CLINICAL OPINION Episiotomy in modern clinical practice: friend or foe? Maurizio Serati 1 & Stefano Salvatore 2 & Diaa Rizk 3 Received: 25 January 2019 /Accepted: 15 February 2019 # The International Urogynecological Association 2019 Abstract The Cochrane library first published a meta-analysis in 2000 on the role of the episiotomy in modern clinical practice, which concluded that only a policy of selective episiotomy is acceptable with evidence-based improvement in maternal health compared with routine episiotomy. Many years later, however, the new version of the Cochrane meta-analysis changed the previous recommendations in that the selective use of episiotomy could not be considered beneficial in all cases. A selective policy is associated with a statistically significant reduction in severe perineal and/or vaginal trauma, whereas routine episiotomy seems to protect against these complications only after instrumental deliveries. Both in the short and the long term, selective medio-lateral episiotomy has no additional beneficial effects without clear evidence of causing harm to the mother or baby. Keywords Anal incontinence . Episiotomy . Urinary incontinence . Pelvic floor dysfunction . Vaginal delivery Introduction Episiotomy is one of the most commonly performed surgical procedures in medicine. The Cochrane library first published a meta-analysis in 2000 on the role of the episiotomy in modern clinical practice that concluded that only a policy of selective episiotomy is acceptable with evidence-based improvement in maternal health compared with routine episiotomy [1]. An up- date of this review in 2008 confirmed the same conclusions [2]. Ten years later, however, the new version of the Cochrane meta- analysis changed the previous recommendations in that the se- lective use of episiotomy could not be considered beneficial in all cases, although there is no clear evidence that this approach would result in harm to mother and baby [3]. What are the advantages of selective versus routine episiotomy? Is there a difference between the complications of medio-lateral and mid- line procedures? What are the reasons for the recent change in the recommendations of Cochrane’ s review? It seems timely to revisit this debate by urogynecologists to give a balanced and evidence-based opinion on whether or not episiotomy is routine- ly indicated at vaginal birth and whether the benefits and risks of medio-lateral versus the midline procedures are different. Discussion Episiotomy is defined as a surgical incision in the perineum to enlarge the vaginal introitus and facilitate delivery of the fetus. Sir Fielding Ould, an obstetrician, introduced this procedure into obstetric practice in 1742. In 1920, Joseph DeLee, an eminent obstetrician from Chicago, recommended the use of Belective^ medio-lateral episiotomy although the standard of care in the USA gradually shifted to the midline procedure in the 1970s. The routine use of episiotomy was perceived as a milestone in obstetric care, resulting in significant improve- ment in maternal and neonatal outcomes worldwide. By the 1980s, the prevalence of episiotomy reached 90% of all vag- inal deliveries in some South-American and Asian countries, and was performed in more than 60% of deliveries in North America. In Europe, the frequency of episiotomy was only 30% in that period, but progressively increased in the 1990s [4]. Despite the promising results in the 1980s, both women and physicians, however, began questioning whether the hy- pothetical Bbenefits^ of episiotomy were true because of the associated morbidity. In fact, two prestigious scientific journals introduced an entirely different paradigm as early as * Maurizio Serati mauserati@hotmail.com 1 Department of Obstetrics and Gynecology, Urogynecology Unit, University of Insubria, Piazza Biroldi 1, 21100 Varese, Italy 2 Urogynaecology Unit, Obstetrics and Gynecology Unit, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy 3 Department of Obstetrics and Gynecology, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain International Urogynecology Journal https://doi.org/10.1007/s00192-019-03912-1