Episiotomy: routine cutting causes more damage, not less
The evidence reversed, and practice followed slowly.
An episiotomy is a cut through the perineum to enlarge the opening. It was once done routinely on the theory that a clean cut heals better than a ragged tear. That theory is wrong.
Across 12 trials and 6,177 women, using episiotomy selectively rather than routinely reduced severe perineal trauma by about 30% (relative risk 0.70). There was no clear difference in infection, long-term painful sex, or urinary incontinence. The reviewers concluded that believing routine episiotomy reduces trauma is not justified by current evidence.
US practice has changed substantially. Episiotomy in spontaneous vaginal delivery fell from 26.4% in 2000 to 4.9% in 2018.
If an episiotomy is needed, the angle matters. Across 16 studies and more than 650,000 women, a mediolateral cut, angled away from the midline, was associated with less sphincter injury than no episiotomy (relative risk 0.67). A midline cut runs straight toward the anus and carries higher sphincter injury risk.