Confused by cover illustration of cerclage … and more

These patients also need a complete evaluation of their lipid status. The standard lipid profile ordered by most physicians is not accurate enough in today’s world. A vertical auto profile (VAP), which gives much more information about a patient’s lipid status, should be done because many of these patients already have significant dyslipidemia.

Although the American Diabetes Association states that an HbA_1c greater than 6.5 is diagnostic of diabetes, there are occasional patients in the 6.5 to 7 range who are not diabetic and these people also should have a glucose tolerance test. Anyone with an HbA_1c of 7 or greater should be considered diabetic without additional testing.

I fully agree that we need to be very aggressive in looking for these problems so that we can prevent the serious complications associated with uncontrolled diabetes.

Michael D. Birnbaum, MD
Elkins Park, Pennsylvania

L&D without support facility and trained personnel is irresponsible

Is collaboration too risky? The answer is absolutely! An OB would have to be crazy to lend his or her name or back-up to a midwife working outside the hospital setting.

Assisting women in labor and delivery without support facilities and trained personnel at hand is irresponsible. Every practicing OB knows that, even in the most “routine” labor, things can go very bad very quickly. The ability to immediately intervene has saved countless lives.

In addition, I cannot believe any medical liability insurance provider would agree to cover an OB who is involved with deliveries outside a hospital setting. Add that some midwives are so poorly trained, and the multiple dangers are intensified.

Who would want to voluntarily carry that burden of the death of a child or mother for the rest of their lives?

To those physicians who do want to stick their necks out and agree to provide back up: keep in mind that, when a lawsuit comes, the deep pockets are not with the midwife, but with you.

James P. Haley, MD
Rome, Georgia

Do what you’re comfortable doing, based on your experience and dexterity

I have to disagree with Dr. Barbieri’s recommendation to start using a mediolateral episiotomy. I read the comparisons from the studies mentioned—all good, sound data—but from a personal point of view, from a physician who has been in practice more than 19 years, and from one who has done both mediolateral and median episiotomies, I find it far easier to repair the median type.

I have had very few complications of breakdown, infection plus breakdown, or poor sphincter control with median episiotomies. In fact, my incidence of the above complications is close to nill, and my frequency of third- and fourth-degree tears is low. I know how to repair third- and fourth-degree tears, and you still can get one of these tears with a mediolateral episiotomy. It also depends on the physician performing delivery and whether or not they know how to support the perineum in the second stage, to reduce tearing in general.

I get consults from patients who have had mediolateral repairs elsewhere, and they suffer an increased incidence of marked vaginal asymmetry (one side higher than the other). For these patients, I perform vaginoplasties and vaginal tightening. I have seen horrible results from a mediolateral repair, one of which developed necrotizing fasciitis. There is also concern about scarring: Dr. Barbieri’s Editorial mentioned that the median incision group had “good” appearance (43%) compared with 27% in the mediolateral group. (I know I’m cherry picking data now.)

My point is that recommending mediolateral episiotomy across the board may cause more morbidity, especially in the hands of someone who doesn’t know how to make a good repair.

The pearl on page 10 is good. However, I think that the physician should do what he or she is comfortable doing, based on his or her experience and surgical dexterity. I shall continue to use the median episiotomy as my “go to” procedure.

Marcus D. Barnett, MD
Houston, Texas

Dr. Barbieri responds Consider occasionally trying mediolateral episiotomy?

I deeply respect the clinical experience and insights of Dr. Barnett. I understand that he has concluded that the benefits of median episiotomy are superior to mediolateral episiotomy, and I encourage him to continue performing median episiotomy. I wonder if he would consider occasionally performing mediolateral episiotomy when doing an operative vaginal delivery?

A recent article concluded that when performing an operative vaginal delivery, a mediolateral episiotomy was associated with a 6-fold decreased odds for developing an obstetrical anal sphincter injury compared with a median episiotomy.¹