软产道损伤的诊断与处理

1 软产道裂伤1.1 会阴及阴道裂伤:正常情况下会阴及阴道伸展性很大,临产后胎头下降,提肛肌向两侧扩展,阴道扩张,会阴体也随之变薄,有利于胎儿娩出.当胎儿与产道不相适应,如胎儿过大或产道狭窄;过期妊娠,胎头较硬,不易变形或会阴坚韧不易扩张;产力过强,胎头娩出过快或产道扩张不足;会阴切开术切口过小;因滞产、营养不良及全身重度水肿而致会阴水肿等时均易致裂伤.会阴裂伤按撕裂的深度可分为三度:Ⅰ度裂伤指阴道下部粘膜,阴唇系带,小阴唇及会阴皮肤破裂,肌层及筋膜完整,裂伤一般较浅,出血不多;Ⅱ度裂伤时累及会阴体或盆壁肌肉筋膜,肛门括约肌完整.Ⅲ度裂伤则已累及部分或全部肛门括约肌     

改良式低位产钳术联合无保护会阴助产的临床观察

目的:探讨改良式低位产钳术联合无保护会阴助产的临床应用效果。方法:回顾性分析采用改良式低位产钳术联合无保护会阴助产的36例初产妇临床资料(观察组),并与36例初产妇常规会阴侧切行低位产钳术助产作对照(对照组),比较分析两组母婴妊娠结局。结果:观察组会阴黏膜擦伤、Ⅰ度裂伤、Ⅱ度裂伤发生率分别为30.56%、52.78%、16.67%,对照组Ⅱ度裂伤5.56%,与观察组Ⅱ度裂伤发生率比较,差异无统计学意义(P0.05)。观察组会阴严重疼痛与尿潴留发生率、产时与产后出血量、住院时间与费用、产后42天会阴不适发生率均低于对照组,差异有统计学意义(P0.05)。第二产程时间、新生儿1分钟Apgar评分两组间比较,差异均无统计学意义(P0.05)。结论:采用改良式低位产钳术联合无保护会阴助产,减少了母婴损伤及并发症,提高了阴道分娩质量,值得推广应用。     

四度会阴裂伤修复后的会阴病率

会阴四度裂伤可发生于会阴切开术和未作会阴切开术者。能导致严重后果,如伤口裂开、感染及直肠阴道瘘等。本研究旨在了解产后会阴四度裂伤修复后并发症的发生率。 1989～1990在帕兰纪念医院经阴道分娩的23986例产妇中有404例(1.7％)会阴四度裂伤及会阴切开术延伸者接受修补术。其中记录完整的390例(97％)。四度会阴裂伤修复后的病率为5.4％,较以往的报告者为高,其原因为:①四度会阴裂伤的产后会阴病率本来就较三度裂伤为高。②以往检查会阴切开术的刀口裂开未列入四度裂伤的病率分析。③会阴裂伤修补术多系由产科住院医生操作。④主要研究对象为经济收入低的人群,与     

女性尿道功能不全的手术矫治——改良的Raz针悬吊术

女性压力性尿失禁可分为最常见的尿道内括约肌功能正常但尿道活动亢进和尿道内括约肌功能不全有或无尿道活动亢进二类型。改良的Raz针经阴道膀胱尿道悬吊术,治疗第一类型效果满意。手术方法:取膀胱截石位。洗涤、消毒会阴及阴道。Foley导尿管排空膀胱。阴道后壁置重锤拉钩,显露阴道前壁。Foley尿管气囊充盈后稍牵拉,确定膀胱颈位置。阴道前壁行倒“U”形切口。切口顶端横过尿道中段平面,在此处识别白色的尿道旁筋膜。游离阴道壁瓣,若非复杂性悬吊术也可不游离。在膀胱颈平面,于阴道前壁粘膜下向耻骨分离。耻骨和盆内筋膜之间,锐性或钝性分离     

骶主韧带复合体-耻骨阴道肌交叉缝合联合骶棘韧带悬吊术治疗重度盆腔器官脱垂48例分析

目的探讨骶主韧带复合体-耻骨阴道肌交叉缝合术联合骶棘韧带悬吊术治疗重度盆腔器官脱垂的临床应用价值。方法回顾性分析2012年5月至2015年1月于南方医科大学附属佛山市妇幼保健院应用骶主韧带复合体-耻骨阴道肌交叉缝合术联合骶棘韧带悬吊术治疗48例重度盆腔器官脱垂患者的临床资料。48例盆腔器官脱垂患者均以中盆腔、前盆腔缺陷为主,盆腔器官脱垂定量(pelvic organ prolapse quantification,POP-Q)分期均为Ⅲ期以上,均行经阴道全子宫切除术+骶主韧带复合体-耻骨阴道肌交叉缝合术+骶棘韧带悬吊术+阴道后壁修补术+会阴裂伤修补术,5例(10.4%,5/48)术前有压力性尿失禁者同时行经闭孔无张力尿道中段悬吊带术。术后对患者的主、客观疗效进行分析,包括围手术期情况以及近远期并发症。结果 48例患者手术时间(95±20)min,失血量(150±50)m L,随访时间(22±12)个月。随访时间内1例患者解剖学复发,客观治愈率为97.9%(47/48),主观满意度为97.9%(47/48),PFDI-20、PFIQ-7调查问卷中位评分分别为5、6分,均较术前(分别为65、67分)明显降低(P0.01)。术后3 d1例患者(2.1%,1/48)出现尿量减少,予拆除骶主韧带复合体-耻骨阴道肌交叉缝合缝线后排尿恢复正常。结论骶主韧带复合体-耻骨阴道肌交叉缝合术联合骶棘韧带悬吊术治疗重度盆腔器官脱垂主、客观治愈率高,且简单、安全、有效,值得在临床推广运用。     

产后阴道静脉丛出血伴腹膜外血肿、失血性休克的抢救及护理

产后阴道静脉丛出血伴腹膜外血肿、失血性休克的抢救及护理孙雪梅产后大出血是产科严重并发症，系产妇死亡四大原因之一，多见于子宫收缩乏力，胎盘滞留，软产道裂伤及出凝血机制障碍。而阴道穹窿裂伤致阴道静脉丛出血伴腹膜外血肿者却甚是少见．本院收治１例，现就抢救及...     

甲硝唑+硅胶管引流在阴道复杂性裂伤中的应用

目的:探讨甲硝唑+硅胶管引流治疗产后阴道复杂性裂伤的临床效果。方法:将阴道分娩发生阴道复杂性裂伤患者112例,随机分为两组,治疗组60例,采用甲硝唑术中静脉点滴+阴道伤口硅胶管引流;对照组52例,采用术后头孢曲松钠静脉点滴+常规缝合术,观察并记录两组手术时间及产后并发症。结果:治疗组手术时间明显短于对照组,无缝针损伤肠壁、伤口感染及阴道血肿,对照组缝针损伤肠壁8例(15.4%),伤口感染4例(7.7%),阴道血肿8例(15.4%)。两组手术时间及产后并发症相比较有显著差异性(P<0.05)。结论:甲硝唑+硅胶管引流在阴道复杂性裂伤中的应用,方法简单有效,值得推广。     

会阴侧切术后11天阴道切口裂开

会阴侧切术后１１天阴道切口裂开致大出血１例蒙阴县人民医院王荣珍，李萍患者，２６岁。因产后１１天，阴道流血２小时于１９９５年２月２７日１１ｐｍ收入院。患者１１天前因足月妊娠临产、持续枕横位、继发性宫缩乏力在本院行会阴侧切加胎头吸引术助娩一足月男婴，胎盘...     

会阴切开术对产后的影响

目的 回顾分析足月自然产会阴侧切开术和会阴裂伤对产后的影响。方法 我院2012年1月至12月182例足月孕妇会阴侧切开术92例和会阴裂伤90例,比较伤口出血量和手术时间,切口延伸、愈合率和裂开,伤口肿胀、触痛和硬结,采用视觉模拟评分法(VAS)评估术中、术后疼痛和产痛的比较,产后日常活动对母乳喂养的影响,产后盆底的检查。结果 ① 伤口出血量裂伤组低于侧切组,有统计学性意义[(33.2±6.0)mlvs (53.2±8.8)ml,P <0.05];缝合时间裂伤组短于侧切组,有统计学意义[(13.2±3.0)minvs (16.2±2.2)min,P <0.05];② 切口延伸、伤口愈合率和裂开两组无统计学意义(P >0.05);产后会阴伤口肿胀(38% vs22.2%)、触痛(63.8% vs17.8%)、硬结(53.3% vs12.2%),会阴侧切组明显高于会阴裂伤组,有统计学意义(P <0.01);③ 侧切组术后疼痛VAS评分比裂伤组高,有统计学意义(P <0.05),术中疼痛和产痛两组无统计学意义(P >0.05),两组均表现为产痛>术后疼痛>术中疼痛。术后疼痛对产妇影响依次坐、行、排便、睡眠、排尿、翻身活动;④ 产后母乳喂养会阴侧切组在产后第三天100%母乳喂养,裂伤组产后第二天100%母乳喂养,有统计学性意义(P <0.05);⑤ 产后盆底的检查两组比较无统计学意义(P >0.05)。结论会阴切开术没有降低损伤的发生,反而增加产后疼痛。     

12例会阴Ⅲ度裂伤行肛门括约肌修复术后盆底支持功能情况分析

目的:了解阴道分娩时会阴Ⅲ度裂伤的产妇行肛门括约肌修复术后盆底支持功能的情况。方法:选择2006年6月至2011年6月北京大学人民医院产科阴道分娩会阴Ⅲ度裂伤并行肛门括约肌修复术的12例患者为裂伤组,同时随机选取同期正常分娩孕妇20例为对照组。对两组盆底不适调查表短表20(PFDI-20)中盆腔脏器脱垂标准(POPDI-6)评分和结肠直肠功能异常(CRADI-8)评分的产前、产后及产前与产后变化值(产前-产后)及两组产后盆腔器官脱垂分度法(POP-Q)的测量数值进行比较。结果:两组同期评估时间为产后18~60个月。裂伤组和对照组的PFDI-20和CRADI-8评分,其产前与产后的自身比较,差异无统计学意义(P0.05);裂伤组PFDI-20评分、CRADI-8评分的产前-产后值与对照组比较,差异无统计学意义(P0.05)。产后POP-Q分期中,裂伤组C点和D点的位置均低于对照组,裂伤组会阴体长度小于对照组,差异有统计学意义(P0.05)。结论:会阴Ⅲ度裂伤采用肛门括约肌修复术可以使局部肠道功能以及盆底功能得到较好的恢复,但对中盆腔脏器解剖的恢复意义有限。     

Vaginal delivery with intrapartum pubic symphysis separation. A case report

BACKGROUND: Pubic symphysis separation is an uncommon complication of pregnancy. It can occur during the antepartum, intrapartum and postpartum period. CASE: A 29-year-old woman, gravida 2, para 1, at 39 weeks' pregnancy, experienced regular labor pain and suprapubic pain for 3 hours. Her clinical presentation and physical examination led to the diagnosis of intrapartum pubic symphysis separation. Vaginal delivery was chosen because there was no cephalopelvic disproportion. The obstetric outcome was favorable, with a healthy female infant of 3,150 g. The patient underwent conservative management during the postpartum period. She was doing well at the 6-week follow-up. CONCLUSION: In the absence of obstetric indications for cesarean delivery, vaginal delivery can be achieved in cases of intrapartum pubic symphysis separation. Conservative management usually results in complete recovery.     

Pubic Symphysis Separation and Regression in Vaginal versus Cesarean Delivery

ObjectiveTo quantify the association of pubic symphysis separation with mode of delivery and follow the resolution of this physiologic separation in the postpartum period.MethodsProspective observational cohort study that recruited two cohorts of primiparous women: those undergoing vaginal and cesarean delivery (45 and 46 patients, respectively). Chart review collected intrapartum factors. Patients were followed with serial anterior-posterior radiographs within 48 hours of delivery and at 6, 12, and 24 weeks postpartum, to evaluate the extent of pubic symphysis separation. Differences between the two cohorts in intrapartum factors were assesses as was pubic symphysis separation at each time point.ResultsMean age of women was 25.8 (SD 5.1) years, and 56% were White. Mean birth weight was 3.5 (SD 0.52) kg. Mean immediate postpartum pubic symphysis separation was 7.6 (SD 2.2) mm and did not differ between groups, at 7.18 mm for vaginal delivery versus 8.04 mm for cesarean delivery (CD; P = 0.08). Pubic symphysis separation was not significantly different for CD with and without labour. Black race and obesity were associated with increased pubic symphysis separation. No intrapartum events were related to extent of separation. Normalization of pregnancy pubic symphysis separation to 4–5 mm occurred by 6 weeks postpartum. Separation of >10mm and <15mm occurred in 10 of the 91 women and occurred after vaginal and cesarean delivery. The widest pubic symphysis separation was observed in 3 patients after vaginal delivery.ConclusionPhysiological pubic symphysis separation occursduring pregnancy and regresses postpartum with minimal effects from labour and delivery. Cesarean deliverydoes not prevent physiological pubic symphysis separation.     

Peripartum pubic symphysis separation: a case report and review of the literature

Although peripartum pubic symphysis diastasis is an uncommon complication of delivery, it can lead to considerable and sometimes long-term disability. Although the initial clinical examination and diagnostic workup for this complication are relatively straightforward, the best treatment for a peripartum pubic symphysis diastasis is less clear. Historically, nearly all women were treated conservatively with bed rest and pelvic binders. However, more recent case reports have described more invasive orthopedic procedures being used to help speedy recovery. In this study, we present a case of a 22-year-old primigravida who had a severe pubic symphysis separation after a vaginal delivery complicated by a shoulder dystocia. We also reviewed the literature on this topic over the past 20 years to gain a better understanding of the clinical factors surrounding peripartum pubic symphysis separation and the treatment option available to women with this complication. TARGET AUDIENCE: Obstetricians & Gynecologists. LEARNING OBJECTIVES: After completing this CME activity, physicians should be better able to identify the clinical factors that associated with peripartum pubic symphysis separation; perform a diagnostic workup when a peripartum pubic symphysis separation is suspected; distinguish the conservative and invasive orthopedic interventions available for the treatment of peripartum pubic symphysis separation; and show that the degree of patient disability after peripartum pubic symphysis separation varies greatly and no clinical factors or diagnostic studies effectively predict the course of patient recovery.     

Symphyseal separation, sacroiliac joint dislocation and transient lateral femoral cutaneous neuropathy associated with McRoberts' maneuver. A case report.

BACKGROUND: McRoberts' maneuver is often used prophylactically with the onset of active maternal expulsive efforts or immediately before delivery of the fetus. CASE: A 31-year-old woman, gravida 1, para 0, at 39 + 2 weeks' gestational age, was continuously maintained in an exaggerated lithotomy position while actively pushing during the second stage of labor. Immediately following spontaneous vaginal delivery of a 3,598-g infant, the patient noted left gluteal pain and left anterior thigh dysesthesia. Orthopedic evaluation revealed a 5-cm symphyseal separation, sacroiliac joint dislocation and transient lateral femoral cutaneous neuropathy. The patient underwent closed reduction of the left hemipelvis, followed by open reduction and internal fixation of the symphysis pubis two weeks later after failing conservative treatment. CONCLUSION: Although McRoberts' maneuver is generally safe, care should be exercised with use of excessive force or prolonged placement of the patient's legs in a hyperflexed position.     

Anal sphincter laceration at vaginal delivery: is this event coded accurately?

OBJECTIVE: To determine the error rate for discharge coding of anal sphincter laceration at vaginal delivery in a cohort of primiparous women. METHODS: As part of the Childbirth and Pelvic Symptoms study performed by the National Institutes of Health Pelvic Floor Disorders Network, we assessed the relationship between perineal lacerations and corresponding discharge codes in three groups of primiparous women: 393 women with anal sphincter laceration after vaginal delivery, 383 without anal sphincter laceration after vaginal delivery, and 107 after cesarean delivery before labor. Discharge codes for perineal lacerations were compared with data abstracted directly from the medical record shortly after delivery. Patterns of coding and coding error rates were described. RESULTS: The coding error rate varied by delivery group. Of 393 women with clinically recognized and repaired anal sphincter lacerations by medical record documentation, 92 (23.4%) were coded incorrectly (four as first- or second-degree perineal laceration and 88 with no code for perineal diagnosis or procedure). One (0.3%) of the 383 women who delivered vaginally without clinically reported anal sphincter laceration was coded with a sphincter tear. No women in the cesarean delivery group had a perineal laceration diagnostic code. Coding errors were not related to the number of deliveries at each clinical site. CONCLUSION: Discharge coding errors are common after delivery-associated anal sphincter laceration, with omitted codes representing the largest source of errors. Before diagnostic coding can be used as a quality measure of obstetric care, the clinical events of interest must be appropriately defined and accurately coded.     

Episiotomy and increase in the risk of obstetric laceration in a subsequent vaginal delivery

OBJECTIVE: To examine whether episiotomy at first vaginal delivery increases the risk of spontaneous obstetric laceration in the subsequent delivery. METHODS: A review was conducted of women with consecutive vaginal deliveries at Magee-Womens Hospital between 1995 and 2005, using the Magee Obstetrical Maternal and Infant database. The primary exposure of interest was episiotomy at first vaginal delivery. Multivariable polytomous logistic regression modeling of potential risk factors was used to estimate odds ratios (ORs) for obstetric laceration in the second vaginal delivery. RESULTS: A total of 6,052 patients were included, of whom 47.8% had episiotomy at first delivery. Spontaneous second-degree lacerations at the time of second delivery occurred in 51.3% of women with history of episiotomy at first delivery compared with 26.7% without history of episiotomy (P<.001). Severe lacerations (third or fourth degree) occurred in 4.8% of women with history of episiotomy at first delivery compared with 1.7% without history of episiotomy (P<.001). Prior episiotomy remained a significant risk factor for second-degree (OR 4.47, 95% confidence interval 3.78-5.30) and severe obstetric lacerations (OR 5.25, 95% confidence interval 2.96-9.32) in the second vaginal delivery after controlling for confounders. Based on these findings, for every four episiotomies not performed one second-degree laceration would be prevented. To prevent one severe laceration, performing 32 fewer episiotomies is required. CONCLUSION: Episiotomy at first vaginal delivery increases the risk of spontaneous obstetric laceration in the subsequent delivery. This finding should encourage obstetric providers to further restrict the use of episiotomy. LEVEL OF EVIDENCE: II.     

Risk of repetition of a severe perineal laceration.

OBJECTIVE: To compare the outcome of subsequent delivery in women with a history of a third- or fourth-degree laceration with outcomes in women without such a history. METHODS: This retrospective study used a perinatal database and chart review from 1978 to 1995. Only women whose first delivery was at our institution at more than 36 weeks' gestation, vaginal singleton, vertex presentation, and birth weight greater than 2500 g, with a subsequent delivery were included. The women were grouped by presence or absence of a third- or fourth-degree (severe) perineal laceration in their first delivery. The subsequent delivery was analyzed for maternal age, weight, birth weight, gestational age, method of delivery, use of episiotomy, and occurrence of a severe laceration. Comparison of data was by Fisher exact and t tests. RESULTS: Four thousand fifteen women met our starting criteria. In their first delivery, the average birth weight, use of instrumentation, and episiotomy rate were significantly higher in those women sustaining a severe laceration. When compared with women without a history of severe perineal laceration, women with such a history were at more than twice the risk for another in their subsequent delivery. The women at highest risk (21.4%) were those sustaining a laceration in their first delivery who underwent instrumental vaginal delivery with episiotomy in their subsequent delivery. When episiotomy or instrumental delivery was performed in the second vaginal birth, 52 (11.6%) of 449 women with a history of a severe perineal laceration sustained another, compared with 98 (6.5%) of 1509 without such a history (P < .001, odds ratio 1.9, 95% confidence interval 1.3, 2.7). CONCLUSION: Women delivering their second baby, and in whom episiotomy or instrumentation is used, are at increased risk of severe perineal laceration compared with women delivery spontaneously.     

Risk factors for severe perineal tear: can we do better?

Our aim was to investigate the risk factors associated with severe perineal tears defined as either third- or forth-degree tears and, ultimately, find strategies for prevention. We carried a retrospective analysis of a computerized perinatal database, collected prospectively, from a single county hospital between January 1, 1993 and June 30, 1998. Singleton vaginal vertex deliveries were analyzed for potential risk factors using univariate and multiple logistic regression analysis including all two-way interactions. Severe perineal tear occurred in 1905 (8.2%) of 23,244 vaginal deliveries. In the multiple logistic regression analysis, the following factors carried a significantly higher risk for severe laceration: midline episiotomy, primary vaginal delivery, use of pudendal block, forceps deliveries, and birth weight more than 4000 g. The study of interactions demonstrated that mediolateral episiotomy was associated with an increased risk for severe tear only during the first vaginal delivery, but not during a repeat vaginal delivery. Our data suggest that primary vaginal delivery, fetal weight above 4000 g, and the use of pudendal analgesia can help identify in advance patients at highest risk for severe perineal tear. During the delivery of these patients usage of vacuum (instead of forceps) and restricting the use of midline episiotomy might reduce the incidence of severe perineal tear. In cases where episiotomy seems crucial, the use of a mediolateral episiotomy may reduce the likelihood of severe perineal tear.     

External skeletal fixation as treatment for total puerperal rupture of the pubic symphysis.

A case of total puerperal rupture of the pubic symphysis during non-operative delivery is reported and the literature reviewed. The patient in our case was successfully treated by external skeletal fixation. In agreement with the literature the authors recommend external skeletal fixation when lesions are unstable, when inadequate reduction is achieved, or when the diastasis is more than 40 mm.     

Obstetric Perineal Tears in Pregnant Adolescents and the Influencing Factors

Study ObjectiveThe incidence and risk factors of obstetric perineal tear occurrence in vaginal delivery of adolescent pregnant patients are not well established. We aimed to describe the incidence of obstetric perineal tears in adolescents and the maternal obstetric risk factors associated with this situation.DesignRetrospective cohort studySettingDepartment of Obstetrics and Gynecology, Tepecik Education and Research Hospital, Izmir, TurkeyParticipantsAdolescent pregnant patients (≤19 years) who delivered vaginally in our institution between January 2014 and January 2021Interventions and Main Outcome MeasuresThe main outcome measures were the incidence of perineal tears, the degree of perineal tears, and the risk factors associated with severe perineal tears in adolescents. Severe perineal tears include third- and fourth-degree lacerations. A third-degree tear is defined as partial or complete disruption of the anal sphincter muscles, and a fourth-degree tear is defined as lacerations involving the rectal mucosa.ResultsA total of 3441 adolescents who had a vaginal delivery were included in the study. The rate of severe perineal tear was 5.8% (200/3441). Risk factors associated with obstetric laceration in adolescents in multivariate analysis were nulliparity (OR = 1.72; 95% CI, 1.14–2.41; P = 0.007), high birth weight (OR = 4.1; 95% CI, 2.71–6.21; P < 0.001), and labor induction (OR = 1.36; 95% CI, 1.01–1.85; P = 0.02). Spontaneous onset of labor and previous delivery reduced the risk of severe perineal tear in adolescent pregnant patients (respectively, OR = 0.68; 95% CI, 0.51–0.94; P = 0.02 and OR = 0.51; 95% CI, 0.33–0.79; P = 0.007).ConclusionsIn adolescents, the risk of severe perineal tear was associated with nulliparity, birth weight, and labor induction. The only possible modifiable risk factor was labor induction.