Episiotomy in Operative Vaginal Delivery Reduces the Risk of Obstetric Anal Sphincter Injuries in Nulliparous Women: A Systematic Review and Meta-Analysis

Background: Although routine use of episiotomy is widely discouraged in spontaneous vaginal deliveries, the use of episiotomy in operative vaginal delivery (OVD) remains highly debated. This systematic review and meta-analysis evaluated the current evidence on the safety of episiotomy in preventing obstetric anal sphincter injuries (OASIS) during OVD. Methods: A systematic literature search was conducted on PubMed/MEDLINE and CENTRAL databases with a cut-off date of November 2025. The protocol was registered in PROSPERO. We included studies which encompassed the incidence of OASIS when episiotomy (median or medio-lateral) was performed during vacuum or forceps delivery and when episiotomy was not performed. Randomized controlled trials (RCTs), prospective or retrospective cohort studies and observational studies were considered appropriate study designs. A meta-analysis using risk ratio as the outcome measure was performed to compare the presence of the event (OASIS) in patients with or without episiotomy. Results: A total of 15 studies were analyzed to evaluate the role of medio-lateral episiotomy (MLE) in OVD. The results demonstrated a statistically significant lower rate of severe perineal trauma in the experimental group (pooled RR 0.5; 95% CI: 0.30–0.84). A statistically significant difference in support of the use of MLE was found in two further subgroup analyses, comprising 14 studies focusing on the role of MLE during vacuum delivery (VD) and 9 studies considering the role of MLE during forceps delivery (FD). Conclusions: This study highlights that the use of MLE in nulliparous women undergoing OVD is associated with a significantly decreased risk of OASIS.