Everything Worse: How Routine Episiotomy Persisted for Decades`
We were taught that a clean surgical incision done routinely healed better than a tear. We were wrong, and 90% of women got one anyway.
There is a number buried in the literature that changes everything about how you think about episiotomy.
In some institutions in the 1980s, the routine episiotomy rate for first-time mothers exceeded 90%. Nine out of ten women having their first baby received a surgical incision in their perineum. Not because they were tearing. Not because the baby was in distress. Because the obstetrician was taught to cut.
The rationale was elegant and entirely wrong. A clean surgical incision, the argument went, heals better than a ragged laceration. Episiotomy prevents third- and fourth-degree tears. It prevents pelvic floor damage. It prevents long-term incontinence. It protects the baby’s head from prolonged pressure against the perineum.
Every element of this rationale has been disproven by randomized controlled trials and systematic reviews.
The Argentine Episiotomy Trial in 1993 was the first large randomized study. Hartmann’s systematic review in JAMA in 2005 was comprehensive. Multiple Cochrane analyses confirmed the finding. The conclusion was the same every time: routine episiotomy increased perineal trauma, increased blood loss, increased pain, and provided no benefit for maternal or neonatal outcomes.
The intervention caused the very injury it was designed to prevent.
ACOG now recommends against routine episiotomy. But it took more than a decade after the Argentine Trial for guidelines to change. And in some institutions, in some hands, the practice persists.
🎯 Free Subscriber Bottom Line: Routine episiotomy, once performed on up to 90% of first-time mothers, was shown by multiple randomized trials and systematic reviews to increase perineal trauma, blood loss, and pain while providing no benefit. ACOG now recommends restrictive use only. The gap between evidence and practice change was more than a decade, and the practice persists in some institutions and with operative vaginal deliveries.
Below, paid subscribers get: - The Bansal natural experiment from AJOG that showed abandoning routine episiotomy reduced severe lacerations - Rate trends from 90%+ to current levels, and where the practice still persists - The operative vaginal delivery nuance: where evidence is still debated - The Kristeller maneuver evidence (levator ani injury) and why fundal pressure should stop - A complete evidence table: study, year, finding, impact on practice - Malpractice implications of routine episiotomy in 2026 - Patient counseling scripts for discussing episiotomy with your provider.
