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This systematic review and meta-analysis evaluated the impact of a restrictive episiotomy protocol on the incidence of severe perineal tears in first vaginal deliveries. A comprehensive search was conducted in PubMed, CENTRAL, Embase, Latin American and Caribbean Health Sciences Literature and ClinicalTrials.gov until June 2024. The study followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and was registered in PROSPERO (CRD42024550295). Randomised controlled trials comparing restrictive episiotomy (for foetal indications only) with selective episiotomy in first-time vaginal deliveries were included. Two reviewers independently extracted data, assessed bias using the Cochrane Risk of Bias tool and conducted assessment according to Grading of Recommendations Assessment, Development and Evaluation (GRADE). Statistical analyses were performed using R (v.4.4.0) and RevMan (v.8.6.1). Two trials with a total of 785 participants met the inclusion criteria. The restrictive episiotomy group showed a 51.8% reduction in severe perineal tears (risk ratio (RR)=0.50, 95% CI 0.21 to 1.21), though this result was not statistically significant. Episiotomy rates were lower in the restrictive group (RR=0.61, 95% CI 0.49 to 0.76). There were no significant differences in minor perineal tears, intact perineum rates or neonatal outcomes between the two groups. Despite the lack of statistical significance in the reduction of severe perineal tear occurrence, the findings suggest a trend towards improved perineal outcomes with restrictive episiotomy. Additionally, given the potential physical and psychological consequences of episiotomies, limiting their use to foetal indications may be beneficial. Further research is needed to confirm these findings and guide clinical practice.