Third-degree perineal tears are a major complication in vaginal childbirth and are more frequent in vaginal operative deliveries (VOD). Several studies have reported on risk factors associated with severe perineal trauma and its complications, such as faecal and urinary incontinence. Within this, the role performance and type of episiotomy remains controversial, especially if combined with VOD. Although midline and mediolateral episiotomies are commonly performed in combination with VOD, their role for prevention of severe perineal trauma in VOD is still unclear. In order to elucidate the impact of midline and mediolateral episiotomy in conjunction with VOD, the present review focuses on the potential risks and benefits of these episiotomy types and their role in VOD.