Routine Episiotomy — the Preventive Cut That Caused the Very Tears It Promised to Stop

In 1920 the Chicago obstetrician Joseph Bolivar DeLee, in a paper titled “The Prophylactic Forceps Operation,” urged physicians to cut the perineum of laboring women as a routine to spare them the worse damage of a ragged spontaneous tear — and the gap between that protective promise and the eventual evidence is the entire case. By the late twentieth century the operation DeLee reasoned his way into was one of the most common surgical procedures performed on American women, done on the order of a third of all vaginal deliveries (60.9% in 1979) and on a clear majority of first-time mothers, almost none told there was no trial behind it.

The justification was intuitive: a clean, controlled incision must heal better than a jagged laceration, and a pre-emptive cut must protect the pelvic floor against future prolapse and incontinence. The intuition was wrong in the most consequential way. When the procedure was finally tested against the comparator it had skipped for decades — selective use, cutting only on indication — the routine cut did not prevent severe trauma. A midline episiotomy extended the wound straight toward the anal sphincter and rectum, so the prophylactic incision was itself causally linked to the third- and fourth-degree tears it was meant to forestall.

The reckoning was slow because the practice was entrenched, not because the data were ambiguous. A 1983 interpretive review of more than 350 sources spanning 1860 to 1980 found no defensible evidence for routine use; the 1993 Argentine Episiotomy Trial, a randomized study of 2,606 women, showed routine use conferred no benefit and more harm; and the 2005 AHRQ-commissioned systematic review in JAMA closed the question, finding routine episiotomy improved no immediate outcome and prevented no incontinence or prolapse. In April 2006 the American College of Obstetricians and Gynecologists issued Practice Bulletin No. 71, recommending the routine be restricted. The procedure was not banned — it retains narrow, evidence-based indications — but its eighty-year career as a default was abandoned. It stands as obstetrics’ cleanest case of a plausible, near-universal intervention adopted on reasoning and reversed only by the trial that should have come first.