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Great expense for uncertain benefit.

I 1982, Banta and Thacker1 published an article that questioned the benefits of episiotomy—then the second most common surgical procedure in the United States after umbilical cord ligation. Their impetus for doing so was to continue their assessment of the “frequent use of low-capital procedures such as episiotomy that are done at great expense for uncertain benefit.” The methodology they used was to review more than 200 years of literature, which was somewhat lacking in rigor and which failed to demonstrate any evidence of benefit from routine use of episiotomy. This is in keeping with the award, 3 years earlier by Archie Cochrane, of the “Wooden Spoon Award”2 to obstetrics, as the specialty that had demonstrated the least use of randomized controlled trials to evaluate the effectiveness of patient care and treatment. More than a quarter century later, this issue of Obstetrics & Gynecology contains two studies of episiotomy that continue this dialogue and contribute scientific data to inform us. Unless vaginal deliveries themselves become obsolete, thirdand fourth-degree lacerations will occur. It is critical that we incorporate techniques that will decrease the complications stemming from their repair. Dr. Duggal and her coauthors3 (see p. 1268) show a significantly decreased risk of perineal wound infections 2 weeks after thirdor fourth-degree laceration repairs in those women randomly assigned to receive a single dose of broad-spectrum antibiotics during the repair, compared with women receiving placebo. Those in the antibiotic arm had only 23–40% of the complications of those in the placebo arm 2 weeks after delivery. Importantly, the study excluded women who were group B streptococci–positive who presumably had already received intrapartum antibiotics. Caution in the liberal use of antibiotics is certainly appropriate in this era of methicillin-resistant Staphylococcus aureus and other antibiotic-resistant organisms. However, given the morbidity associated with surgical site infections and the frequency of infections with thirdand fourth-degree lacerations, if a simple, relatively inexpensive measure has such a positive effect on short-term outcome, we should consider adopting this strategy in appropriate patients. Dysparunea, perineal pain, bleeding, infection, and pelvic floor dysfunction have been shown in multiple studies since Banta and Thacker’s 1982 description of the poor state of the science about episiotomy.4,5 In the second episiotomy article in this issue, Alperin et al6 (see p. 1274) have shown a significant increase in the occurrence of sponantaneous lacerations at delivery in the pregnancy after one in which episiotomy occurred. These authors have quantified what I and others have noted empirically: women tend to re-tear along prior perineal injuries. The risks of spontaneous lacerations in a second vaginal birth increase with the degree of injury in the first, A second-degree laceration in the first delivery has a significant odds ratio (OR) of 3.82 for a spontaneous laceration in the second; an initial episiotomy without extension has an OR of 4.47 in the second; and a thirdor fourth-degree laceration in the first has an 8.55 OR for spontaneous laceration in the second. See related articles on pages 1268 and 1274.