Don’t let others decide how you should practice


“It’s time to restrict the use of episiotomy” by Robert L. Barbieri, MD

I appreciate Dr. Barbieri’s thoughtful editorial on episiotomy. However, I am afraid we are being victimized by arbitrary numbers thrown at us by a bunch of desk-bound, nonpracticing physicians and bureaucrats. Is the cesarean section rate too high? Is the episiotomy rate too high? Did any lawyer or insurance company executive help you reach the crucial decision?

Yes, the vaginal ring structure may dilate to accommodate the baby’s passage, but how about the introitus? It is a rare perineum that opens to 10 cm! I most certainly don’t like to repair an irregularly torn perineum! No one can make the decision for you; you have to be there to determine the best approach, based on how the perineum stretches. (Have your scissors handy, just in case!)

Don’t let the players of numbers, such as Cochrane reviewers, reduce a complicated procedure like childbirth into a simpler model. And don’t let bystanders dictate what you can or cannot do. Remember, we have been trained to do the best for the woman and baby under the circumstances, and no two cases are alike!

Yasuo Ishida, MD
St. Louis, Mo

Dr. Barbieri responds: Episiotomy is bound to attract more scrutiny, not less

I appreciate Dr. Ishida’s assessment of “battlefield conditions” from the front lines of obstetrical care, and I empathize with his perspective. Unfortunately, I think we are entering an era when assessment of physician practice patterns, expressed as rates of performance of certain procedures and rates of “complications,” will become routine. It is likely that the rate of episiotomy will decrease in the United States. The degree to which “outlier” physicians will attract scrutiny from hospital credentialing committees and regulatory agencies is unclear.

Next Article: