Nursing care
Episiotomy and Perineal Care: the nurse's role, start to finish
Written and reviewed by Dana Whitfield, RN, MSN · 5 min read · Updated September 2026
Short answer
Episiotomy and perineal care nursing management follows a clear sequence: ice to the perineum for the first 24 hours to limit swelling, then warmth such as sitz baths afterward to promote healing and comfort. Cleansing is always front to back to keep bacteria away from the incision, and the nurse monitors for infection, haematoma and wound breakdown at every assessment.
What the procedure achieves
An episiotomy is a controlled surgical incision of the perineum made during the second stage of labor to enlarge the vaginal opening, most often to expedite delivery when fetal distress is present, to prevent a more extensive or jagged spontaneous tear, or to accommodate instrumental delivery with forceps or vacuum. A mediolateral incision is angled away from the anal sphincter and reduces the risk of a fourth-degree extension compared with a midline incision, though midline heals with less discomfort when it does not extend.
Routine episiotomy is no longer standard practice; current guidance favours a restrictive approach, using it selectively rather than for every delivery, because unrestricted use increases perineal trauma without improving outcomes for most women. Understanding that shift matters for nursing assessment, since a spontaneous laceration and a surgical episiotomy are managed with the same core principles once repair is complete.
Pre-procedure nursing responsibilities
When an episiotomy looks likely, the nurse prepares the perineum, positions the patient in lithotomy or a supported position the provider requests, and has suture material, local anaesthetic and repair instruments ready at the bedside before crowning. Confirm the patient's understanding that this may be needed and, where time allows, that consent has been discussed.
Continue fetal heart rate monitoring through crowning and delivery, since the decision to cut is often made in response to fetal status. After delivery, assist with positioning for the repair, provide analgesia as ordered, and support the patient through what can be an uncomfortable few minutes of suturing immediately after birth.
Equipment and positioning
The provider needs local anaesthetic, a needle driver, suture, scissors, forceps and adequate lighting, and the nurse's role is to have these ready and to assist with retraction and swabbing as requested. Positioning is typically dorsal lithotomy with stirrups, adjusted for the patient's comfort and the provider's access.
After repair, help the patient into a side-lying or supported position that keeps pressure off the perineum, and apply the first ice pack promptly. Correct early positioning reduces oedema and sets up the comfort measures that follow for the next day.
Complications and early signs
Watch for haematoma formation, a firm, painful, discoloured swelling at the repair site that does not match the expected mild bruising, since it can expand quickly and cause significant blood loss concealed in the tissue. Infection presents as increasing pain, redness, warmth, purulent discharge or fever, and wound breakdown, dehiscence, shows as separated suture line edges, often with associated infection.
Report a REEDA assessment (redness, oedema, ecchymosis, discharge, approximation) that is worsening rather than improving over successive checks. Escalate any suspected haematoma immediately, since it is the complication most likely to cause rapid deterioration if missed.
Post-procedure care
Apply ice to the perineum for the first 24 hours; cold constricts vessels, limits oedema and numbs the area, and is the correct first-line comfort measure regardless of whether the trauma was a surgical episiotomy or a spontaneous tear. After that first day, switch to warmth, sitz baths or warm compresses, which improve circulation to the healing tissue and continue to ease discomfort as the acute swelling settles.
Perineal hygiene is always front to back, whether wiping, showering, or using a peri bottle, to keep gastrointestinal flora away from the healing incision and the urethra. Offer a peri bottle for use after toileting, encourage a high-fibre diet and adequate fluids to keep the first bowel movement soft, and give a stool softener as ordered, since straining threatens the repair. Assess the wound at each perineal check using REEDA, and give analgesia proactively rather than waiting for the patient to ask.
What to teach before discharge
Reinforce the ice-then-warmth sequence in the patient's own words before she leaves: cold packs for the first day, then sitz baths or warm compresses from day two, and to keep using a peri bottle front to back with every toileting for as long as the area feels tender. Most perineal repairs heal within two to three weeks, though full comfort can take longer.
Teach the warning signs that mean she should call rather than wait: fever, worsening rather than improving pain, foul-smelling discharge, or a wound that looks like it is coming apart. Cover pelvic floor exercises once the acute soreness has settled, and remind her that intercourse and tampon use should wait until the provider confirms healing at the postpartum check.
The next step on this is the same as on everything else here: answer questions and read the rationales. Our maternity and newborn practice questions are the closest set to what this page covers.
Common questions
How long should ice be used on the perineum after episiotomy?
Ice is used for the first 24 hours to reduce swelling and numb the area. After that, warmth, such as sitz baths or warm compresses, takes over to support healing and comfort.
Why is front-to-back cleaning so important after episiotomy?
Wiping or rinsing front to back keeps bacteria from the rectal area away from the healing incision and the urethra. It is a basic infection-prevention step, not an optional detail, and should be reinforced with every perineal care instruction.
What does a perineal haematoma look like?
A firm, tense, increasingly painful and discoloured swelling at or near the repair site that seems out of proportion to expected bruising. It can expand rapidly with concealed blood loss and needs prompt provider notification.
Is episiotomy done for every vaginal delivery?
No. Current practice favours a restrictive approach, reserving episiotomy for situations such as fetal distress, instrumental delivery, or risk of a more severe spontaneous tear, rather than performing it routinely.
When can a patient resume intercourse after an episiotomy repair?
Most providers advise waiting until the postpartum check, usually around four to six weeks, confirms the wound has healed. Timing depends on how the repair is healing at that visit, so it should be individualised rather than fixed to a set date.