I am considering getting pregnant, but I am very squeamish and have a low threshold for pain. One thing that really makes me nervous is the episiotomy. Can you explain this? How painful is it? What if the doctor sews you back up too tightly -- will you have pain with sex afterwards?

Edna

It is amazing how well we can adapt and how much we can actually tolerate once challenged. Most women who are convinced they cannot handle labor do quite well, especially if they have taken a childbirth class beforehand and if they have a good support person with them throughout labor (be it husband, best friend or a doula, a professional labor coach). Educating yourself is your best defense -- the more you learn, the less fear of the unknown you will have, and the less fear, the less pain.

An episiotomy is a purposely made incision, or cut, in the perineum (the area between vagina and rectum) in order to enlarge the birth opening. It may decrease the duration of the final "pushing" phase by 15 to 20 minutes. The vast majority of the time it is only a couple of inches long and does not go near the rectum. If an episiotomy is deemed necessary, first the skin will be cleansed, then numbed with an injection of lidocaine (like the novocaine the dentist uses); I inject this while you are pushing so as to minimize discomfort from the shot. Next, surgical scissors are used to make the cut, usually during a push.

Episiotomies are not always necessary, and the routine use of episiotomy is something you need to discuss with your obstetrician. The decision whether to perform an episiotomy can only be made in the delivery room, when one can see how labor is progressing, how the perineum is stretching, and most important, how the baby is doing.

After the baby and the placenta are delivered, the doctor sews up the episiotomy. If you are not sufficiently numb, more lidocaine will be injected. The episiotomy is repaired anatomically, meaning everything is put back where it was in the first place; a good repair will be neither too tight nor too loose. Absorbable sutures that dissolve over time are used. Discomfort is common for a couple of weeks afterwards, but most women do not have problems by the time they are able to have intercourse again (four to six weeks after delivery). Women who are breastfeeding may be drier, and therefore intercourse, regardless of whether an episiotomy was done, may be uncomfortable, for a while longer.

If you would like to decrease your chances of needing an episiotomy, there are steps you can take before delivery. Practice Kegel exercises regularly throughout pregnancy; these exercises, which you will learn about during childbirth preparation, strengthen and tone the tissues around the vaginal opening. You -- or your partner -- can also regularly massage the perineum with warm oil (olive oil works well) for four to six weeks before your due date, to prepare the tissues to stretch more easily. You can find instructions on how to do this massage through childbirth preparation courses, in books and on the Internet. During labor, use warm moist compresses to keep the perineum supple; continue massage, especially while pushing; and aim for controlled, steady pushes to allow the perineum time to stretch.