Why Routine Episiotomy Practice Has Declined
Routine episiotomy is no longer performed because evidence-based medicine has proven that selective (restrictive) episiotomy policies result in 30% fewer severe perineal and vaginal injuries compared to routine use, without any demonstrated benefits to justify the guaranteed trauma of a surgical incision. 1, 2
The Evidence Against Routine Episiotomy
The shift away from routine episiotomy is driven by high-quality randomized controlled trials demonstrating clear harm from the practice:
Maternal Outcomes with Selective vs. Routine Episiotomy
Selective episiotomy reduces severe perineal trauma by 30% (RR 0.70,95% CI 0.52-0.94) compared to routine use, meaning women are actually better protected when episiotomy is used only when truly necessary rather than routinely. 2
Routine episiotomy guarantees perineal trauma requiring sutures, while selective policies result in 26% less need for suturing (RR 0.74,95% CI 0.71-0.77) and 31% fewer wound healing complications (RR 0.69,95% CI 0.56-0.85). 2, 3
No protective benefit exists for the outcomes clinicians historically believed episiotomy would prevent: There is no difference in severe vaginal or perineal trauma rates, no difference in long-term dyspareunia (painful intercourse) at 6 months or beyond (RR 1.14,95% CI 0.84-1.53), and no difference in urinary incontinence. 2
The Morbidity of Perineal Trauma
The consequences of perineal injury—whether from episiotomy or severe spontaneous tears—are substantial and directly impact quality of life:
Obstetric anal sphincter injuries (OASIS) occur in 4-11% of vaginal births and carry devastating consequences: 29-53% of affected women experience flatal incontinence and 5-10% develop fecal incontinence within the first 6 months postpartum. 1, 4
Wound complications after perineal trauma are common, with infection rates of 0.1-23.6% and wound breakdown (dehiscence) rates of 0.21-24.6%. After anal sphincter injuries specifically, infection occurs in nearly 20% and dehiscence in nearly 25% of cases. 1
Long-term quality of life impacts include persistent perineal pain, dyspareunia, delayed resumption of sexual activity, depression, and interference with maternal-infant bonding and newborn care. 1
Why the Practice Persisted Despite Evidence
Historical beliefs that have been disproven included:
The false belief that episiotomy prevents severe tears: In reality, restrictive policies result in less posterior perineal trauma overall. 1, 2
Cultural misconceptions and time pressures: Studies from settings with persistent high episiotomy rates reveal providers cite fear of tears, unfounded beliefs about anatomical differences, overcrowded delivery rooms, and cosmetic concerns—none of which are evidence-based justifications. 5
The misunderstanding that "controlled" surgical incisions are safer than natural tears: Evidence shows the opposite—allowing the perineum to stretch naturally (or tear minimally when necessary) results in better outcomes than routine cutting. 3, 6
Current Evidence-Based Practice
Modern obstetric guidelines recommend selective (restrictive) episiotomy, meaning the procedure should only be performed when there is a clear clinical indication, not as routine practice:
Most women (over two-thirds) who avoid episiotomy will either have an intact perineum or only first-degree tears, which are benign injuries that often don't require suturing. 6
When episiotomy rates dropped from 18.8% to 1.3% in one high-risk maternity ward, intact perineum rates increased from 28.8% to 37.5%, and severe perineal injuries with sphincter damage decreased from 1% to 0.3%. 6
The Lancet Global Health explicitly identifies routine episiotomy as an example of intervention misuse or overuse leading to iatrogenic complications, noting that randomized trials have long demonstrated restrictive policies are associated with less posterior perineal trauma and fewer complications. 1
Clinical Implications
The evidence is unequivocal: routine episiotomy causes more harm than benefit. The practice declined because selective use protects women from unnecessary surgical trauma while maintaining safety for both mother and infant (no difference in 5-minute Apgar scores less than 7). 2 This represents evidence-based obstetrics prioritizing maternal morbidity and quality of life outcomes over outdated surgical tradition.