双侧阴部神经阻滞麻醉用于阴道分娩镇痛效果观察

目的观察双侧阴部神经阻滞麻醉用于阴道分娩镇痛效果.方法产妇宫口开全后将采用常规会阴处理的1 018例产妇分为对照组,采用双侧阴部神经阻滞麻醉的1 327例产妇分为观察组.比较两组镇痛效果、第二产程时间、拨露至胎头娩出时间、会阴完整、裂伤及侧切率.结果上述各项除会阴裂伤率外,观察组均显著优于对照组(P＜0.05,P＜0.01).结论双侧阴部神经阻滞麻醉镇痛效果好,可缩短第二产程,提高会阴完整率及降低侧切率,减轻产妇痛苦.     

以会阴中心腱紧张度控制胎头娩出速度对会阴损伤和产程的影响

目的 以会阴中心腱紧张度为标准控制胎头娩出速度,以减轻会阴损伤及缩短产程。方法 将520例经阴道分娩的初产妇按照住院时间分为观察组和对照组各260例。观察组以会阴中心腱紧张度为标准控制胎头娩出速度,对照组依据每次用力时胎头露出阴道外口直径<1 cm为标准控制胎头娩出速度。结果 两组均未发生会阴Ⅲ、Ⅳ度裂伤,观察组会阴裂伤或会阴切开、会阴切开伴裂伤率显著低于对照组,且观察组胎头拨露至胎头娩出时间、第二产程时间显著短于对照组（均P<0.05）。结论 在无保护或适度保护会阴接产中以会阴中心腱紧张度为标准控制胎头娩出速度,有利于减轻分娩期会阴损伤程度,促进胎儿娩出。     

阴部神经阻滞阴道扩张法与托肛法保护会阴分娩的观察

为了减少产妇会阴裂伤及侧切率，对132例足月经阴道分娩产妇，采用阴部神经阻滞阴道扩张法加托肛法助产，并与采用单纯托肛法助产的132例产妇进行对照，结果两组第二产程时间、胎头拨露至娩出时间比较，差异有显著性和极显著性意义（P＜0.05和P＜0.01）；会阴侧切率、裂伤率比较，差异有极显著性意义（均P＜0.01）。提示阴部神经阻滞阴道扩张法结合托肛法可提高助产质量。     

改良会阴麻醉预防无保护助产会阴损伤的效果

目的探讨改良会阴麻醉预防无保护会阴助产会阴损伤的效果。方法将400例自然分娩的单胎头位初产妇随机分为观察组和对照组各200例。对照组按无保护会阴助产法助产;观察组在无保护会阴助产前实施双侧阴部神经阻滞麻醉联合外阴多点麻醉。比较两组产妇会阴侧切率及会阴裂伤情况。结果观察组产妇会阴完整率显著高于对照组、会阴侧切率显著低于对照组、会阴裂伤程度显著轻于对照组(均P0.01)。结论无保护会阴助产前实施改良会阴麻醉,可有效降低会阴侧切率和会阴裂伤程度。     

硬膜外阻滞联合超声引导下阴部神经阻滞分娩镇痛的效果

目的探讨硬膜外阻滞联合超声引导下阴部神经阻滞的分娩镇痛方案对产妇分娩疼痛、产程及保护会阴完整性的临床效果。方法选择2017年6—12月于本院要求行分娩镇痛的初产妇107例,年龄22～30岁,BMI 20～39.9 kg/m~2,ASAⅡ级。随机分为硬膜外阻滞联合超声引导下阴部神经阻滞组(T组,n=54)和单纯硬膜外阻滞组(C组,n=53)。所有产妇在宫口扩张至3 cm时行硬膜外穿刺置管并连接镇痛泵。T组产妇在宫口开全时夹闭镇痛泵,并行超声引导下双侧阴部神经阻滞。C组产妇直至第三产程结束时停用镇痛泵。记录两组产妇宫口扩张至3 cm、硬膜外阻滞后30 min、胎头着冠时和会阴缝合时的VAS评分;记录第二产程时间,使用器械助产、会阴侧切情况和会阴撕裂程度;记录产妇分娩后24 h内局部血肿、局麻药中毒、蛛网膜穿破和大小便失禁等不良反应发生情况。结果与硬膜外阻滞后30 min比较,胎头着冠时T组VAS评分明显降低(P0.05)、C组明显升高(P0.05)。胎头着冠和会阴缝合时T组VAS评分明显低于C组(P0.05)。T组第二产程时间明显短于C组(P0.05),会阴侧切率明显低于C组(P0.05),会阴撕裂程度明显轻于C组(P0.05)。两组使用器械助产率差异无统计学意义。所有产妇均未发生局部血肿、局麻药中毒、蛛网膜穿破、大小便失禁等不良反应。结论硬膜外阻滞联合超声引导下阴部神经阻滞较单纯硬膜外阻滞能更有效地缓解分娩疼痛,缩短产程,减少会阴损伤,保护会阴完整性。     

探讨改良双侧阴部神经阻滞麻醉法在分娩中的应用效果

目的探讨改良双侧阴部神经阻滞麻醉法在分娩中的应用效果。方法将60例分娩产妇随机分为2组,各30例。常规组行常规会阴处理,麻醉组行改良双侧阴部神经阻滞麻醉,对比2组产妇预后状况。结果麻醉组产妇麻醉有效率高于常规组,产妇依从性优良率高于常规组,会阴切口出血量低于与常规组,差异均有统计学意义(P0.05)。结论改良双侧阴部神经阻滞麻醉法能有效提高麻醉效果及产妇治疗依从性,减少会阴切口出血,效果显著。     

阴部双侧神经阻滞麻醉降低会阴切开率的临床观察

我院2004年1月～12月对足月初产妇运用阴部双侧神经阻滞麻醉进行分娩,降低了会阴切开率,取得了较好的效果,现介绍如下：     

分娩镇痛初产妇第二产程运用腹压的时机分析

目的探讨分娩镇痛初产妇第二产程运用腹压的最佳时机。方法将172例经阴道分娩初产妇按入院时间分为对照组和观察组各86例。对照组宫口全开后即使用腹压,观察组胎先露下降至3 cm时使用腹压。比较两组第二产程时间、使用腹压时间、会阴裂伤程度、侧切率、产后疲倦度及分娩结局。结果观察组腹压使用时间显著短于对照组(P0.01);第二产程时间两组比较,差异无统计学意义(P0.05);观察组会阴裂伤程度显著轻于对照组,侧切率、产后疲倦评分、产后出血、新生儿窒息率显著低于对照组(P0.05,P0.01)。结论对分娩镇痛初产妇当胎先露下降至3 cm时使用腹压,可有效缩短腹压使用时间,同时改善产妇分娩结局。     

硬膜外阻滞麻醉镇痛对产程的影响

为探讨硬膜外阻滞麻醉镇痛对产程的影响,将100例初产妇随机分为观察组（行硬膜外阻滞麻醉分娩）和对照组（正常分娩）各50例,观察两组产妇的总产程及第一产程时间,活跃期宫口扩张速率和胎头下降速率。结果观察组产妇的部产程及每产程时间均较对照组明显缩短;宫口扩张和胎头下降速率较对照组显著增快（均P＜0．01）,表明硬膜外阻滞麻醉用于分娩镇痛的同时能明显促进产程进展。     

会阴侧斜切开术后伤口再撕裂的危险因素及护理对策

目的 对会阴侧斜切开术后伤口再撕裂的危险因素进行探讨,以有效降低会阴侧斜切开术后伤口的再撕裂率.方法 回顾性分析住院分娩的97例产妇会阴侧斜切开术后伤口再撕裂的发生原因.结果 持续性枕后位、枕横位等头位不正致会阴侧斜切开术后伤口再撕裂率占16.49%,耻骨弓过低、胎儿体质量≥3 500 g均占15.46%,手抱肩娩出占13.40%.结论 正确估计胎儿大小、胎位和先露部位情况,充分了解骨产道和软产道的情况,是预防会阴侧斜切开术后伤口再撕裂的关键.     

Neuroanatomy of the male urethra and perineum

OBJECTIVE: To describe the topography of the perineal nerves from their pudendal origin to their course into the male genitalia, with specific attention on the course of the perineal nerve along the ventral penis, including branches into bulbospongiosus muscle and corpus spongiosum. MATERIALS AND METHODS: The study comprised 18 normal human fetal penile specimens at 17.5-38 weeks of gestation (determined by fetal heel-to-toe length). Specimens were fixed in formalin, embedded in paraffin wax and serially sectioned at 6 micro m. The penile specimens contained the whole penis from the glans to the crural bodies, beneath the pubic arch and the perineum up to the anal verge. Immunocytochemistry was assessed on selected sections with antibodies against the neuronal markers S-100 and nitric oxide synthase (nNOS). Three-dimensional computer reconstruction of serial sections allowed an in-depth analysis of the neuroanatomy of the fetal penis, perineum and surrounding structures. RESULTS: After the pudendal nerve leaves the pudendal canal it gives rise to the perineal nerve branches in the ischiorectal fossa. Perineal nerves travel alongside the ischiocavernous and bulbospongiosus muscles and before reaching the latter, nerve branches course into the bulbospongiosus muscle. During its pathway within this muscle, fine nerve fibres course into the corpus spongiosum by piercing through the junction of the muscle. At the penoscrotal area, the perineal nerves give branches to the scrotum, funnelling into the interscrotal septum. Perineal nerves continue their pathway over the ventral side of penis covering the ventral surface of corpus spongiosum. Branches of the dorsal nerve of the penis at the junction of corpus cavernosum and corpus spongiosum assemble into a network with the perineal nerves. All perineal nerves from their main trunk at the ischiorectal fossa until their interaction with dorsal nerve of penis at the base of penis were nNOS negative. After the interaction with the dorsal nerve of penis, they become nNOS positive. CONCLUSION: Integrating neuroanatomical knowledge about the perineal nerves and their communication with the dorsal nerve of penis should facilitate a strategic approach to reconstructive procedures on the penis. Special care should be taken at the junction between the corpora cavernosa and spongiosa, where the dorsal nerve joins the perineal nerve, and at the proximal bulbospongiosus muscle, thereby protecting the fine nerves piercing into the cavernosa spongiosa.     

Determinants of the length of episiotomy or spontaneous posterior perineal lacerations during vaginal birth

The objective of this study was to measure the length of episiotomy or spontaneous posterior perineal laceration and their relationship to perineal measurements and obstetric variables. The length of the perineum and genital hiatus and vertical length of episiotomy or posterior perineal tears were measured in 114 consecutive parturients with spontaneous singleton term deliveries. Seventy-four (65%) women underwent episiotomy while 40 (35%) sustained spontaneous posterior tears. Perineal or genital hiatus length was significantly correlated to episiotomy (r=0.34, p=0.003) or laceration (r=0.37, p=0.02) length, respectively. This association was significant (p=0.001) in a generalized linear model with duration of second stage of labor (p=0.005), degree of tear (p=0), and parity (p=0). Perineal length was significantly related to maternal age (p=0.036) and weight (p=0.037) and hiatal length (p=0). Short perineum and genital hiatus, long second stage of labor, and low parity are associated with longer posterior perineal injury.     

Identification of communicating branches among the dorsal,perineal and cavernous nerves of the penis

PURPOSE: The mechanism of human erection requires the coordination of an intact neuronal system that includes the cavernous, perineal, and dorsal nerves of the penis. We defined the communication of these 3 nerves that travel under the pubic arch using specific neuronal immunohistochemical staining and 3-dimensional reconstruction imaging technique. MATERIALS AND METHODS: A total of 18 normal human fetal penile specimens at 17.5 to 32 weeks of gestation were studied by immunohistochemical techniques. Serial sections were stained with antibodies raised against the neuronal markers S-100, and neuronal nitric oxide synthase (nNOS), vesicular acetylcholine transporter (VAChT), calcitonin gene-related peptide and substance P. RESULTS: The continuation of the dorsal neurovascular bundle of the prostate was documented under the pubic arch. Two distinct nerve bundles were identified superior to the urethra and medial to the origin of the crural bodies. Nerve bundles were observed to join the corporeal bodies at the penile hilum. Proximal to the penile hilum the dorsal nerves stained only for S-100 and VAChT. From the junction of the crural bodies at the hilum to the glans penis dorsal nerve fibers stained positive for S-100, VAChT and nNOS. Calcitonin gene-related peptide and substance P demonstrated positive staining at the distal nerves, particularly at the glans. In contrast, the whole course of the cavernous nerve stained for S-100 and nNOS. Under the pubic arch at the penile hilum the cavernous nerves were found to convey nNOS positive branches to the dorsal nerve to transform its immunoreactivity to nNOS positive. Proximal nNOS negative perineal nerves were shown to stain positive for nNOS distal on the penis. Interaction between nNOS positive dorsal nerve branches and perineal nerves was at the cavernous-spongiosal junction, where the bulbospongiosus muscle terminates. CONCLUSIONS: At penile hilum, where the corporeal bodies start to separate, the cavernous nerve sends nNOS positive fibers to join the dorsal nerve of the penis, thereby, changing the functional characteristics of the distal penile dorsal nerve. Similarly the nNOS negative, ventrally located perineal nerve originating from the pudendal nerve becomes nNOS reactive at the cavernous-spongiosal junction. These 2 examples of redundant neuronal wiring in the penis may impact erectile function, especially during reconstructive surgery.     

What are the risk factors of anal incontinence after vaginal delivery?

Fecal incontinence is one of the most feared complications of vaginal delivery. It may be the consequence of sphincter tears, of pudendal neuropathy, or of a combination of the two. Fecal incontinence occurs immediately following 13-54% of vaginal deliveries but its persistence in the mid and long term is poorly known. The incidence of perineal tear with anal sphincteric defect varies from 1-9% and the incidence of unrecognized sphincter injury may be as high as 18-35%. Half the women who undergo primary anal sphincter repair have short or long term continence problems. Pudendal neuropathy is caused by nerve stretch during pushing in the second stage of labor and descent of the fetal head; it may occur even with the first delivery. Risk factors for sphincter injury and pudendal neuropathy include forceps delivery, large neonatal size, and prolonged second stage of labor. The risk of fecal incontinence must be considered even during the first pregnancy. Routine episiotomy does not prevent sphincter injury and may even predispose to it. Pudendal neuropathy following delivery may lead to delayed fecal incontinence abetted by postmenopausal hormonal deficiency and tissue senescence. The possible benefit of early episiotomy for women at high risk of sphincter injury must be evaluated by prospective studies.     

Anatomical risks of transobturator suburethral tape in the treatment of female stress urinary incontinence

INTRODUCTION: The objective of this study was to define the anatomical structures crossed by transobturator tape. MATERIALS: Ten fresh, female anatomical subjects aged 74 to 89 years. METHODS: Transobturator tape was inserted by outside-in way. The position of the tape was verified by perineal and abdominal dissection. RESULTS: Transobturator tape has a transverse course. It crosses the adductor muscles close to their pubic insertion and passes over the inferior border of the obturator foramen by crossing the obturator membrane, before reaching the middle plane of the perineum after having crossed the obturator internus muscle. The tape passes above the internal pudendal pedicle and then under the levator ani muscle, under the tendinous arch of the pelvic fascia and continues in the middle third of the urethrovaginal septum. It avoids femoral and obturator vessels in the thigh and pudendal vessels in the perineum. CONCLUSION: The anatomical course of transobturator tape shows that the anatomical structures crossed by the tape are muscle and fascia and, when the technique is performed correctly, no major neurovascular structures are in contact with the tape.     

阴道分娩会阴Ⅲ～Ⅳ度裂伤原因分析及缝合修复对阴道、肛门直肠功能的影响

为提高阴道分娩会阴Ⅲ～Ⅳ度裂伤的诊治水平．及探讨缝合修复对阴道、肛门直肠功能的影响．本研究对足月妊娠阴道分娩的15例会阴Ⅲ～Ⅳ度裂伤的原因及诊治过程进行分析。结果发现,本组巨大儿（体重≥4000g）2例,急产2例,胎儿即将娩出时产妇不合作1例,会阴瘢痕3例,会阴体较短、发育薄弱3例,会阴体过长伴肥厚1例,胎位不正以持续性枕后位娩出2例,外阴未完全扩张助产人员急于让胎儿娩出在宫底部加压1例。且经产妇多于初产妇。给予严格消毒、止血、缝合后阴道及肛门直肠功能均恢复良好。结果表明,减少产生会阴裂伤的关键在于预防,一旦发生应及时处理,对阴道及肛门直肠功能无明显影响。     

阴部神经阻滞麻醉的解剖学基础

目的:为阴部神经阻滞麻醉提供解剖学证据。方法:利用10例低位直肠癌患者腹会阴联合切除做会阴解剖时,以两侧坐骨结节前缘为参照基点,解剖出双侧阴部神经及其分支。后3例患者用亚甲蓝标记阴部神经封闭位点。结果:阴部神经在Alcock管出口处位于阴部内动脉、静脉下方,分出会阴神经和肛神经,左侧有个别散发肛神经。经皮穿刺至坐骨结节,再垂直其内侧进针26mm注射亚甲蓝,可见阴部神经周围被蓝染。结论:距坐骨结节前缘内侧26mm是阴部神经阻滞麻醉的恰当位点。     

Neuraxial labor analgesia is not an independent predictor of perineal lacerations after vaginal delivery of patients with intrauterine fetal demise

IntroductionThe role of neuraxial labor analgesia in perineal trauma following live births is controversial, and no studies have assessed the association in women delivering an intrauterine fetal demise. We evaluated the relationship between neuraxial labor analgesia and perineal laceration in these patients.MethodsThis was a retrospective case-control study of women with a diagnosis of fetal death after 20 weeks of gestation, a vaginal delivery, and an Apgar score of 0 at delivery, during the period from January 2007 through December 2015. The presence of a perineal laceration and its severity, graded from grade I to IV based on the 2014 American College of Obstetricians and Gynecologists guidelines, was recorded.ResultsA total of 329/422 (78%) patients received neuraxial, and 93/422 (22%) non-neuraxial, labor analgesia. A perineal laceration occurred in 23% in the neuraxial versus 10% in the non-neuraxial analgesia group, a difference of 13% (95% CI of difference 4% to 20%, P=0.005). After adjusting for confounder bias, greater birthweight (OR 4.22, 95% CI 3.00 to 5.92, P <0.001) and lower parity (OR 0.44, 95% CI 0.24 to 0.82, P=0.009), but not neuraxial analgesia (OR 1.29, 95% CI 0.47 to 3.57, P=0.61) were independent predictors of perineal laceration. The maintenance concentration of bupivacaine did not affect the rate of perineal injury.ConclusionsNeuraxial labor analgesia does not appear to be an independent risk for a perineal laceration in patients with intrauterine fetal demise. Our data suggests that the use of neuraxial analgesia should not raise concern about increased rates of perineal injury.     

PENILE ANATOMY UNDER THE PUBIC ARCH: RECONSTRUCTIVE IMPLICATIONS

PURPOSE: We have previously defined the anatomy of the neurovascular bundle in the normal and hypospadiac penis. These studies were based on analysis of the fetal penis distal to the pubic arch without total inclusion of the crural bodies. To our knowledge the neuroanatomy beneath the pubic arch has not been well described. We defined the nerve distribution under the pubic arch and the relationship of the nerves to the crural bodies, corporeal bodies and urethra of the penis. MATERIALS AND METHODS: Eight normal human fetal penile specimens (at 17.5 to 29 weeks of gestation and 1 hypospadiac specimen at 32 weeks were serially sectioned and stained with Masson's trichrome, and the neuronal markers protein gene product 9.5 and S-100. These specimens were unique in that they contained the whole penis from the glans to the crural bodies beneath the pubic arch. Older specimens were decalcified before fixation. Computer reconstruction with commercially available graphics software allowed 3-dimensional analysis of the nerves and crural bodies in relation to the pubic arch and surrounding structures. RESULTS: The nerves of the penile shaft and glans surrounded the corporeal bodies, extending from the junction of the urethral spongiosum to the classic 11 and 1 o'clock positions with a paucity of nerves at the 12 o'clock position in the dorsal midline. Beneath the pubic arch the nerves to the penis were an extension of the dorsal neurovascular bundle of the prostate. The nerves formed 2 bundles following a path just under the pubic arch in close proximity to the bone, superior to the urethra and medial to the origin of the crural bodies. The nerve bundles joined the corporeal bodies at the proximal origin, where the 2 crural bodies fused together. At this point perforating branches into the corporeal bodies from the cavernous nerves were documented. As the dorsal nerves joined the dorsal aspect of the corporeal bodies, they immediately began to fan out along the surface of the corporeal tissue to the junction of the urethral spongiosum. Three-dimensional reconstruction showed the relationship of the nerves to the pubic arch and urethra in multiple views. CONCLUSIONS: A precise understanding of penile anatomy beneath the pubic arch and at the origin of the crural bodies is important for preserving neuronal structures. This anatomy is especially germane in children undergoing posterior urethral reconstruction secondary to trauma, intersex requiring feminizing genitoplasty and severe hypospadias.