Puerperal sepsis due to infected episiotomy wound]

A healthy 31-year-old woman showed a severe septic shock syndrome a few days after vaginal delivery. In the episiotomy wound were found Group A Streptococci and E. coli. Although an antibiotic therapy was instituted immediately, the condition of the patient worsened. Platelet counts fell below 5000/microliter and she developed respiratory, cardiocirculatory and renal insufficiency, so that mechanical ventilation, high-dose-catecholamine therapy and continuous venovenous hemodiafiltration had to be performed. In the course of the disease the patient showed a reversible cardiomegaly with pulmonary hypertension and an extensive desquamation of the skin. Fever persisted in spite of the fact that in all following clinical and laboratory examinations no septic focus could be revealed any longer. She recovered slowly and could not be weaned from the respirator for four weeks because of a severe critical illness polyneuromyopathy.     

Fistula-in-ano after episiotomy

Background: In the past 2 years, we treated three women with fourth-degree lacerations or episiotomy infections presenting with persistent pain and drainage not responding to standard treatment.Cases: These women were referred for evaluation 5 weeks, 3.5 months, and 2 years postpartum. After diagnosing fistula-in-ano, we treated them with fistulotomy and curettage, which resolved the problem.Conclusion: When a patient presents with pain or drainage at her episiotomy site, fistula-in-ano should be considered.     

Restricted use of episiotomy

Objective

To compare the outcome of restricted versus routine use of episiotomy in a tertiary care center.

Method

A prospective observational study was conducted for singleton normal vaginal term deliveries. Deliveries managed with routine use of episiotomy formed the ‘Control Group’, while those managed with restricted use of episiotomy formed the ‘Study Group’. Data so obtained was analyzed.

Results

Total number of deliveries analyzed was 458 (‘Control Group’: n=210, ‘Study Group’: n=248). Restricted use of episiotomy led to 64% (n=159) women delivering without any perineal laceration, in ‘Study Group’. This translated into 41% (n=38) reduction in the number of perineal lacerations in primipara, and 23% (n=36) in multipara, compared to the ‘Control Group’. Only 2% of primipara in ‘Study Group’ had severe third degree perineal tears.

Conclusion

Restricted use of episiotomy resulted in considerable reduction in maternal morbidity due to perineal lacerations.     

Need for episiotomy in a subsequent delivery following previous delivery with episiotomy

Purpose

To assess the need of episiotomy in a subsequent delivery in women with previous primiparous vaginal delivery with episiotomy.

Methods

In this historical prospective study, we followed primiparous women who had an episiotomy at a normal vaginal delivery. The study group included parturient women (n = 201) who underwent an episiotomy at a vaginal delivery during a 2-year period (2001–2002). Inclusion criteria were: primiparity, term singleton vaginal delivery, episiotomy, and a subsequent vaginal delivery in Edith Wolfson Medical Center. Exclusion criteria were instrumental delivery at the index delivery, preterm delivery or twins at the subsequent delivery. Episiotomy in the enrolled parturient women was done when it is thought that failure to perform episiotomy would result in perineal tears. The control group (n = 201) was formed from the same time period and included women who had a spontaneous vaginal delivery without episiotomy.

Results

Of the 201 women with episiotomy at the index delivery, 48 (23.9 %) had episiotomy at the subsequent delivery compared to only 20 women (10.0 %) out of the 201 women without an episiotomy at index delivery (p < 0.05). Having an episiotomy at the index delivery significantly increased odds of a subsequent episiotomy (OR 2.84, 95 % CI 1.62–4.99, p < 0.05) and the risk of spontaneous perineal tears (59.2 vs. 23.4 %, p < 0.05) at the subsequent delivery.

Conclusion

Episiotomy at first vaginal delivery significantly and independently increased the risk of repeated episiotomy and spontaneous perineal tears in a subsequent delivery.     

Necrotizing fasciitis arising from episiotomy

Necrotizing fasciitis is a fatal, rapidly progressive, often initially unrecognized condition. Mortality rates range from 30% to 76%. Prognosis depends on the delay of diagnosis, antimicrobial treatment and surgical excision of all necrotic tissue. A case of postpartum perineal necrotizing fasciitis arising from episiotomy is presented. Prompt recognition and aggressive therapy resulted in a favorable outcome despite significant morbidity.     

Carcinoma in episiotomy scars.

The finding of primary or metastatic carcinoma in an episiotomy scar is a rare event; we report three cases. The first patient presented with an abnormal cervical smear and was found to have a primary squamous cell carcinoma of the vulva in an old, healed episiotomy scar. A second patient, diagnosed as having cervical carcinoma 6 months postpartum, was found to have a metastatic deposit in the episiotomy scar during the staging of her disease. The third patient developed adenocarcinoma metastatic from an endocervical primary in an episiotomy scar that presented as a small nodule at the introitus. These cases exemplify the need for careful inspection and biopsy of any nodular lesions in episiotomy scars as part of the initial assessment and follow-up of patients with premalignant or malignant lesions of the lower genital tract.     

Early repair of episiotomy dehiscence

We retrospectively reviewed the medical records of our hospital between 1 March 2001 and 1 March 2003 for patients with episiotomy dehiscence. In the study period, there were 37 patients with episiotomy dehiscence. While 12 of the patients with episiotomy dehiscence were allowed to heal by secondary intention, 25 patients underwent early repair. All the episiotomies were mediolateral. Infection was the obvious cause of dehiscence in the majority (25 out of 37) of the women. The average time from recognition of dehiscence to discharge from hospital was 5.6 +/- 2.8 days for the patients with early repair of episiotomy dehiscence and 5.8 +/- 2.4 days in patients allowed to heal by secondary intention. Patients were seen 2 weeks after being discharged. Among the patients treated by early repair, three patients had a superficial separation of skin edges. Healing was complete in the rest of the patients with early repair of episiotomy dehiscence. We concluded that with adequate preoperative care, primarily wound cleansing and intravenous antibiotics, early repair of episiotomy dehiscence is safe and effective.     

Early repair of episiotomy dehiscence

Early repair of episiotomy dehiscence was performed in 22 women with an initial fourth-degree episiotomy, four with third-degree episiotomy, and five with a mediolateral episiotomy. Early complications were limited to development of a pinpoint rectovaginal fistula in two women, both subsequently repaired by a rectal mucosal flap procedure. Of the 27 women now 1 year or more post-repair, all are completely continent and report resumption of normal coital activity.     

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。     

Determinants of episiotomy in rural Zimbabwe

BACKGROUND: To assess the influence of parity, mode of birth, place of birth, a history of birth by only cesarean section and birthweight on episiotomy rates. METHODS: Retrospective study of 3589 women giving birth vaginally from October 1997 to October 1998 in the Gutu district in Zimbabwe, to obtain the rate of episiotomy and its determinants. RESULTS: The overall episiotomy rate was 27%; 54% in nulliparous and 6% in multiparous women. Perineal tears varied between 5 and 11% in the different places of birth. DISCUSSION: An episiotomy rate of 54% in nulliparous women is higher than necessary. Medical and midwifery training should be adapted to facilitate a more restrictive use of episiotomy.     

The effect of epidural analgesia on rates of episiotomy use and episiotomy extension in an inner-city hospital

Objective : To determine the relationship between epidural analgesia and episiotomy usage and episiotomy extension in parturients delivering vaginally. Methods : A database of 20 888 women experiencing spontaneous vaginal delivery at Grady Memorial Hospital from 1990 to 1995 was examined to identify those receiving epidural analgesia. Patients who underwent epidural catheter placement and had adequate perineal anesthesia at delivery comprised the epidural group, and all others comprised the control group. Demographic characteristics and obstetric outcomes were compared. Univariate and multivariate analyses were used to test the association between epidural analgesia, rates of episiotomy and episiotomy extension. Results : Of the 20 888 women experiencing spontaneous vaginal deliveries 6785 (32.5%) received epidural analgesia. Women receiving epidural analgesia were more likely than those not receiving epidural analgesia to be African-American and nulliparous, and to have an occiput posterior presentation. Women receiving epidural analgesia were also more likely to receive an episiotomy (27.8% vs. 13.1%, odds ratio (OR) 2.56, 95% confidence interval (CI) 2.38-2.75) and were less likely to experience a second-degree perineal laceration (11.6% vs. 14.4%, OR 0.75, 95% CI 0.69-0.82) or a third- or fourth-degree extension (8.9% vs. 12.4%, OR 0.81, 95% CI 0.68-0.97). When the results were adjusted for nulliparity, posterior presentation, macrosomia, shoulder dystocia and prolonged second stage, epidural analgesia remained independently associated with receipt of episiotomy (OR 1.97, 95% CI 1.88-2.06) and reduced episiotomy extension (OR 0.74, 95% CI 0.54-0.94). Conclusion : Epidural analgesia increases the rates of episiotomy use, and decreases the rate of episiotomy extension, independently of clinical factors associated with episiotomy.