Is the EPI-NO useful?

I’ve had a few queries about the efficacy of perineal trainers (specifically the EPI-NO) in reducing birth trauma to your lady bits.

This post ain’t for you if:

  • You’re squeamish about medical stuff;
  • If the thought of someone pushing out a watermelon through an opening the size of a lemon freaks you out;
  • If you’re that husband/ boyfriend/ partner who plans to stay away from the ‘business end’ in labour;
  • If the words ‘episiotomy’ and ‘perineal trauma’ make you feel ill.

Consider yourself warned!


If you’re interested, please check out the official EPI-NO website.

I love the leading line… “German innovation is making a natural childbirth easier…”  GERMAN INNOVATION MAKES EVERYTHING BETTER – EVEN YOUR VAGINA!

Anyway, there are less than 10 EPI-NO specific studies out there… I thought it would easier to summarise them in a table…

Year Country Purpose Study Design Results Conclusion
2001 Germany Effectiveness of EPI-NO in avoiding episiotomies and improving foetal outcome Comparison of EPI-NO group (50 pregnant women) against group not using EPI-NO EPI-NO group had: reduced episiotomies, less perineal tears (2 vs 4%), less analgesia required, better one-minute APGAR scores Birth training with EPI-NO significantly decreases the rate of episiotomies in primiparous
2004 Singapore To study the use, safety and effectiveness of EPI-NO in primiparous women Comparison of EPI-NO group (31 pregnant women, primiparous, prospective) vs not using EPI-NO group (60 pregnant women, primiparous, retrospective) EPI-NO group had: lower perineal trauma rate (90 vs 97%, not significant). EPI-NO was well tolerated, no lacerations or infection resulting from its usage; one case of minimal bleeding post-usage EPI-NO is safe and acceptable to users. EPI-NO reduced episiotomy rates. Overall perineal trauma rate was slightly (but not significantly) lower in the EPI-NO group
2004 Australia Pilot study of the first use of the EPI-NO birth training device in Australia for women having their first baby Comparison of EPI-NO group (48 primigravidae) vs not using EPI-NO group (matched for ?) EPI-NO group had: improved outcome for the perineum compared with the non-user group The EPI-NO device should be offered as an option to all primigravidae to use during the late third trimester
2009 Germany To verify the preliminary results with EPI-NO in a prospective randomised trial Randomised, single-blind multicentre trial in four university hospitals in Germany including 276 primigravidae EPI-NO group had:  significant increase in the incidence of intact perineum (37 vs 26%) and a tendency towards lower episiotomy rates (42 vs 51%).  No significant differences between the two groups regarding incidence of perineal tears, duration of second stage of labour, use of pain relief and rate of vaginal infection Training with EPI-NO increases significantly the likelihood of having an intact perineum and reduces the episiotomy rate
2011 Australia Whether antepartum use of the EPI-NO may reduce levator trauma 200 nulliparous women were examined with four-dimensional translabial ultrasonography at 35-37 weeks of gestation and 3 months postpartum in a randomised controlled pilot study The EPI-NO group had:  a non-significant 42% and 30% reduction in levator avulsion and microtrauma There is a non-significant lower incidence of pelvic floor muscle injury in women who used the EPI-NO device from 37 weeks onwards
2014 Brazil How tolerable is the EPI-NO as a perineal distensibility technique 227 full-term pregnant women were asked about their sensation of discomfort (measured on the Visual Analogue Scale) The greater the perineal distensibility on the EPI-NO, the lower the pain reported by the patients The assessment of perineal distensibility with EPI-NO was well tolerated by the pregnant women
2014 Brazil Comparison of perineal distensibility between women with twin and singleton pregnancies Prospective cross-sectional case-control study with 20 twin and 23 singleton pregnancies. The greater a pregnant woman’s abdominal circumference, the greater the perineal distensibility, regardless of whether the pregnancy is twin or singleton

The final study doesn’t relate to EPI-NO but the findings are interesting all the same…

Bottom line:

  • Overall there is evidence that EPI-NO is useful in reducing rate of episiotomy, perineal tears, trauma to pelvic floor muscles, and pain levels during delivery;
  • Quality of study design is variable; some results are significant, some not significant (but remember this doesn’t mean that the findings aren’t useful; significance could change with tweaks in study design);
  • Certainly there are no complications associated with use of the EPI-NO; from the studies there was one case of mild bleeding post usage, no biggie;
  • The price tag in Australia is in the region of AUD 200 so if you can afford this, and you are motivated to use it correctly, then certainly no harm (and most likely some good) would come from using it;
  • One thing the studies don’t mention is that the EPI-NO is also recommended for use after delivery to get your bits back into shape. Surely not a bad thing.

Please share your feedback and comments – has anyone used this? Love it? Hate it? Don’t want to discuss it because it’s your punani? It’s OK… you can share with Dr Nat… 🙂

(Don’t want to judge, but if I had the surname of the 2nd author, final reference, I would consider changing it…)

Hillebrenner J, Wagenpfeil S, Schuchardt R, Schelling M, Schneider KT.  Initial experiences with primiparous women using a new kind of EPI-NO labor trainer. Z Geburtshilfe Neonatol. 2001 Jan-Feb;205(1):12-9.
Kok J, Tan KH, Koh S, Cheng PS, Lim WY, Yew ML, Yeo GS. Antenatal use of a novel vaginal birth training device by term primiparous women  in Singapore. Singapore Med J. 2004 Jul;45(7):318-23.
Kovacs GT, Heath P, Heather C. First Australian trial of the birth-training device EPI-NO: a highly significantly increased chance of an intact perineum. Aust N Z J Obstet Gynaecol. 2004 Aug;44(4):347-8.
Ruckhäberle E, Jundt K, Bäuerle M, Brisch KH, Ulm K, Dannecker C, Schneider KT. Prospective randomised multicentre trial with the birth trainer EPI-NO for the prevention of perineal trauma. Aust N Z J Obstet Gynaecol. 2009 Oct;49(5):478-83.
Shek KL, Chantarasorn V, Langer S, Phipps H, Dietz HP. Does the EPI-NO Birth Trainer reduce levator trauma? A randomised controlled trial. Int Urogynecol J. 2011 Dec;22(12):1521-8.
Nakamura MU, Sass N, Elito Júnior J, Petricelli CD, Alexandre SM,  Araujo Júnior E, Zanetti MR. Parturient perineal distensibility tolerance assessed by EPI-NO: an observational study. Einstein (Sao Paulo). 2014 Jan-Mar;12(1):22-6.
Kubotani JS, Moron AF, Araujo Júnior E, Zanetti MR, Soares VC, Elito Júnior J. Perineal Distensibility Using EPI-NO in Twin Pregnancies: Comparative Study with  Singleton Pregnancies. ISRN Obstet Gynecol. 2014 Mar 27;2014:124206.

If you have found a spelling or grammatical error, please notify me by highlighting that text and pressing Ctrl+Enter.



  1. I was told by a midwife to avoid as it’s the equivalent to giving birth 50+ times and no one wants that pelvic floor when they’re 50. Does the pelvic floor study suggest this isn’t true or is that a study we need to weight 30 years for?

    • Hi Kimberley,

      Thanks for reading and thanks for your comment!

      I’d be interested to know what evidence your midwife bases her opinion on – because certainly the available literature/ evidence suggests otherwise. If it her ‘opinion’ then unfortunately that doesn’t even factor on the ‘levels of evidence’ scale, and is not strong in terms of evidence (which is what this blog is about).

      The EPI-NO does not stretch the whole birth canal – it specifically targets the pelvic floor muscles and perineum – and studies to date (and I’ve listed all of them here) suggest benefits as listed. In that sense, using the EPI-NO is not equivalent to giving birth, where a baby is moving down from the uterus, through the cervix and pelvic floor muscles, vagina, perineum and out!

      The results of the pelvic floor study are in direct contrast to what your midwife is claiming. Also (and she should know this) that simply giving birth is not the only factor affecting pelvic floor function later in life – it depends on type of birth/ delivery, duration of labour (in fact lots of other factors associated with the labour and delivery) and also to ‘intrinsic’ patient factors (eg. some women just have tissues that bounce back better than others), age of menopause, and lots more.

      Please feel free to direct her to the ‘references’ section so she can read the evidence for herself.

      Thanks again for the comment, please keep them coming! Dr Nat.

      • Thanks

        I had (bub is now 4.5 months) come to the conclusion that most of what midwives said to me was opinion.

        I really like your evidence based info… Refreshingly helpful.

  2. Hi Dr Nat

    I know it’s been some time since this post but I am now looking into using the epi-No and wanted to know if you have any references on:
    1. prolapse due to or post EPi-no use
    2. ability of perineal skin/tissues to return to pre baby state ie not be “floppy” so to speak due to continuous stretching over a 3-5week period (from week 37 to potentially 41/42)

    thank you

    • Thanks Tennille for your questions!

      Prolapse is affected by many things – childbirth being just one factor. Other causative factors include congenital factors, smoking, obesity, and the use of instrumentation during delivery. Prolapse classically arises from damage to the levator ani, which occurs in 10-20% of deliveries.

      There isn’t any literature looking specifically at whether EPI-NO causes prolapse but I would doubt it does because (1) The literature actually supports more the fact that EPI-NO protects the pelvic floor muscles – and would therefore protect again later prolapse and (2) I doubt that repeated gentle stretching of the perineal tissues could cause such significant damage to the pelvic floor muscles that it causes prolapse. (If anyone can produce literature to the contrary, please let me know!) (3) How on earth could researchers tease apart the factors causing prolapse and be prepared to follow up these women until likely menopause (when most causes present to healthcare professionals) – maybe these studies will be coming out in the years to come…

      With regards to your second question, about the ability of the perineal skin and tissues to return to pre-baby state, again there is no hard literature on this, probably because it is impossible to separate the effects of childbirth itself, the effect of hormones relaxing the perineal issues, and the effects of the perineal dilator from each other.

      Overall, the EPI-NO literature, while a bit fuzzy, does suggest it has benefits, and as yet there is no evidence supporting side-effects or dangers of EPI-NO usage. The ‘complications’ I have personally heard of are personal opinion from healthcare professionals, along the line of “the perineum isn’t made to be stretched prior to birth”, “use of a man-made device must surely be unnatural and wrong” which unfortunately isn’t evidence-based.

      Hope that helps!

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