The recent review of the Epi-No birth trainer [1] cannot be used to draw conclusions about the usefulness of Epi-No because the reviewed research studies took place where episiotomy is still practiced. The protocols used in such settings do not conform to those proven to optimize outcomes. The adoption of any new therapy should be based on research using scientific methodology adhering to evidence-based protocols.

Between 1940 and 1990, in most high-income countries, 100 % of women having their first child vaginally in a hospital underwent episiotomy. Episiotomy became obsolete in 1983 with the publication of a review of the previous 120 years of use of episiotomy which concluded that episiotomy results in more bleeding, perineal damage, third and fourth degree tears, pain, and incontinence of feces and urine than no episiotomy [2]. Lacking data to support its use, ACOG recommends that practitioners base their decision to perform an episiotomy on ‘expert opinion’ [3].

The optimal test of Epi-No is to test it in settings where protocols are based on evidence, i.e. where episiotomy is not practiced. Among 80 consecutive primiparous vaginal births delivered by practitioners who never performed episiotomies, 99 % were delivered without the need for suturing [4]. In settings where episiotomy is not practiced, using a combination of prenatal practice with Epi-No and slow delivery of the head starting at crowning, almost all primiparous vaginal births can be delivered without the need for suturing. Where episiotomy is still practiced, it is challenging to identify the benefits of Epi-No.