To the Editor:
I read with interest Dr. John T. Repke’s article, “When is episiotomy warranted? What the evidence shows” (October 2003). I have been involved in obstetrics and gynecology in private practice in the same area since 1965, and frequently supervise residents at a local teaching hospital. In recent years I have become concerned by the reluctance of many residents to do episiotomies. Often the result is a tear perineally, vaginally, or—worst of all—periurethrally. I have tried to impress on residents that an episiotomy accomplishes some positive outcomes: namely, less stress of pushing by the mother, as well as fewer painful, hard-to-repair tears that can sometimes lead to fistulae.
In my training we were required to perform episiotomy on almost all primiparous patients and many multiparas. I am not sure whether that resulted in less pelvic relaxation, but I do believe it was better for the mother.
All my episiotomies are midline, and I have never had a rectovaginal fistula. If a fourth-degree extension is properly repaired, a fistula should never develop.
ALLAN CLEMENGER, MD