‘Play it safe’ to minimize introitus damage


To the Editor:

I have always marveled over the elasticity of the cervix and vagina. The former stretches to full dilation to accommodate a descending fetal head, usually about 10 cm in diameter—yet just 6 weeks postpartum we find only a “fishmouth” appearance. The latter is capable of amazing expansion that lets a full-term baby wiggle through with relative ease, and 2 weeks later I have seldom detected any “battle scar.”

The introitus, on the other hand, is something else. I have never seen the introitus stretch to 10 cm in diameter without incurring some tear for the passage of an 8-lb baby. Some such tears are small and easy to repair, while others may be large and irregular with serious consequences.

Allow me to use an analogy: What would happen if you forced your adult-sized head through the opening of an infant’s turtleneck? Clearly the rim would be damaged, but we have no way to predict where that damage would occur or how severe it would be.

Have we forgotten Dr. James Marion Sims? Or the Hamlins, who set up a vesicovaginal repair hospital in Ethiopia? One wonders if the rectovaginal tear is one excuse for polygamy.

Statistics offer only the big picture. You have to individualize. Vaginal birth after cesarean may be safe, but if uterine rupture occurs, then what? Play it safe!


Dr. Repke Responds:

I appreciate the interest in my article shown by Drs. Clemenger, Williams, and Ishida.

Dr. Clemenger reasserts many of the clinical biases addressed in my article—clinical biases unsubstantiated by data. That said, I would agree with Dr. Clemenger’s assessment that avoiding episiotomy may result in slightly greater risk of anterior damage—a fact pointed out in my article. The question is whether such avoidance is worth the “routine” use of episiotomy. The data would say it is not.

Dr. Williams is correct in stating that proper surgical technique is essential for achieving a satisfactory anatomic and functional result after episiotomy repair. While an appropriately designed clinical trial may be impossible to conduct, his points are nonetheless well taken.

Dr. Ishida likewise expresses concern over damage to the introitus resulting from episiotomy avoidance. His citation of the African experience with rectovaginal fistulae is misleading, however, as these fistulae have very little to do with episiotomy use or nonuse, but instead are nearly always related to mismanaged and protracted labors (lasting days, not minutes or hours). I would, however, agree with his cautionary note about individualization of care. The point of my article was actually to emphasize precisely that concept. Episiotomy should be performed when clinical judgment dictates its use is indicated. Episiotomies should not, however, be routine.

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