Episiotomy is one of the most prevalent surgical interventions at the delivery room, ranging in frequency from less than 10% and up to 75% of vaginal births. However, cumulative evidence in the recent decades points to the lack of episiotomy efficiency and even to potential adverse consequences of this procedure. The objective of our trial was to examine the effect decreased episiotomy use on various maternal and neonatal obstetric outcomes. This randomized (1:1) parallel-group superiority trial was conducted between the years 2015 and 2018 in Bnai-Zion Medical Center, Haifa, Israel. Pregnant women towards first vaginal delivery underwent randomization into two groups: "avoidance of episiotomy” (i.e. the study group) or the "standard care” (the control cohort). In the study group, episiotomy was allowed only in cases of fetal distress, while in the control cohort the decision to perform episiotomy was based on the discretion of the attending caregiver. The primary endpoint was the incidence of advanced (3rd and 4th degree) perineal tears. Secondary outcomes included perineal integrity, suturing characteristics, second stage duration, incidence of postpartum hemorrhage, neonatal variables and various postpartum symptoms two days and two months after the delivery. Overall, 669 women were included in the trial - 334 in the study group vs. 335 controls. The two groups did not differ in terms of baseline demographic and obstetric characteristics. The rate of episiotomy was 29.6% in the standard care group, compared with 19.8% in the study group (p=0.004). Four (1.2%) advanced perineal tears were diagnosed in the study group (in one of these episiotomy was also performed), vs. ten=3.0% in the "standard care” group (three of these in conjunction with episiotomy). This yielded a Relative Risk for advanced perineal tears of 0.57 (95% confidence interval 0.25-1.30) in favor of "avoidance of episiotomy” group, a non-statistically significant effect. No noticeable differences were noted in any abovementioned secondary outcomes. Decreased use of episiotomy was not associated with increased rate of advanced perineal tears or any other adverse maternal or neonatal outcomes. Further studies should be conducted examining this important issue, with absolute avoidance of episiotomy in the study group.