Written by Leah Morrow
You may have heard that an episiotomy can help protect your pelvic floor after childbirth. But what does the research actually tell us?
An episiotomy is a surgical cut made to the perineum during vaginal birth. It was historically used more routinely, partly because it was thought that making a controlled incision could reduce more severe perineal trauma and potentially protect the pelvic floor.
But as our understanding of childbirth and pelvic health has developed, so has the evidence surrounding episiotomy.
So, does an episiotomy actually protect your pelvic floor in the long term?
What is an episiotomy?
An episiotomy involves making an incision through the perineum — the area of tissue between the vaginal opening and anus — during vaginal birth.
It may be performed in certain clinical situations where it is considered necessary, but routine episiotomy is not recommended as a way of preventing long-term pelvic floor dysfunction.
Historically, some of the proposed benefits included reducing severe perineal trauma, urinary incontinence and pelvic organ prolapse.
However, the evidence doesn't support using episiotomy routinely for these purposes.
What does the research tell us?
One of the key pieces of evidence is a 2019 systematic review by Frigerio et al., which examined the long-term effects of episiotomy.
The review included 24 studies, with women followed for a mean period of at least five years.
The researchers specifically looked at outcomes including urinary incontinence and pelvic organ prolapse.
Their findings were interesting.
There was no evidence that episiotomy provided a long-term protective effect against urinary incontinence.
In fact, the authors concluded that episiotomy might be detrimental in relation to urinary incontinence symptoms.
This challenges the idea that performing an episiotomy protects the pelvic floor from future problems.
What about urinary incontinence?
Urinary incontinence is common after pregnancy and childbirth, but it isn't something women simply have to accept as a normal consequence of having a baby.
The evidence reviewed by Frigerio et al. included several studies reporting higher rates of urinary incontinence among women who had undergone an episiotomy.
For example, studies by Akkus et al. and Ge et al. reported associations between episiotomy and urinary incontinence, while Zhang et al. found an association with increased urinary storage symptoms.
Song et al. also reported higher rates of both stress urinary incontinence and urgency urinary incontinence following episiotomy.
However, it is important to interpret these findings carefully.
These studies show associations, rather than proving that an episiotomy directly caused someone's urinary symptoms.
Childbirth is complex, and many factors can influence pelvic floor function.
What about pelvic organ prolapse?
This is where the evidence becomes more nuanced.
When Frigerio et al. looked at pelvic organ prolapse, they did not find that episiotomy clearly increased the development of prolapse.
There was some evidence suggesting that episiotomy could potentially be associated with lower prolapse severity or prevalence in certain circumstances.
However, it did not appear to alter the rate of prolapse surgery.
So we cannot simply conclude:
"Episiotomy causes prolapse."
Nor can we say that episiotomy is a reliable way of preventing prolapse.
The relationship between childbirth, perineal trauma and pelvic organ prolapse is much more complicated.
So, does an episiotomy cause pelvic floor dysfunction?
Not necessarily.
This distinction is really important.
The available research does not prove that having an episiotomy causes urinary incontinence or pelvic floor dysfunction.
At the same time, there isn't good evidence to support performing an episiotomy as a strategy to prevent long-term urinary incontinence.
Pelvic floor health following pregnancy and birth is influenced by many different factors, including:
Pregnancy itself
Vaginal birth and mode of delivery
Perineal trauma
Pelvic floor muscle function
Baby's size and position
Number of previous births
Individual anatomy and genetics
Age and hormonal changes
Recovery following birth
An episiotomy is therefore only one part of a much bigger picture.
What does this mean if you've had an episiotomy?
If you've had an episiotomy, it doesn't mean that you are destined to develop pelvic floor problems.
And it certainly doesn't mean that something has gone wrong.
Many women recover extremely well following an episiotomy.
However, if you're experiencing symptoms that aren't improving, it's worth getting them assessed rather than assuming they're simply part of being postpartum.
You may notice:
Leaking urine
Perhaps when running, jumping, coughing, sneezing or exercising.
A feeling of heaviness or bulging
This may occur in the vagina or pelvis, particularly towards the end of the day or after exercise.
Pain with sex
Pain during or after sex is common following childbirth, but persistent pain deserves appropriate assessment.
Changes to your bladder or bowel
This could include urgency, difficulty emptying, constipation or changes in bowel control.
Persistent perineal or scar pain
An episiotomy scar can sometimes remain sensitive, tight or painful after the initial healing period.
These symptoms aren't something you simply have to put down to "having a baby."
How can pelvic health physiotherapy help?
A pelvic health physiotherapist can assess your symptoms and help identify the factors that may be contributing to them.
Depending on your individual presentation, this might include looking at:
Pelvic floor muscle strength and coordination
Relaxation and lengthening of the pelvic floor
Bladder and bowel habits
Scar mobility and sensitivity
Pain
Breathing and pressure management
Core and abdominal function
Your return to exercise and impact activities
Importantly, pelvic floor rehabilitation isn't simply about doing more pelvic floor squeezes.
Some women need to build strength.
Others may need to work on relaxation, coordination, managing pain or improving how the pelvic floor responds to movement and increased pressure.
Your rehabilitation should be based on your symptoms and your assessment — not simply on the fact that you've had an episiotomy.
The takeaway
An episiotomy isn't a "protective" procedure for the pelvic floor.
The current evidence does not support performing an episiotomy as a strategy to prevent long-term urinary incontinence.
But having an episiotomy also doesn't mean that you will develop pelvic floor dysfunction.
Every woman's pregnancy, birth and recovery are different.
If you're experiencing leaking, heaviness, pain, bowel or bladder changes, or persistent perineal discomfort after birth, you don't have to simply live with it.
Understanding what is happening is the first step towards getting the right support.
Your postpartum recovery deserves more than "that's normal after having a baby."
Evidence
Frigerio M, Mastrolia SA, Spelzini F, et al. (2019). Long-term effects of episiotomy on urinary incontinence and pelvic organ prolapse: a systematic review. Archives of Gynecology and Obstetrics, 299, 317–325. doi:10.1007/s00404-018-5009-9.