Abstract Objective: To evaluate the effect of preemptive episiotomy in the prevention of perineal tears (PT) in multiparous women with high striae gravidarum (SG) score. Methods: A randomized controlled study (Clinical Trials.Gov: NCT02717676) included multiparous women with singleton full-term pregnancy. SG score was assessed according to Atwal score at four body sites (Abdomen, breast, buttocks, hips). Women with total score >12 were randomized to Group (A): episiotomy was done after crowning of the fetal head during the second stage of labour and Group (B): no episiotomy was done. The primary outcome was the rate of third and fourth degree perineal tears. Results: Two-hundred fifty women were included in the study (125 in each arm). The overall incidence of PT was significantly high in group (B) than group (A) (90.4% Vs. 23.5%respectively, p < 0.001). In addition, the incidence of third and fourth-degree perineal tears was significantly higher in group (B) (15% Vs. 3.3%, p = 0001). Similarly, the incidence of first and second-degree perineal tears was significantly higher in group (B) (75.4% vs. 20.2%, p = 0.001) than group (A). Conclusion: Preemptive episiotomy in multiparous women with high SG score seems to be an effective strategy in prevention of perineal tears during vaginal delivery, especially the third and fourth-degree tears.