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What is it
A cut made with scissors to enlarge the vaginal opening at the time of birth. Historically routine, now recommended only selectively — for specific situations like shoulder dystocia, an urgent assisted delivery, or when a severe tear is imminent.
How your body works here
A natural tear generally follows the path of least resistance and is often superficial. A midline episiotomy cuts straight through skin, muscle, and can propagate into the anal sphincter (3rd/4th degree extension) more easily than a spontaneous tear. Mediolateral episiotomies are safer but still involve muscle. There is no evidence that routinely cutting prevents severe tearing; in most cases it makes it more likely.
Benefits (B)
- In true emergencies (shoulder dystocia, urgent instrumental delivery, non-reassuring fetal heart rate at crowning) can speed delivery of a baby that needs to come out fast.Review sources ↓
Risks (R)
- Compared with spontaneous tearing: more pain in the first days postpartum, higher risk of severe (3rd/4th degree) extension into the anal sphincter, more blood loss, and slower healing.Review sources ↓
- May affect long-term pelvic floor function and sexual comfort.Review sources ↓
Alternatives (A)
- Selective (indicated-only) episiotomy — the current standard.Review sources ↓
- Warm compresses, slow controlled pushing, and position changes to reduce the chance of severe tearing without cutting.Review sources ↓
Evidence summary
Cochrane review (12+ trials) and ACOG Practice Bulletin 165 both recommend selective, not routine, episiotomy. Routine episiotomy increases severe tears, blood loss, and postpartum pain without benefit.
Sources
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Questions to ask your provider
- What's your episiotomy rate?
- Under what specific circumstances would you recommend one for me?
- Would you use midline or mediolateral?
Intuition & Nothing/Wait (the I and N in BRAIN)
What is your gut telling you? What happens if you do nothing or wait?
Add to my birth plan
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This is a personal preference, not a decision. Final choices happen in conversation with your care team.
After you talk it through
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