Prior third- or fourth-degree perineal tears and recurrence risks.

OBJECTIVE: The objective of the present study is to determine the recurrence risk of a third-degree (into the anal sphincter) or a fourth-degree (into the rectum) perineal tear in women with a prior extensive laceration. METHODS: Data were gathered from our computerized perinatal database between January 1990 and December 1994. Women who had two consecutive singleton deliveries were chosen as subjects. RESULTS: The rate of an extensive perineal laceration was greater if a tear had occurred in a previous pregnancy (19 of 178 cases, 10.7% vs. 56% of 1563 cases, 3.6%, odds ratio 3.4. A 95% confidence interval: 1.8-6.4; p < 0.0001). A prior tear remained a risk factor after controlling for other variables (epidural analgesia, episiotomy, oxytocin use, operative vaginal delivery, fetal macrosomia). CONCLUSION: A prior third-degree or fourth-degree perineal tear is associated with a 3.4-fold increased risk of a recurrent severe obstetrical laceration.     

Epidural analgesia and cesarean section for dystocia: risk factors in nulliparas.

A retrospective study assessing the effect of epidural analgesia in labor on the incidence of cesarean section was performed. The first 500 consecutive nulliparas meeting the following criteria were included in this study: term (37 weeks or longer) and singleton gestation, cephalic presentation, spontaneous onset of labor, and 5 cm or less of cervical dilation on admission. Patients were grouped according to their rate of cervical dilation in early labor (greater than or equal to 1 cm/hr, and less than 1 cm/hr) and the timing of epidural placement (none, early, or late). There was no effect of epidural analgesia on the incidence of cesarean section for fetal distress. The incidence of cesarean section for dystocia was significantly greater (p greater than 0.000001) in the epidural group (15.6%) than in the nonepidural group (2.4%). The greatest effect of epidural analgesia on the incidence of cesarean section for dystocia was observed in nulliparas who dilated at slower rates (less than 1 cm/hr) in early labor and who had epidural analgesia placed at 5 cm or less of cervical dilation (20.6% versus 3.4%, relative risk of 6, p less than 0.0005). The increase of cesarean section for dystocia associated with epidural analgesia could not be accounted for when other possibly confounding variables were studied. Both the dilation rate prior to epidural placement and the cervical dilation at epidural placement were significantly correlated to frequency of cesarean section for dystocia (p less than 0.01). This study suggests that epidural analgesia in labor may increase the incidence of cesarean section for dystocia in nulliparas.     

Epidural analgesia.

The most frequently used postoperative analgesia techniques are intramuscular injection (IM) and patient controlled analgesia (PCA). Recently, the use of epidural catheter injection (EPI) has been done with success. This study was done to prospectively compare these three techniques for postoperative analgesia after extensive operations upon the colon and rectum. Patients were randomized to one of three analgesia groups--IM, intramuscular morphine sulfate; PCA, patient controlled morphine sulfate, and EPI, epidural morphine sulfate. Data collected included age, time to first bowel movement, amount of narcotic, number achieving 75 per cent of preoperative forced vital capacity, postoperative pruritus, headache, nausea and vomiting, respiratory depression, atelectasis or pneumonitis. A visual analog pain scale was used to evaluate postoperative pain severity (0, no; 1, partial; 2, marked, and 3, total relief). Sixty-eight patients were eligible for study (IM, 19; PCA, 22; EPI, 23, and excluded, four). The EPI group required significantly less daily narcotic compared with either the IM or PCA groups (17.0 +/- 6.12 milligrams; 67.8 +/- 26.8 milligrams; 40.5 +/- 20.6 milligrams, respectively, less than 0.05 ANOVA) and total narcotic (81.3 +/- 31.3 milligrams; 355.4 +/- 147.7 milligrams; 215.3 +/- 105.4 milligrams, respectively, p less than 0.05 ANOVA). EPI achieves excellent pain control in more patients with a significantly lower dose of narcotics and significantly fewer pulmonary complications. Therefore, epidural analgesia is the optimal method of postoperative analgesia after extensive abdominal operations.     

Epidural analgesia in midtrimester abortion.

Epidural analgesia was performed in 78 women with abortion in the midtrimester or pre-term delivery of up to 27 weeks of pregnancy. The patients were divided into three groups. The first group included thirty women with signs of inevitable abortion. The second group comprised of 9 cases of induced abortion and the third one of 39 cases of pre-term delivery. The three groups were statistically evaluated in relation to time of abortion or labor, fetal weight, weeks of pregnancy, parity and patient's age and were consequently compared with 90 women divided into three similar control groups. The effect of the epidural analgesia was satisfactory in all cases in the three experimental groups, and no complications or side-effects were observed. The advantages of the use of epidural analgesia were the diminished psychological reaction to the abortion, the possibility to perform surgical procedures without any additional anesthesia and the reduction in the duration of the abortion or labor. These advantages justified in our opinion the use of the procedure.     

Differences in outcomes after third- versus fourth-degree perineal laceration repair: a prospective study

OBJECTIVE: The purpose of this study was to compare outcomes after third- versus fourth-degree laceration repair. STUDY DESIGN: Fifty-six primiparous women who sustained a third- or fourth-degree tear were enrolled at delivery and demographic and obstetric data were collected. At 6 weeks' postpartum, subjects completed a bowel function questionnaire and endoanal ultrasonography was performed. Fisher exact test and chi-square were used for statistical analysis. RESULTS: Thirty-nine women with third- and 17 with fourth-degree tears were enrolled. Subjects with fourth- were more likely to report bowel symptoms (59% vs 28%, P = .03), and to demonstrate persistent combined defects of the internal (IAS) and external anal sphincter (EAS) (48% vs 8%, P = .002) than third-degree tears. Combined defects were associated with the highest risk of bowel symptoms (OR 18.7, 95% CI 3-101, P < .001). CONCLUSION: Bowel symptoms were more common after fourth- than third-degree repair, and may be secondary to higher rates of combined defects of the IAS and EAS.     

Epidural and spinal analgesia and labour.

Epidural and spinal analgesia for pain relief in labour are now commonplace. Adverse effects such as hypotension and toxicity to anaesthetic agents are well described and easily managed. The effects on obstetric outcome, however, have been unclear to both obstetricians and anaesthetists, but are important due to the large number of pregnancies involved. Efforts to define implications for mother and child have been frustrated by a relative lack of evidence derived from good quality, large randomized trials. Ethical and methodological difficulties together with an abundance of confounding factors have conspired to cause considerable difficulties for researchers in this area. Nevertheless, recent evidence has significantly advanced knowledge in the field and has implications for future practice.     

Epidural analgesia in labor and fetal hyperthermia.

OBJECTIVE: To assess the effect of epidural analgesia on fetal temperature in labor, contrasting intrauterine with oral thermometry. METHODS: Fetal skin and maternal uterine wall temperatures were measured with an intrauterine probe in 57 laboring women at term. Maternal oral temperatures were measured in the normal way by birth attendants unaware that their measurements would be examined. Maximum recorded fetal, uterine, and oral temperatures were compared. RESULTS: Epidural analgesia resulted in a significant fetal temperature rise compared with other methods of analgesia. Duration of epidural analgesia correlated with the fetal temperature (R = 0.44, P = .012). Oral thermometry underestimated fetal temperature in 95% of the studies. CONCLUSIONS: We estimate that 5% of fetuses reached a core temperature in excess of 40C in this study, all in association with epidural analgesia. We suggest that antipyretic measures be considered after 5 hours of epidural analgesia in ambient temperatures above 24C.     

Effectiveness of an instructional DVD on third- and fourth-degree laceration repair for obstetrics and gynecology postgraduate trainees

Objective

To assess the effectiveness of an instructional DVD on the anatomy and repair of anal sphincter lacerations to improve postgraduate trainees’ understanding.

Methods

A total of 71 obstetrics and gynecology trainees completed a pretest of third- and fourth-degree lacerations to assess baseline knowledge and perceptions. Question categories included anatomy, antibiotics, anesthesia, repair methods, complications, postoperative care, and risk factors. After 1 year of clinical experience, 67 trainees (94%) were randomly assigned into DVD (intervention) and non-DVD (control) groups. A post-test was administered 4 weeks later.

Results

In the DVD group (n = 34), mean scores on the pretest versus the post-test were 65% vs 74% for postgraduate year (PGY)-1 (P = 0.09); 72% vs 83% for PGY-2 (P = 0.06); 67% vs 83% for PGY-3 (P = 0.01); and 75% vs 87% for PGY-4 (P < 0.001). In the non-DVD group (n = 33), mean scores did not change significantly for any year level. The increase in score from pretest to post-test was significantly different between the 2 groups, independent of year (P < 0.001). DVD group scores improved significantly over non-DVD group scores in anatomy (P = 0.005) and repair methods (P = 0.042) subscales.

Conclusion

An educational video is an effective tool for improving understanding of third- and fourth-degree lacerations for physicians-in-training.