Episiotomies: Why They're Less Common Than They Used to Be

An episiotomy is no longer a routine part of vaginal delivery in the US. Forty years ago, it was performed in the majority of births. Today, it's done in around 10 percent or fewer of vaginal deliveries, and the recommendation from ACOG is that it should only be performed when there's a specific clinical reason — not as a default.

If you've been picturing labor with an automatic episiotomy as part of the script, that picture is significantly out of date.

#What an Episiotomy Is

An episiotomy is a small surgical cut made to the perineum — the area between the vagina and the anus — just before delivery to enlarge the vaginal opening. It is done by the delivering clinician with scissors or a scalpel, and the cut is repaired (sutured) after the baby is delivered.

The cut direction varies:

• A midline (straight back) cut is the older standard in US practice.
• A mediolateral (angled) cut is more common in some other countries.

Both heal. Both involve a brief stinging cut at the moment they're done. With an epidural in place, most moms don't feel the cut itself.

#Why It's No Longer Routine

For decades, routine episiotomy was thought to:

• Shorten the second stage of labor
• Reduce severe perineal tearing
• Heal better than a natural tear

Research over the past 30 years has not supported these claims. The current evidence actually suggests the opposite in many cases:

• Episiotomy does not consistently shorten the second stage
• Routine episiotomy is associated with more severe perineal injury overall, not less
• Healing from an episiotomy is not better than from a comparable natural tear, and is often worse in some specific ways
• The cut can extend further than intended, sometimes into deeper tissues

The accumulating evidence led ACOG and other bodies to formally recommend against routine use. The current standard is "restrictive" episiotomy — done only when specifically indicated.

#When It's Still Done

A few specific situations where an episiotomy may still be used:

• Urgent delivery for fetal distress when the baby needs to come out within minutes and the perineum is genuinely the bottleneck.
• Operative vaginal delivery (vacuum or forceps) where the instrument needs more room to operate.
• Shoulder dystocia or other situations where additional maneuvering room is needed.
• A specific clinical judgment by the delivering clinician based on the picture in the moment.

Even in these situations, episiotomy is not automatic. The decision is made in real time based on what would actually help.

#What to Do If You Have Preferences

If you'd like to avoid an episiotomy, you can:

• Bring it up in your prenatal care. Most US clinicians are already practicing restrictive episiotomy, but stating your preference confirms it.
• Have your preferences in writing in any birth plan documents you bring to the hospital.
• Verbalize during pushing if you want to confirm. "I'd prefer to tear naturally if possible" is a clear sentence.

If you'd like to consent to an episiotomy more readily, that's also a fair conversation to have. Your preferences shape the team's threshold for using it.

A few honest things:

• In a true emergency, your team may need to act quickly and explain afterward. The decision in that moment is about safety.
• Even with strong preferences against, an episiotomy may be the right answer at the moment of delivery. Trust the team's reading of the picture.
• Tearing on your own is not "bad" or "worse than" an episiotomy. Most natural tears are smaller and heal differently than the older lore suggests.

#A Few Practical Notes

• The repair, if you have one, is part of the delivery experience. It happens after the baby is born and the placenta is delivered. Local anesthetic is used if you don't have an epidural; the existing epidural can be topped up if you do.
• Healing is similar to a natural tear of comparable depth. The same care principles apply: keep clean, ice, witch hazel, sitz baths after the first day, supportive comfort tools.
• First bowel movement can be the first time you really notice the repair. Stool softeners, hydration, and patience help.

#The Reframe

If you've been worried about an automatic episiotomy as part of labor, the modern reality is that it isn't automatic anymore. Routine episiotomy is no longer recommended, US rates have dropped substantially, and clinicians are taught to use episiotomy selectively only when there's a real reason. Your preferences are usually consistent with current practice — you may not need to advocate for them, but stating them costs nothing and confirms alignment with your team.

The picture from a generation ago has moved on. Your labor will reflect the current standards, not the historical ones.