade is decided. Immediately after the baby is born the obstetrician or midwife examines the perineum carefully, often with a finger gently inserted into the rectum to confirm whether the anal sphincter is involved. The grade is documented in your delivery notes and determines the type of repair, the antibiotic plan, the analgesia plan and the follow up. Always ask after delivery what grade of tear or episiotomy you had — it matters for your recovery plan and for any future pregnancy.

The WHO has recommended since the mid 1990s that routine episiotomy be abandoned and that the rate be kept below ten percent of vaginal deliveries, with the cut reserved for specific indications such as fetal distress requiring rapid delivery or instrumental delivery. Most high income countries have moved to selective episiotomy with national rates between five and twenty percent. India is a striking exception. Studies from large Indian hospitals consistently report routine episiotomy rates of thirty to fifty percent in urban private hospitals, with rates above sixty percent in some teaching hospitals for first-time mothers, and very high rates of cutting without specific clinical indication.

The reasons are structural rather than clinical. Most senior obstetricians in India trained in an era when routine episiotomy for every first delivery was taught as good practice, and the habit has been hard to unlearn. Junior doctors and trainees in busy labour wards are often instructed to cut as a way of speeding delivery and reducing the time they spend at the bedside. Many hospitals do not audit episiotomy rates against any benchmark. In private hospitals there is sometimes a perception that the cut allows a quicker, more controlled delivery and reduces medico-legal risk for the doctor, even when the evidence does not support this for the mother.

The cost to mothers is real. Routine episiotomy means more women than necessary leave the delivery room with a surgical wound, more pain in the first two weeks, more difficulty with breastfeeding because of the pain of sitting, slower return to comfortable walking, more anxiety about the first bowel movement, more anxiety about sex, and in some cases scar tenderness and painful intercourse that can persist for months. Most of these women would have had no tear or only a first degree tear if the delivery had been allowed to proceed without the cut.

Consent is often skipped. The cut is frequently made at the moment of crowning without an explicit conversation, sometimes with the mother told only afterwards that a cut was needed. This pattern is changing slowly in some private chains and in baby-friendly accredited hospitals, but the average urban Indian delivery still proceeds with little discussion of whether an episiotomy is necessary. The single most important thing you can do is raise the conversation early in pregnancy and put it in a written birth plan that goes to the labour ward. See what is a birth plan for templates.

• Fetal distress requiring a rapid delivery. If the baby's heart rate drops significantly in the second stage and the head is already close to crowning, an episiotomy can shave a few minutes off the delivery and is a justified intervention.
• Shoulder dystocia. If the baby's head delivers but the shoulders get stuck behind the pubic bone, an episiotomy is sometimes performed to give the obstetrician more room to perform the shoulder dystocia manoeuvres safely.
• Instrumental delivery with forceps or vacuum. When forceps or a vacuum cup is being used to assist delivery, an episiotomy is often performed to make space for the instrument and to reduce the risk of an uncontrolled third or fourth degree tear, although recent evidence suggests even this is not always required for vacuum deliveries.
• Imminent severe tear. If the obstetrician or midwife can see the perineum stretching in a way that suggests a deep uncontrolled tear is about to happen — for example a very thin band of perineal skin that is blanching white under pressure — a controlled mediolateral cut may be preferable to a likely third or fourth degree tear, although this judgement is hard to make accurately and is sometimes over-called.
• Specific maternal conditions where prolonged pushing must be avoided. Examples include certain heart conditions, severe pre-eclampsia or recent eye surgery, where the obstetrician decides that the second stage needs to be shortened.
• When it is not needed. The vast majority of spontaneous vaginal deliveries in healthy women, almost all multiparous (second or later) deliveries, and most slow controlled first deliveries do not require an episiotomy. Letting the perineum stretch slowly during the pushing stage, with warm compresses and hands-on perineal support from the midwife, allows most women to deliver with either no tear or only a small first or second degree tear that heals well.

• Antenatal perineal massage from thirty four weeks. Five to ten minutes a day of self massage using a plain oil (almond, coconut, vitamin E) helps the perineum stretch during delivery and is one of the most evidence-based ways to reduce both episiotomy and severe tears, especially in first time mothers. Your partner can help if you find the angle awkward.
• Warm compresses on the perineum during the pushing stage. A clean cloth soaked in warm (not hot) water held against the perineum while you push has good evidence for reducing third and fourth degree tears and is a low-cost intervention that any labour ward can offer. Ask for this in your birth plan.
• Hands-on perineal support by the midwife. A trained midwife or obstetrician supporting the perineum with one hand while gently controlling the speed of the baby's head with the other reduces severe tears compared with a hands-off approach. This is standard practice in many baby-friendly hospitals.
• Slow controlled pushing rather than forceful directed pushing. Breathing the baby down with gentle pushes timed to the urge rather than the loud counting-to-ten coaching that is still common in Indian labour wards gives the perineum time to stretch and reduces both episiotomy and severe tears.
• Side-lying or all-fours birth position rather than the standard lithotomy (flat on the back with legs in stirrups). Upright, side-lying and all-fours positions reduce perineal trauma compared with the lithotomy position and are increasingly offered in baby-friendly hospitals. Ask your hospital what positions they support before you book.
• Avoiding routine forceps where possible. While forceps and vacuum are sometimes essential, asking for vacuum extraction in preference to forceps when an instrumental delivery is needed (where clinically appropriate) reduces the severity of perineal trauma.

Pain after an episiotomy or a sutured tear is at its peak in the first twenty four to forty eight hours and then decreases steadily. Hospital pain management is usually a combination of local infiltration with anaesthetic at the time of repair, oral paracetamol one gram four times a day around the clock and oral ibuprofen four hundred milligrams three times a day with food, both fully safe with breastfeeding. A short course of a stronger oral medication such as tramadol or a codeine combination may be added for breakthrough pain in the first two to three days.

Ice packs wrapped in a clean cloth and applied to the perineum for ten to fifteen minutes at a time, several times in the first twenty four hours, reduce swelling and dull the pain. Most Indian hospitals now provide gel ice packs or ask the family to bring frozen peas in a clean cloth. After the first twenty four hours, warmth is usually more soothing than cold — a warm sitz bath two or three times a day is the simplest and most evidence-based comfort measure.

Positioning matters more than people expect. Sitting flat on a hard surface drives weight directly onto the wound and is very painful in the first few days. A doughnut cushion (an inflatable ring you sit on) or even a folded soft pillow with a hollow in the centre takes the weight off the wound and makes feeding and meal times much easier. Lying on the side for breastfeeding is far more comfortable than sitting upright in the first week. Many Indian hospitals do not stock doughnut cushions — bring one with you in your hospital bag.

The first bowel movement is often the single biggest fear after a perineal repair, because women worry the stitches will tear with the strain. In practice the stitches are far stronger than a bowel movement, and a stool softener (lactulose syrup or isabgol at night) plus plenty of water and fibre makes the first bowel movement uncomfortable but safe. Supporting the perineum with a clean folded pad of toilet paper during the bowel movement reduces the pulling sensation.

Sitz baths can be started from day one if you are comfortable. A clean shallow tub or basin filled with warm (not hot) water, no soap, sat in for ten to fifteen minutes two or three times a day, soothes the wound, encourages healing and is calming after the intensity of delivery. A pinch of salt can be added if you wish but is not essential. Pat the area dry gently with a soft clean towel afterwards — do not rub.

• Pain medication. Continue paracetamol one gram four times a day around the clock for the first seven to ten days and ibuprofen four hundred milligrams three times a day with food for the first one to two weeks. Both are fully safe with breastfeeding. Do not wait for the pain to peak — take the next dose on time. Taper down as the pain decreases.
• Sitz baths two to three times a day. A shallow basin or clean bucket of warm water, no soap, sat in for ten to fifteen minutes. This is the single most useful comfort measure of week one and continues to help into week two and three. Add a pinch of salt if you wish.
• Peri bottle for hygiene. Squeeze warm water over the perineum every time you use the toilet, instead of wiping with toilet paper. This rinses the wound clean, dilutes urine that would otherwise sting and is far gentler than any wiping. Peri bottles are available online and in chemists in India for under three hundred rupees, or any squeezable plastic bottle can be repurposed.
• Pat dry, do not wipe. After the peri bottle or a sitz bath, dab the area gently with a soft clean towel or a clean cotton pad. Rubbing pulls on stitches and slows healing.
• Cotton sanitary pads, frequent changes. The lochia (postpartum bleeding) continues for four to six weeks and a clean pad changed every two to four hours, or sooner if soaked, prevents infection of the wound. Avoid tampons and menstrual cups for at least six weeks until full healing.
• Loose cotton clothing, and air the wound when you can. Tight underwear and synthetic fabric trap moisture and slow healing. Loose cotton pyjamas and going without underwear for short periods at home (lying on a clean towel) allow the wound to air dry.
• Doughnut cushion or folded pillow for sitting. Take the weight off the wound when sitting on hard surfaces, during feeds, at meal times and when sitting on the floor for poojas or family gatherings is unavoidable.
• Gentle kegels from day one. Squeezing and releasing the pelvic floor muscles ten times, two to three times a day, even within twenty four hours of delivery, improves blood flow to the wound, reduces swelling and speeds healing. Do not worry about being too forceful — the contractions are gentle and do not strain the stitches.
• Hydration and fibre to prevent constipation. Three to four litres of water a day, plenty of fruit and vegetables, oats, isabgol (one to two teaspoons in warm water at night) and lactulose syrup if prescribed all help avoid the constipation that makes the first bowel movement much harder than it needs to be.
• Rest, accept help, and avoid sitting on the floor cross-legged for the first two weeks. The cross-legged sukhasana position pulls directly on the stitches. Use a chair or sit with the legs extended on a bed instead.

Days one to three. Pain is at its peak, the wound is swollen and tender, sitting is uncomfortable and the lochia is heavy and bright red. Pain medication around the clock, ice packs for the first twenty four hours, sitz baths from day one, the peri bottle after every bathroom visit and lying on the side for feeding are the core practices. Most women find the first bowel movement happens on day two or three and is uncomfortable but manageable with stool softeners.

Days four to seven. The swelling starts to settle and the sharp pain begins to ease into a duller tenderness. Sitting becomes easier with a doughnut cushion. The lochia transitions from bright red to a darker red or brown. Stitches are absorbing well and the wound edges are knitting together. Most women are walking gently around the house by day four or five.

Week two. The stitches continue to dissolve and some women feel small pieces of stitch coming away in the underwear — this is normal and not a cause for concern. The wound starts to itch as healing progresses, which is a sign that nerves and skin are regrowing rather than a sign of infection. Pain medication can usually be reduced to as-needed only by the end of week two. Walking outside in the building or compound for ten to fifteen minutes becomes comfortable.

Week three and four. External healing is largely complete by the end of week four for most first and second degree injuries. The wound is closed, tender to firm touch but no longer painful at rest, and the lochia is light and pink or yellowish. Walking distances increase to twenty to thirty minutes a day. The doughnut cushion is usually no longer needed.

Week five and six. The deeper muscle layer continues to remodel and most women feel almost back to normal by week six. The six week postpartum visit confirms full external healing, screens for any concerns, gives the clearance to resume sex when you feel ready, and discusses contraception. See healing from a C-section for the wider six week visit picture which applies equally to vaginal delivery.

Beyond six weeks. A small amount of tenderness with deep pressure on the scar, occasional itching and very mild pulling sensations can continue for three to six months as the deeper tissue and nerves finish remodelling. If pain with intercourse, persistent burning or any new symptoms appear after six weeks, see your obstetrician — these are treatable and worth raising rather than living with.

Third and fourth degree tears involve the anal sphincter and need a different care plan from a standard episiotomy or first or second degree tear. The repair is done in an operating theatre rather than on the delivery bed, often by a senior obstetrician with experience in obstetric anal sphincter injury (OASIS) repair, under regional or general anaesthesia, with careful identification and approximation of each muscle layer. A course of broad spectrum antibiotics is given to reduce the risk of infection at the rectum, and a stool softener (usually lactulose syrup) is prescribed for at least six to eight weeks to keep stools soft and reduce strain on the repair.

The risk factors for a third or fourth degree tear are a first vaginal delivery, a baby weighing more than four kilograms, a forceps or vacuum assisted delivery, an occiput posterior position (baby facing the mother's front rather than back), a prolonged second stage of labour, a previous third or fourth degree tear and an Asian ethnicity (Indian women have slightly higher rates than the average European population, partly due to perineal anatomy and partly due to obstetric practice). Knowing your risk factors before delivery helps you and the labour ward team plan for slower controlled pushing, warm compresses and hands-on support.

Pelvic floor physiotherapy is essential after a third or fourth degree tear. A trained pelvic floor physiotherapist assesses sphincter function, teaches targeted exercises to strengthen the anal sphincter and the wider pelvic floor, and follows up over three to six months to monitor recovery. Access to pelvic floor physiotherapy in India is still limited but growing — Apollo, Cloudnine, Fortis, Manipal, Cult.fit and several specialist physiotherapy clinics in metro cities offer it, with sessions costing between five hundred and three thousand rupees. If your hospital does not refer you, ask explicitly for a referral.

The long term outlook with a good repair and physiotherapy is reassuring. Around ninety percent of women with a third or fourth degree tear have no long term symptoms of incontinence. Around ten percent have some degree of urgency, wind incontinence or occasional leakage of stool, especially with diarrhoea or wind, that can usually be improved with continued pelvic floor work. A smaller proportion (around one percent) have more significant long term incontinence that may need a further specialist procedure. The risk is lower with a well done repair, longer with delays in pelvic floor rehabilitation, and significantly reduced with structured follow up.

Future deliveries after a third or fourth degree tear need an explicit conversation with your obstetrician. The recurrence risk in a second vaginal delivery is around four to eight percent, which is higher than the baseline risk but most women can still safely have a subsequent vaginal birth with careful management. Some women, especially those with ongoing symptoms after the first repair, choose an elective C-section for future deliveries. There is no single right answer and the decision should be made with full information.

The medical guidance is to wait until the six week postpartum visit before resuming penetrative sex, so that the wound has healed externally and internally, the lochia has stopped and the cervix has closed. Many women take longer than six weeks to feel ready, and that is entirely normal. There is no medal for resuming sex on day forty two and the timing is a personal decision that should not be driven by partner expectation or social pressure.

Vaginal dryness is very common in the first few months after delivery, especially in breastfeeding mothers, because the high prolactin and low oestrogen of lactation reduce natural lubrication. A good water based lubricant (KY Jelly, Astroglide, Durex Play and similar Indian brands) makes a substantial difference and should not be seen as a problem — it is a normal response to the hormonal landscape of the postpartum months. Silicone based lubricants last longer if water based ones dry out too quickly. Avoid oil based lubricants if you are using condoms because they degrade latex.

Start with non-penetrative intimacy. Touch, holding, oral sex if you are comfortable, mutual masturbation and gentle exploration help rebuild closeness without the pressure of penetration. Many couples find that several weeks of non-penetrative intimacy before the first attempt at penetration makes the transition much easier.

The first time after delivery may feel different — tighter at the introitus from scar tissue, more sensitive in places that did not feel much before, less sensitive in places that did. Some of this settles over the next few months as nerves regrow and the scar softens, and gentle scar massage from week six (with clean fingers and a small amount of vitamin E oil or plain coconut oil, in small circles for two to three minutes a day) helps soften the scar and improve sensation.

If sex is painful at any point in the first six months, stop. Pain is information, not something to push through. The most common reversible causes are insufficient lubrication, scar tenderness that needs more time and physiotherapy, position discomfort that improves with side-lying or woman-on-top positions, and pelvic floor muscle tension that responds well to physiotherapy. If pain persists beyond three to six months, see your obstetrician. Painful sex after delivery is treatable and worth raising rather than enduring. See intimacy after childbirth for a fuller conversation.

• Raise the conversation at the thirty six week visit. Ask your obstetrician directly what their personal episiotomy rate is, what conditions they consider an indication, and whether they routinely cut for first deliveries. Their answers will tell you a great deal about the hospital culture you are walking into.
• Put it in a written birth plan. A short paragraph that says "I would prefer to avoid a routine episiotomy. Please use perineal massage, warm compresses and hands-on support to reduce the chance of a severe tear. Please obtain my verbal consent before any episiotomy unless there is an immediate emergency" carries real weight. Give a copy to your obstetrician at the thirty six week visit and pack two copies in your hospital bag for the labour ward.
• If an episiotomy is suggested during labour, ask why. "What is the indication?" is a fair question and most obstetricians will respect it. If the answer is a genuine emergency reason such as fetal distress or shoulder dystocia, give consent. If the answer is vague or amounts to "it is routine for first deliveries here", you can decline and ask for more time, warm compresses or a position change instead.
• Bring a doula or a trained birth partner if you can. Doulas are still uncommon in India but growing in metro cities. A good doula knows the labour ward dynamics, can advocate on your behalf when you are mid-contraction, and helps your partner stay calm and supportive. Costs range from fifteen thousand to seventy five thousand rupees for full antenatal plus delivery support in metro cities.
• Choose your hospital and obstetrician with this in mind. Some hospitals and obstetricians have explicitly low episiotomy rates and are open about it. Baby-friendly hospital accredited centres and many midwife-led birth centres have lower rates than the average urban private hospital. Ask other mothers who have recently delivered and read reviews on Indian parenting forums. If your current hospital does not feel like a good fit, switching obstetrician or hospital is genuinely possible up to thirty four to thirty six weeks.
• After delivery, ask exactly what happened. "Did I have an episiotomy or a tear? What grade? How was it repaired?" The answers matter for your recovery plan and for any future pregnancy. Get the details written into your discharge summary. See when doctors don't listen for the wider conversation on advocating in the Indian medical system.

• Myth. An episiotomy is always needed for a first baby. Fact. The WHO recommends routine episiotomy below ten percent of vaginal deliveries, and most first time mothers can deliver without one if the second stage is supported with warm compresses, hands-on midwife support and slow controlled pushing. The thirty to fifty percent rate seen in urban Indian private hospitals reflects local practice, not biological necessity.
• Myth. The wound heals in a week. Fact. External skin healing takes around three to six weeks for a standard episiotomy or second degree tear, and the deeper muscle layer takes up to eight weeks to feel fully comfortable. Stitches dissolve over two to six weeks. Telling yourself it should be healed in a week sets up an unfair expectation that drives anxiety when normal healing takes longer.
• Myth. A controlled cut always heals better than a natural tear. Fact. A controlled cut and a natural tear of the same depth heal at the same pace. A first degree tear actually heals better than either a second degree tear or a standard episiotomy because less tissue is injured. The old teaching that cuts heal better than tears has been disproven by decades of evidence.
• Myth. Sex is never the same after an episiotomy. Fact. With full healing, gentle scar massage from week six, good lubrication, time, communication and pelvic floor work where needed, the great majority of women have a satisfying sex life after vaginal delivery. Persistent pain after six months is treatable and should not be accepted as the new normal.
• Myth. All episiotomies lead to incontinence. Fact. First and second degree injuries (including standard episiotomies) have very little impact on long term continence in most women. Third and fourth degree tears carry a higher risk of some incontinence, but with a good repair and pelvic floor physiotherapy around ninety percent of women have no long term symptoms. Incontinence after delivery is also responsive to pelvic floor exercises and physiotherapy — see kegel and pelvic floor exercises in India for the full program.