I finally found a homebirth MW in my area (most MWs are hospital based). When we were discussing episiotomies she said a woman 'rarely' ever needs one. She said, however, that there are rare instances when she can just tell that the mama is going to tear upwards- into the urethra, for example, or some other type of tear that might result in long term harm & discomfort. At these times she makes a small cut into the supple, fast healing perineum and the mama is then spared from any other tears. Everything I have read says that there is no proof for this- the mother might not tear at all, and, if she does get cut, it might extend into something terrible. But the MW assured me that it does indeed happen, and as a MW for 30+ years, she just instinctively knows when a bad upwards tear is going to happen and the only way to try and avoid it is an episiotomy.
My deepest fear is having yet another episiotomy and I am worried that if she actually believes they are *sometimes* useful, I might just end up with another one.
That said, she has a very hands off attitude regarding birth and sees her role as a MW as that of an unobtrusive observer watching a natural process unfold.