What it is
Episiotomy used to be performed on most first-time vaginal births under the belief that a clean cut healed better than a tear. Modern evidence turned that on its head: routine episiotomy causes more severe injury than letting the perineum tear (or often stay intact) on its own. Today episiotomy is reserved for specific situations — mainly shoulder dystocia, some assisted (vacuum/forceps) births, and non-reassuring fetal status where delivery must happen very quickly.
Evidence review links
Each link opens the full review on the publisher's site in a new tab.
- ACOG Practice Bulletin 165: Prevention and Management of Obstetric Lacerations at Vaginal DeliveryACOG
- Selective versus routine use of episiotomy for vaginal birth (Cochrane Review)Cochrane
- Perineal techniques during the second stage of labour for reducing perineal trauma (Cochrane Review)Cochrane
- ACOG Committee Opinion 766: Approaches to Limit Intervention During Labor and BirthACOG
- ACOG Practice Bulletin 178: Shoulder DystociaACOG
Possible benefits
- In shoulder dystocia, an episiotomy can give more room for internal maneuvers[ACOG↗][ACOG↗]
- May shorten the second stage when speed is genuinely needed for the baby[ACOG↗]
- For a small number of instrumental deliveries, mediolateral episiotomy may reduce severe tears[Cochrane↗]
Possible risks
- Routine episiotomy causes MORE 3rd/4th-degree tears than restrictive use[Cochrane↗][ACOG↗]
- Increased pain, blood loss, and healing time compared with an intact perineum or small spontaneous tear[Cochrane↗]
- Possible long-term impact on sexual function and pelvic-floor recovery[ACOG↗]
Alternatives
- Warm compresses on the perineum during pushing lower severe tears[Cochrane↗]
- Slow, controlled pushing (breathing baby down) at crowning[ACOG↗]
- Hands-on vs. hands-poised approaches — both are reasonable; ask what your provider is comfortable with[Cochrane↗]
- Upright, side-lying, or hands-and-knees positions for pushing[ACOG↗]
Current evidence
ACOG Practice Bulletin 165 recommends restrictive rather than routine episiotomy. Cochrane's review found restrictive use reduces severe tears, healing complications, and pain compared with routine use. When one is needed, mediolateral (angled) rather than midline is generally preferred to reduce anal-sphincter injury.
Where the evidence is clear · where people may choose differently
For most topics, guidelines from ACOG, WHO, and other major bodies broadly agree on the core safety points (when to act in an emergency, informed-consent standards, monitoring baselines). Where reasonable people — and even guidelines — differ tends to be around thresholds (when to start or stop something), preferences (comfort, environment, support), and values (how you weigh small risks against benefits). Use the questions below to explore those pieces with your care team.
Educational only. Your care team can help you weigh what applies to your specific situation.
Related evidence topics
- Perineal Tears (Grades 1–4)Most vaginal births involve some tearing. Grades 1–2 are common and heal well; grades 3–4 involve the anal sphincter and need specific repair and follow-up.
- Vacuum vs. Forceps (Operative Vaginal Birth)Instruments used to help the baby out during pushing, usually when the baby is close but not quite born and there's a reason to speed things up.
- Shoulder DystociaAn uncommon emergency where the baby's head is born but a shoulder gets stuck behind the pubic bone; the team uses specific maneuvers to free it quickly.
Questions to ask your care team
- ?Do you perform episiotomy routinely, or only for specific reasons?
- ?If needed, would you use midline or mediolateral, and why?
- ?What do you do to reduce tears (warm compresses, positions, coached vs. spontaneous pushing)?
- ?Will you talk to me before making a cut, unless it's a true emergency?
- ?How will you help me heal afterward — pain management, follow-up?
Universal questions (works for any decision)
A short BRAIN-style set you can bring to any conversation about interventions, monitoring, or care decisions.
- ?Why are you recommending this now — is it urgent, routine, or optional?
- ?What happens if we wait an hour (or longer) before deciding?
- ?What signs would tell us this is working — or that we need to change course?
- ?What are the alternatives, including doing nothing?
- ?What would you recommend if this were your family?
- ?What would change your recommendation?
Sources & provenance
Tap a source to open the original guideline or review in a new tab.
- ACOG Practice Bulletin 165: Prevention and Management of Obstetric Lacerations at Vaginal Delivery — ACOG
- Selective versus routine use of episiotomy for vaginal birth (Cochrane Review) — Cochrane
- Perineal techniques during the second stage of labour for reducing perineal trauma (Cochrane Review) — Cochrane
- ACOG Committee Opinion 766: Approaches to Limit Intervention During Labor and Birth — ACOG
- ACOG Practice Bulletin 178: Shoulder Dystocia — ACOG
Plain-language paraphrase. Re-verify before publish.
Last reviewed: 2026-07-03
Further reading — canonical references
Read the source material directly. Each link opens the publisher's own current guidance in a new tab — cross-check what we summarize against what they say.
Tier 1 · Clinical guidelines
Tier 2 · Systematic reviews
Educational only. Guidelines evolve — the linked publisher pages will reflect newer guidance than any static snapshot.
Version history — v1.0.0
v1.0.0 · 2026-07-03 · LlaMamma editors
Initial episiotomy topic.
New guidance from ACOG, WHO, Evidence Based Birth, or other listed sources is recorded here and can be updated remotely without a new app release.