Generally the consensus is that a natural tear is preferable to an episiotomy. In my practice most multiparae do not need an episiotomy. Quite a number of first time mums do not need one if they push well. However natural tears can also be irregular and extensive. In general, with episiotomies, the likelihood of tears around the urethra or clitoris is less.
The overall recommendation is for restricted use of episiotomies. For example it can be useful in women who tend to be very oedematous and swollen at the perineum after prolonged pushing. I also tend to see more frequent vaginal of vulval haematomas in women who have prolonged distension (>20 min) of the perineum by the fetal head in an attempt to avoid a natural tear or episiotomy. Prolonged distension of the perineum is not ideal and may result in tearing of blood vessels within the vagina walls and this may result in severe pain and haematoma collection which requires a surgical procedure to remove the haematoma.
