Episiotomies are still performed, but at dramatically lower rates than a generation ago. What was once a near-automatic part of vaginal delivery in many hospitals has become a selective procedure reserved for specific clinical situations. In some countries the drop has been steep enough that the procedure feels almost extinct to younger patients, while in others it remains routine. The shift reflects decades of research showing that routine episiotomy caused more harm than it prevented, but the procedure has not disappeared, and understanding when and why it is still used matters for anyone planning a vaginal birth.
How Much Rates Have Actually Fallen
The decline is real and well documented, though it looks different depending on where you are. In one large national study tracking non-instrumental vaginal deliveries from 2013 to 2022, the episiotomy rate dropped from about 63 percent to 21 percent over that decade.1PubMed Central. National trends of episiotomy in non-instrumental vaginal deliveries (2013-2022): A multi-data source approach In the United States, the shift began earlier. By the late 2000s, research confirmed that routine episiotomy had declined since guidelines began discouraging liberal use.2PubMed. Episiotomy in the United States: has anything changed? But “declined” does not mean “vanished.” About one in five vaginal births in that national dataset still involved an episiotomy by 2022, and in some hospital systems and countries the figure remains much higher.
The variation across Europe alone is striking. A study of 20 European countries found episiotomy rates ranging from under 4 percent in Denmark to 75 percent in Cyprus.3PubMed. Variations in rates of severe perineal tears and episiotomies in 20 European countries: a study based on routine national data in Euro-Peristat Project That twenty-fold gap between countries with similar medical infrastructure tells you this is not purely a medical decision. Culture, training traditions, legal environments, and care models all play a role.
Why the Medical Consensus Shifted
For most of the twentieth century, episiotomy was treated as protective. The reasoning sounded logical: a clean surgical cut should heal better than a ragged natural tear, the cut should shield the pelvic floor from damage, and it should speed delivery for the baby’s benefit. Research has contradicted every one of those claims.
A Cochrane review of randomized trials found that a policy of selective episiotomy, rather than routine use, reduced the number of women experiencing severe vaginal or perineal trauma by roughly 30 percent.4PubMed Central. Selective versus routine use of episiotomy for vaginal birth Earlier clinical reviews were even more blunt: episiotomy does not decrease damage to the perineum but increases it, fails to prevent pelvic floor problems later in life, and is associated with greater blood loss, more postpartum pain, and higher rates of painful intercourse compared with allowing natural tears to occur.5PubMed. Routine use of episiotomy in modern obstetrics. Should it be performed? Midline episiotomies in particular raise the risk of the most serious tears, the kind that extend into the anal sphincter. In one comparative study, deep perineal tears occurred in about 15 percent of midline episiotomies versus 7 percent of mediolateral ones.6PubMed Central. The outcomes of midline versus medio-lateral episiotomy
The evidence stacked up consistently enough that the World Health Organization stopped recommending routine episiotomy, and professional bodies around the world followed. The current consensus supports selective use only, meaning that the procedure should be reserved for situations where the clinical benefit outweighs the known risks.
When Providers Still Perform Them
Selective use is not the same as no use. Situations where clinicians still consider episiotomy include assisted deliveries with forceps or vacuum, fetal distress requiring rapid delivery, shoulder dystocia (when the baby’s shoulder gets stuck), and cases where the perineal tissue appears very rigid and at imminent risk of an uncontrolled severe tear. The exact threshold varies by provider, hospital, and country, and there is genuine clinical disagreement about how often these situations truly call for a cut versus watchful management.
The honest reality is that some of the remaining episiotomies fall into a gray zone. A provider who trained in an era of routine use may reach for the scissors more readily than one trained under restrictive guidelines. A hospital with a high-intervention culture may have a rate several times that of a neighboring facility with identical patient demographics. In the United States, hospital characteristics like location, teaching status, ownership, and region were all independently associated with episiotomy rates, even after adjusting for patient factors.7Joint Commission Journal on Quality and Patient Safety. Uptake and Utilization of Practice Guidelines in Hospitals in the United States: the Case of Routine Episiotomy Urban nonteaching and rural hospitals had higher odds compared to urban teaching hospitals.
Do Natural Tears Actually Heal Better?
This is the question that surprises many people, because it sounds counterintuitive. A surgical cut, made with sharp scissors, should logically be neater and easier to repair than a jagged tear. But tissues do not always follow that logic. Most natural tears during vaginal birth are superficial first- or second-degree tears that involve only the skin and some muscle, and they heal well with or without stitching. Episiotomies, by contrast, are always at least second-degree because they deliberately cut through muscle.
One comparative study of first-time mothers found that the majority with perineal tears reported little or no pain, while the majority with episiotomies reported moderate to severe pain. On the third postpartum day, about two-thirds of episiotomy wounds were only partially healed, while the tear group fared better.8Indian Journal of Nursing Studies. Evaluate the Level of Pain and Wound Healing Process in Episiotomy as Compared to Perineal Tear Among Primiparous Mothers: A Comparative Study This does not mean every tear heals better than every episiotomy, but the blanket assumption that cutting is kinder to tissue has not held up.
The serious concern is third- and fourth-degree tears, which extend into or through the anal sphincter. One study at a hospital with a restrictive episiotomy policy found that episiotomies were associated with higher odds of severe tears in an initial analysis, though after adjusting for factors like whether a woman was having her first baby and her BMI, the association weakened.9PubMed Central. Examining the Association Between Episiotomy and Severe Perineal Tears in a Tertiary Care Center Implementing a Restrictive Episiotomy Policy Interestingly, the large national dataset that documented falling episiotomy rates also tracked a small but significant rise in third-degree tears as the episiotomy rate dropped, from about 0.15 percent to 0.31 percent.1PubMed Central. National trends of episiotomy in non-instrumental vaginal deliveries (2013-2022): A multi-data source approach Whether that uptick reflects the absence of episiotomies in cases where they would have been protective, or simply better detection and reporting, remains debated.
What Happens to Sexual Function Afterward
Painful sex after childbirth is common regardless of whether an episiotomy was performed, but the procedure does seem to make it more likely. A study comparing vaginal delivery with mediolateral episiotomy to both intact-perineum vaginal delivery and cesarean section found that women in the episiotomy group had lower overall sexual functioning scores up to five years postpartum. Desire, arousal, and orgasm were all affected, though the study did not find an association with urinary or fecal incontinence.10PubMed. Long-term impacts of vaginal birth with mediolateral episiotomy on sexual and pelvic dysfunction and perineal pain
Another study found that painful intercourse was reported by 21 percent of women who had vaginal deliveries (a group that included episiotomies) compared with 8 percent of those who had cesarean sections.11PubMed Central. Episiotomy and the Development of Postpartum Dyspareunia and Anal Incontinence in Nulliparous Females The original claim that episiotomies would protect sexual function by preserving pelvic floor anatomy has been thoroughly undermined by these findings. If anything, the cut introduces scar tissue that can make intercourse uncomfortable long after the wound itself has healed.
How Repair Technique Affects Recovery
When an episiotomy is performed or a tear needs stitching, the way those stitches are placed matters more than many patients realize. Research has consistently found that continuous (running) suturing techniques cause less pain than interrupted (individual) stitches. A Cochrane review of multiple trials found that continuous suturing was associated with less pain in the first ten days, lower painkiller use, and fewer instances of sutures needing removal.12PubMed Central. Continuous versus interrupted sutures for repair of episiotomy or second degree tears A large trial published in The Lancet confirmed the pattern: about 27 percent of women reported pain at ten days with continuous stitching versus 44 percent with the interrupted method.13The Lancet. The Episiotomy
A more recent randomized trial also found that the continuous non-locking approach led to better wound healing scores, less pain during urination and bowel movements, and earlier return to sexual activity.14PubMed Central. Continuous non-locking vs. interrupted suturing techniques for the repair of episiotomy or second-degree perineal tears: A single-blind randomized controlled trial If you do end up with an episiotomy or a tear that requires stitching, asking your provider about their preferred suturing technique is a reasonable conversation to have during prenatal care. Many providers already use continuous methods, but it is not universal.
When the Wound Does Not Heal Smoothly
Most episiotomies heal within a few weeks, but complications happen. Wound separation, called dehiscence, is the most worrying one, and it was associated with infection in roughly 80 percent of cases in one study.15PubMed. Early repair of episiotomy dehiscence associated with infection In that same study, early re-repair (done an average of about six days after the wound opened) was successful in 94 percent of patients. The takeaway: if your stitches open up, prompt attention usually leads to a good outcome, but waiting too long can make re-repair harder.
Wound care products are also evolving. A systematic review found that lactic acid-based wound care led to roughly 30 percent faster healing, about half the infection rate, and lower pain scores compared with traditional antiseptics like povidone-iodine or saline.16PubMed Central. The Role of Lactic Acid in Episiotomy Wound Healing: A Systematic Review For the rare cases where dehiscence is severe enough to resist conventional repair, newer physiotherapy techniques using radiofrequency and magnetotherapy have shown promising results in small case series, with healing achieved in ten to twenty days compared to four to eight weeks for surgical re-closure.17PubMed Central. Short‐Term Effects in the Treatment of Episiotomy Dehiscence in Physiotherapy: A Novel Approach in a Case Series Report
Can You Reduce Your Chances of Needing One?
Several approaches during labor have been studied. Perineal massage and warm compresses applied during the pushing stage showed strong results in one randomized trial: women in the treatment group were nearly half as likely to need an episiotomy, and the rate of an intact perineum was 47 percent in the massage-and-compress group versus 26 percent in the control group.18PubMed. Perineal massage and warm compresses – Randomised controlled trial for reduce perineal trauma during labor However, a separate trial comparing massage combined with warm compresses to massage alone found no additional benefit from adding the compress to massage in first-time mothers.19PubMed. Combined perineal massage and warm compress compared to massage alone during active second stage of labour in nulliparas: A randomised trial The massage itself seems to be the more active ingredient.
Your choice of care model also matters. In the Netherlands, a nationwide study found that episiotomy rates were about 9 percent in midwife-led care compared with about 24 percent in obstetrician-led care.20PubMed Central. Differences in rates of severe perineal trauma between midwife-led and obstetrician-led care in the Netherlands: A nationwide cohort study Both settings saw rates fall over time, but the gap persisted. In an Australian study, privately insured women, who were more likely to be managed by obstetricians, were up to twice as likely to receive an episiotomy as publicly insured women primarily managed by midwives, even after controlling for clinical factors.21PubMed. Women’s choice? The impact of private health insurance on episiotomy rates in Australian hospitals That does not mean obstetricians are doing something wrong. Higher-risk births are routed to obstetricians, and those births are more likely to need intervention. But the difference is larger than risk profiles alone can explain.
Who Is More Likely to Get One
In the United States, demographic patterns complicate the picture. A large JAMA study found that white women had an episiotomy rate of about 16 percent compared with roughly 8 percent for Black women, and women with commercial insurance had a rate of about 17 percent compared with 11 percent for those on Medicaid.22JAMA. Variation in and Factors Associated With Use of Episiotomy These disparities persisted even after adjusting for clinical and hospital characteristics. The reasons are layered: insurance type influences which provider you see, which hospital you deliver at, and what style of care management that provider practices. Legal environments add another variable. Research on defensive medicine has found that states adopting caps on certain lawsuit damages saw a reduction in episiotomy use without any change in newborn outcomes, suggesting that fear of litigation influences some providers to intervene more.23Journal of Empirical Legal Studies. Defensive Medicine and Obstetric Practices
The Consent Problem
One of the most troubling findings in the episiotomy literature has nothing to do with tissue healing. In a recent survey, 21 percent of respondents reported having had an episiotomy, and 75 percent of those women said they did not have a choice in the matter.24PubMed. Role of Obstetric Violence and Patient Choice: Factors Associated With Episiotomy A separate study found that procedures like episiotomy performed without informed consent or adequate information were strongly associated with women’s perceptions of abuse during childbirth.25PubMed. Informed consent and obstetric violence: Women’s experiences of childbirth
The ethical challenge is real. Episiotomy decisions often happen in the final minutes of pushing, when a woman is exhausted and focused on delivery. Ethicists have proposed using the prenatal period to discuss preferences and values around perineal interventions, so that explicit consent can be sought at the point of action, with clearly communicated opt-out consent as a fallback only when the stakes are high and the woman does not give a clear response.26PubMed Central. The ethics of consent during labour and birth: episiotomies If you have strong feelings about episiotomy, the time to discuss them is during prenatal visits, not when you are ten centimeters dilated. Including your preference in your birth plan and making sure your support person knows your wishes can help bridge the gap when communication during labor is difficult.
The Psychological Dimension
Perineal trauma of any kind, whether from episiotomy or from tearing, has psychological consequences that are often overlooked. A population-based survey found that women who experienced perineal trauma reported more postnatal physical symptoms and were more likely to report post-traumatic stress symptoms. Each additional physical symptom was associated with substantially increased odds of adverse psychological outcomes.27PubMed Central. The relationship between perineal trauma and postpartum psychological outcomes: a secondary analysis of a population-based survey The connection runs through pain, difficulty with daily activities like sitting and walking, disrupted breastfeeding, and the sense of bodily violation that can accompany an unwanted procedure. Providers who frame the episiotomy conversation as purely physical are missing a significant part of the picture.
A Training Paradox
The success of restrictive episiotomy policies has created an unexpected problem. As rates have fallen, junior obstetricians and midwives have fewer opportunities to learn how to perform the procedure well and how to repair complex perineal injuries.28PubMed Central. Educational efficacy of the simulation-based episiotomy training: a multi-center observational study Simulation-based training programs have stepped in to fill the gap, using models that let trainees practice cutting and suturing without a live patient. The concern is straightforward: the cases where episiotomy genuinely is needed tend to be urgent, and having a provider who has rarely performed one fumbling through the technique at that moment is not ideal. This is one of the few areas where “we do it less” introduces a genuine tradeoff in clinical competence, and training programs are actively working to address it.