It is clearly justified in emergencies when the baby has to be delivered immediately. However, the other excuses are just "maybes." Maybe you will tear, maybe you will be stretched, maybe your uterus will prolapse (drop down) in later life and so on. But, maybe not! Twenty years ago, more than 90% of birthing women in the U.S. had an episiotomy. By 1993, it was down to 55% and the incidence continues to decrease, the latest figures being at 30%.

Doctors and midwives who perform episiotomies as a matter of course prefer not to risk a tear! However, once the perineum is cut, the incision may be extended further during the birth. This results in greater damage than if the tissues had torn only the amount required and following natural lines least resistance. Episiotomy causes blood loss: it is minor surgery and your informed consent should be required. A first-degree tear heals spontaneously and so may a second-degree tear, which is usually sutured. Third-degree tears into muscle definitely need suturing, and especially fourth-degree tears since they involve the anal sphincter.

Some believe that even if a tear were avoided, the muscles would be irrevocably stretched. However, cutting and stitching tissues may lead to poor results later. Instead, we recommend exercising the vaginal muscles to prepare and restore temporarily stretched—but intact—tissues. Interrupting the urine flow is a way to identify these muscles. Once you know the exercise, practice frequently throughout the day for the rest of your life. These internal and invisible exercises can be done anywhere at any time. Do them when you finish on the toilet, during sexual intercourse, before you lift or cough or sneeze.
Many women develop loss of urine (incontinence), especially as they get older, in sedentary society where obesity is an additional problem. In cultures where women squat more than they sit, incontinence is rare.
How to Avoid Episiotomy
During birth, your pelvis must be free of your body weight as while squatting, standing, or kneeling. Such positions have the added benefit of gravity. Women who are free to choose will find a position that feels instinctively right. Touch your baby's head as it emerges for important feedback. Massage and hot compresses may help, too. Give birth at your own pace, not according to the commands of others.

AVOID
Pulling on your legs or pushing with your feet against as this increases muscle tension.
Giving birth in a half-lying or backlying position. This reduces the size of your pelvis and its ability to open during birth.
Holding your breath to push. This causes reflex tightening of your vaginal muscles.

If you did have an episiotomy or tear that is still bothering you, seek treatment, even if it is years later. Exercises, ultrasound, and deep massage all help. Biofeedback assists those women who have trouble learning the right exercise or who are not improving.

For more information, see Essential Exercises for the Childbearing Year 4th edition, Harwich, MA: New Life Images, 1995.