Vaginal tears can occur during childbirth, most often at the vaginal opening as the baby's head passes through, especially if the baby descends quickly. Tears can involve the perineal skin or extend to the muscles and the anal sphincter and anus. The midwife or obstetrician may decide to make a surgical cut to the perineum with scissors or scalpel (episiotomy) to make the baby's birth easier and prevent severe tears that can be difficult to repair. The cut is repaired with stitches (sutures). Some childbirth facilities have a policy of routine episiotomy.
The review authors searched the medical literature for randomised controlled trials that compared episiotomy as needed (restrictive) compared with routine episiotomy to determine the possible benefits and harms for mother and baby. They identified eight trials involving more than 5000 women. For women randomly allocated to routine episiotomy 75.10% actually had an episiotomy whereas with a restrictive episiotomy policy 28.40% had an episiotomy. Restrictive episiotomy policies appeared to give a number of benefits compared with using routine episiotomy. Women experienced less severe perineal trauma, less posterior perineal trauma, less suturing and fewer healing complications at seven days (reducing the risks by from 12% to 31%); with no difference in occurrence of pain, urinary incontinence, painful sex or severe vaginal/perineal trauma after birth. Overall, women experienced more anterior perineal damage with restrictive episiotomy. Both restrictive compared with routine mediolateral episiotomy and restrictive compared with midline episiotomy showed similar results to the overall comparison with the limited data on episiotomy techniques available from the present trials.