The use of episiotomy has been widespread in the United States since the 1920s. Obstetric textbooks cite several justifications for its use; the presumed maternal benefits are maintenance of pelvic floor integrity and prevention of lacerations. Despite its frequent use, surprisingly few studies of episiotomy have been undertaken to evaluate its actual effectiveness. Most of these studies were done before the era of active participation in birth by the laboring woman which, along with methodologic problems, severely restricts their value to practitioners today. Additional well-designed studies are sorely needed, not only of episiotomy itself but of other techniques such as antenatal perineal massage, which are recommended as alternatives but remain untested.