Doctors now recognize that episiotomies, especially the type most commonly performed in the United States, can do more harm than good, Dr. Gossett said. The procedure doesn’t prevent severe tears, and some studies suggest that it actually increases the risk, especially when combined with tools such as forceps or a vacuum. Imagine trying to rip your shirt by pulling the hem apart, Dr. Gossett said. It would be nearly impossible. “But if I make a little nick in the hem and you do that again, you’ll be able to rip it all the way open,” she said. There is no evidence that episiotomies heal better than natural tears either, and the procedure has been linked to long-term problems like fecal incontinence. That’s why the American College of Obstetricians and Gynecologists has recommended against routine use of episiotomy since 2006. As a result, episiotomy rates declined dramatically in the United States. According to a data from 2012, about 12 percent of all vaginal births included an episiotomy.

Still, episiotomy rates vary widely, from less than 1 percent to more than 40 percent of vaginal births at some hospitals today, according to The Leapfrog Group, an organization funded by large public and private health care purchasers. That variation suggests that some doctors still perform the snip even when it may not be necessary.

When and how to snip

While organizations like ACOG now advise against routine episiotomy, they stop short of saying the procedure shouldn’t be used. But when it comes to deciding whether an episiotomy is warranted, there is precious little guidance. That’s because high-quality data doesn’t yet exist, so doctors and midwives have to rely on their clinical judgment.

Many will at least consider an episiotomy under certain circumstances, for example when the baby is on the cusp of being born and its heart rate slows. If the heart rate doesn’t recover, the baby needs to come out immediately, said Kelly Gallagher, Ph.D., a certified nurse midwife and chief of the midwifery division at the University of New Mexico in Albuquerque. And snipping through that tight tissue at the back of the vaginal opening can speed up delivery. “With that resistance gone, usually the baby will just come,” she said.

That’s what happened to Ilana Seidmann when she had her first child in 2017. She pushed and pushed, but her son wouldn’t budge. Labor “felt like a hundred marathons,” she said, yet Seidmann refused the doctor’s requests to consider a C-section. “I really wanted to do this the ‘natural’ way,” she said. After more than four hours of pushing, her son’s heart rate fell dramatically. Her doctor performed an episiotomy and pulled the baby out. “As far as I’m concerned, they probably saved my son’s life,” she said.