Episiotomy/perineal tear fistulas, an occasional complication of a fourth-degree tear where lay open should be avoided

21 fistulas on the perineum through an episiotomy wound or a tear are reported. They all presented with pain swelling and discharge intermittently. Diagnosis was delayed beyond a year in 12. All were associated with a fourth-degree tear which was repaired in 3 and missed in 18. The external opening of the track was at 7-11 o’clock in relation to the anus and the internal opening was at 12 o’clock in the anus in all except one, four were complex tracks. Setons were commonly used to drain these fistulas, in which only one healed, lay open was successful in all 8 but was always associated with worsening incontinence especially faecal soiling. Nearly all with a fistula were high risk for OASI: in 18 this was a first vaginal birth, in 4 there was a shoulder presentation and 17 had an assisted delivery: forceps in 8, ventouse in 5 and both in 4. Obstetricians should be aware of this rare complication of fourth degree tear and seek colorectal investigation early.