Episiotomy: A Midwife’s Perspective on the Perineum and the Sacred Threshold

I did not know, the first time, that my body was made to stretch.

I did not know that the perineum—the small, vascular, extraordinary bridge of tissue between the vaginal opening and the anus—was designed by the same God who wove the earth to yield under pressure. That it was built to thin, to soften, to open in millimeters under the guidance of oxytocin, prostaglandins, and time. I trusted the system to decide for me. And in that trust, there was a cut.

I forgive her—the version of me who did not yet know.

I am writing this piece for her. And for you. For the mother who is preparing to cross the threshold and wants to know what she is walking into. For the birthkeeper who stands as watchman at the gate. For the woman who is healing now, wondering if she will ever feel whole again. This is for all three of you—because you are, in many ways, the same woman at different moments on the same journey.

I. The Land of the Crossing

The Perineum as Sacred Ground

There is a moment in birth when the head crowns and the whole world holds its breath. The tissue stretches in millimeters. Time slows. The room—if it is a good room—becomes very quiet.

This is the sacred threshold.

In my tradition, I call this moment the “Land of the Crossing.” It is the narrow place where two lives are held in tension—the baby pressing toward air, the mother pressing toward becoming. The perineum is the keeper of that gate.

Physiologically, it is among the most responsive tissues in the human body. It is rich with blood vessels, laced with estrogen receptors, softened by the hormonal tide of late pregnancy. Under the right conditions—warmth, patience, breath, trust—it is capable of extraordinary elasticity. It is not a wall to be broken. It is a threshold designed to yield.

The body is not an obstacle to birth. It is the architecture of a holy crossing.

II. How We Came to Cut

The History the Body Remembers

In the early 20th century, medicine decided that birth was a pathological process. In 1920, physician Joseph B. DeLee published an influential paper that described normal labor as a disaster requiring surgical management—and the episiotomy, a surgical incision into the perineum, became standard liturgy in the American hospital birth model.

I want you to sit with that for a moment. The body that the Creator designed to open was renamed a problem. The threshold that the Divine intended to be crossed gently was classified as an obstacle requiring the blade.

The episiotomy was justified by several beliefs, all of which have since been dismantled by the weight of evidence. It was believed that a clean surgical cut healed better than a natural tear. It does not—midline episiotomies dramatically increase the risk of severe third- and fourth-degree lacerations extending into the anal sphincter and rectum. It was believed that shortening the second stage protected the baby from brain injury. Modern research shows the opposite: the gentle compression of the birth canal is a “Functional Mercy,” clearing the baby’s lungs and supporting the neurological adaptation from womb to world. It was believed that control was protection. What it actually produced was a generation of women who healed from wounds they did not choose, in bodies they were never taught to trust.

By the 1980s and 1990s, the evidence had accumulated enough that the World Health Organization and the American College of Obstetricians and Gynecologists formally recommended against routine episiotomy. The data bore witness. The reform came. But the cultural memory—the body memory—lingers longer than policy.

Many of us are still healing from a liturgy that was never ours to carry.

III. When the Blade Becomes Mercy

On Rare, True Necessity

Because this is a midwifery space and not simply a spiritual one, I must hold both truths. There are moments—rare, specific, clinically defined—when an episiotomy is not violence but mercy. When it is the tool that saves.

If a baby’s heart tracing shows that the child cannot wait—that the threshold must open now—a well-placed incision can be the difference between life and loss. In shoulder dystocia, when the shoulder is trapped and internal maneuvers are needed, space matters. In an operative vaginal birth with forceps, a carefully angled mediolateral episiotomy can reduce the risk of uncontrolled tearing.

In these moments, the blade is not a betrayal of the body. It is a tool in the hands of a practitioner who honors both the science and the sanctity of birth.

The grief of an episiotomy is not always the grief of harm. Sometimes it is the grief of necessity—the ache of a birth that required more than the body could gently offer. Both griefs are valid. Both deserve tending.

An episiotomy is not always a wound inflicted upon a woman. Sometimes it is a wound shared—one that says: we did what the moment required, and we will not leave you here alone.

IV. Preparing the Soil

The Midwife’s Watch Before the Crossing

We do not only tend the threshold in the moment of birth. We prepare the soil long before the crowning.

Beginning around 34 to 35 weeks, we begin perineal massage—not as a clinical box to check, but as a practice of acquaintance. The mother learns her own tissue. She learns that it can stretch without breaking. She learns to breathe into the sensation rather than guard against it. This is not only physical preparation; it is a re-patterning of the nervous system’s relationship with the threshold. The Ruach moves through breath. Breath teaches the body that opening is not danger.

In the birth room, we use warm herbal compresses—Calendula, Comfrey, or Yarrow—held gently against the perineum as the head descends. This is one of the most evidence-supported tools we have for reducing severe tears. The warmth increases blood flow to the tissues. It softens the tightness that fear and cold create. It tells the body: you are safe. You are warm. You are held.

Position matters as well. The lithotomy position—flat on your back, legs in stirrups—narrows the pelvic outlet and places asymmetric pressure on the perineum. It is the position most suited to the observer, not the birthing body. When we move the mother upright, lateral, or to hands-and-knees, we honor the pelvic architecture. We invite the opening rather than force it.

And at the moment of crowning, we honor what I call “the Pace of the Ruach.” Rather than coached, breath-holding pushing that forces the head through in one forceful surge, we guide spontaneous “puff” breathing—small, rhythmic exhales that allow the head to emerge in millimeters, giving the tissue time to follow. We are not rushing the crossing. We are witnessing it.

V. Your Autonomy at the Threshold

A Guide to Informed Consent

Knowledge is a form of covering. When you understand what is happening at the threshold of your body, you are better able to advocate for yourself—not in opposition to your care team, but in collaboration with them.

You are permitted to say:

“I decline routine episiotomy. I understand that in rare, clearly explained emergencies—such as persistent fetal distress requiring immediate birth—it may be necessary. If that situation arises, I ask that you briefly explain the indication before proceeding whenever possible.”

These words are not combative. They are the language of a woman who understands her body and trusts the process while remaining an active participant in her own care. They are the language of someone who has been prepared.

Write them in your birth plan. Speak them aloud in your prenatal visits. Let your birth team know that you have tended this threshold with care, and that you expect to be met with the same.

VI. The Restoration of the Land

A Ritual Guide for Healing the Episiotomy

If you have received an episiotomy—whether chosen, necessary, or neither—this section is for you. What follows is not simply a clinical aftercare protocol. It is a ritual of return: a way of honoring the tissue that was cut, tending it with the same reverence we would give any wounded sacred ground, and helping it become whole again.

Healing moves in phases, as all true restoration does. We move from fire to knitting to sealing. From Pitta to rebuilding to softening. From the rawness of the cut to the elasticity of new skin.

Phase I: The Cooling Mercy — Days 1 through 7

In the first week, the site is dominated by heat—the Pitta of the surgical wound, the inflammation of the body’s first response. We do not fight this fire. We cool it with mercy.

The Herbal Compress: Soak organic cotton pads in alcohol-free Witch Hazel and Aloe Vera. Chill them in the refrigerator. The Witch Hazel acts as a gentle astringent, helping the edges of the skin begin to knit. The cool press offers brief, targeted relief without shocking the deeper tissue with prolonged cold.

The Peri-Wash: Every time you use the bathroom, rinse the site with warm water from a peri-bottle. Add a small pinch of sea salt and a single drop of Lavender essential oil. Never wipe. Pat dry with soft organic cotton, or use a hairdryer on the cool setting—trapped moisture in the stitches invites complication.

The Strategic Sit: Your weight should never press directly on the stitches in these early days. Use a donut cushion or a rolled blanket beneath the thighs. When you sit to nurse, you are already doing holy work—do not let the position of the body work against the healing of it.

“Lord, You who were wounded for our healing—be near to this wound now. Cool the fire. Hold the edges together. Let this body remember that it was made to be made whole.”

Phase II: The Knitting of the Soil — Days 8 through 21

Once the initial heat begins to subside and the stitches begin their slow dissolving, we move into tissue remodeling—the patient, quiet work of the body rebuilding itself from within.

The Sitz Bath: This is where the Calendula and Yarrow infusion becomes your most faithful companion. Draw a shallow, warm bath and steep the herbs in it before settling in. The warmth draws blood to the surface, bringing with it the oxygen and nutrients that accelerate healing. Sit for 15 to 20 minutes. Let the water hold you. Do this daily if you can.

The Nutrient Watch: Your body cannot knit new skin without the raw materials to do so. Vitamin C feeds collagen synthesis. Zinc supports tissue repair. Bone broth and mineral-rich foods are not optional comforts in this window—they are medicine. You are literally eating the building blocks of your new skin. Receive this as provision, not obligation.

The No-Strain Rule: Constipation is among the greatest threats to episiotomy healing. The pelvic floor cannot be given the rest it needs if it is recruited for strained elimination. Use magnesium glycinate or soaked flax seeds to keep the bowels moving softly. Warm prune juice, warm water with a squeeze of lemon—treat the gut as part of the wound, because it is.

“Creator, who makes all things new—I offer You this healing. Knit what was cut. Restore what was taken. Let the soil of this body be good soil again.”

Phase III: The Sealing and the Softening — Day 21 through Six Weeks

Surgical scars, left untended, can become brittle. The new tissue knits itself tightly, sometimes too tightly, creating rigidity where there was once elasticity. Dyspareunia—pain during intimacy—is not inevitable, but it is common when this phase is neglected. We tend it with oil, with breath, with patience.

Scar Tissue Massage: Once the stitches have fully dissolved and the skin is closed—usually around three to four weeks—begin applying a small amount of Vitamin E oil or Calendula salve to the scar with clean fingertips. Use gentle, small circular motions. You are not forcing the tissue; you are inviting it into conversation. You are breaking up adhesions—the places where the new tissue has bonded too tightly to the layers beneath—and teaching the scar to move.

Pelvic Floor Re-education: This is not the time for forceful Kegel contractions. This is the time for breath. Inhale slowly and feel the pelvic floor soften, lower, and release—like a flower opening. Exhale and feel a gentle, voluntary lift return. You are teaching the nerves to communicate with the muscles again. You are reminding the body that the pelvic floor is not only a wound—it is a living, responsive, capable architecture, and it remembers how to work.

“God of restoration—You who make beauty from ashes and oil from mourning—pour Your Oil of Gladness into this scar. Let it be soft. Let it be whole. Let it yield again in its season.”

The Watchman’s Warning

While the body is resilient and designed to heal, we must remain as Watchmen. Seek clinical care promptly if you notice any of the following:

• A foul or unusually strong odor from the site, which may signal infection.

• Severe, throbbing pain that is increasing rather than gradually decreasing.

• Redness or warmth spreading outward toward the thighs or buttocks.

• The edges of the wound separating rather than coming together—this is called dehiscence, and it requires prompt clinical attention.

These are not signs of failure. They are signals. The body is asking for more help than it can give itself, and seeking that help quickly is an act of stewardship, not weakness.

A Closing Word

The perineum is an altar. But it is also resilient flesh. It is designed to be made whole.

Whether you are reading this in preparation, in the middle of healing, or years later with questions you never got to ask—know this: what happened at your threshold does not define the wholeness of your body. You were made by the same God who breathed life into dust, who turned the rock into a pool of water, who makes all things new. Your body holds that covenant in its very cells.

You are not broken. You are the soil that yields, and then grows again.

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A Liturgy for the Healing Threshold

Lord of the tender places,

You who fashioned the threshold of birth

with the same hands that parted the sea—

come near to this body.

For the mothers who were cut without knowing they could ask.

For the mothers who said yes to the blade because the moment required it.

For the mothers who are still asking what was taken from them.

Come near.

Let the oil of Your healing be the oil of gladness.

Let the warmth of the sitz bath be a remembrance of Your mercy.

Let every careful breath into the pelvic floor be a prayer—

a returning to the body You made and called good.

Teach us that healing is not linear,

that scar tissue is not lesser tissue,

that the threshold that was cut can still be holy ground.

May the women who have crossed here

find their way back to themselves.

May the birthkeepers who stand watch

guard the threshold with gentleness and wisdom.

May the mothers who are preparing

know that their bodies are not obstacles

but the architecture of a holy crossing.

Amen.