The effect of midline episiotomy on the incidence and severity of vaginal outlet lacerations in spontaneous vaginal deliveries was studied in a retrospective manner by pairing women with and without episiotomy on the basis of age, parity and infant birth weight. When we controlled these three parameters, the patient with an episiotomy had fewer or less severe lacerations 33% of the time. However, when the episiotomy itself was counted as a laceration in the analysis, the number of patients benefitting from the procedure was reduced to 6%, with the nonepisiotomy patient having fewer lacerations than the episiotomy patient 78% of the time. The results suggest that for purposes of reducing outlet lacerations, the episiotomy should be used less often in spontaneous vaginal deliveries.