Obstetric Lacerations Research Articles

Association Between Obstetrician Forceps Volume and Maternal and Neonatal Outcomes

OBJECTIVE: To estimate the association between obstetric forceps volume and severe perineal lacerations or adverse neonatal outcomes. METHODS: This is a retrospective cohort of forceps deliveries performed at a tertiary care hospital. Obstetricians were grouped by quartile of forceps volume over the study time period. Severe (third- or fourth-degree) perineal lacerations and adverse neonatal outcomes were compared across quartiles. Individual patient characteristics were controlled for using multilevel multivariable analysis. This study had 90% power to detect a twofold difference in severe perineal lacerations between the first and fourth quartiles. Additional analyses were performed using physician years in practice or year of residency of the involved resident physicians. RESULTS: One hundred eighteen attending physicians (2,369 forceps deliveries) were included. The median (interquartile range) annual number of forceps per quartile was 1.3 (1.0–1.8), 3.8 (3.0–4.3), 6.3 (5.5–6.8), and 11.5 (9.8–17.3). The frequency of severe perineal lacerations from lowest to highest quartile was 29.9%, 27.5%, 33.3%, and 36.9% (P=.013). After adjusting for confounders, the relationship between volume quartile and severe perineal lacerations became nonsignificant. Although not powered to this outcome, the frequency of composite adverse neonatal outcome was not associated with volume quartile in either bivariate or multivariable analysis. Similarly, neither physician years of practice nor resident year was associated with severe perineal laceration. However, more experience as a resident was associated with a reduced odds of composite adverse neonatal outcomes. CONCLUSIONS: After controlling for patient factors, neither attending forceps volume nor physician years in practice was associated with severe perineal lacerations or composite neonatal injury. LEVEL OF EVIDENCE: II

Labial Fusion Causing Recurrent Cyst Formation and a Novel Approach to Surgical Management

Labial fusion may occur as a result of lichen sclerosus, lichen planus, genital mutilation, obstetric laceration, and atrophic vaginitis. Koebner phenomenon, or reformation of scar tissue over the clitoris after trauma to the involved tissue, may confound attempts at surgical management. A 22-year-old nulligravid patient presented with labia minora fusion that had been present since childhood. Her most bothersome symptoms were the recurrence of periclitoral pseudocysts with pain and discharge after spontaneous or needle drainage. Her symptoms and examination findings persisted despite a prolonged course of topical clobetasol, and she desired surgical intervention. A silastic vessel loop was placed through the tract between her clitoris and fused overlying labia. The ends of the vessel loop were brought together and tied in a fashion similar to cutting setons used to manage complex anal fistulae. Over the subsequent weeks, additional ties were used to sequentially tighten the loop and gradually divide the fused labia, ultimately exposing the patient's normal clitoris, which was uninjured by the procedure. Topical clobetasol was used throughout the process to prevent reagglutination of the labia. Our experience suggests that adaptation of a cutting seton may be used effectively in the surgical management of labial fusion to allow for gradual division of the skin bridge while minimizing the risk of recurrence of agglutination.

Vulvar Pyoderma Gangrenosum Originating From a Healed Obstetric Laceration

Pyoderma gangrenosum is a rare dermatologic disorder that can occur on the vulva. A 25-year-old woman, gravida 2 para 1 abortus 1, had development of pain and subsequent ulceration at the location of her previously healed vulvar obstetric laceration. The ulceration and pain continued to worsen despite wound management. Once the diagnosis of vulvar pyoderma gangrenosum was made, cyclosporine was started and the wound rapidly healed. Vulvar pyoderma gangrenosum should be considered when a vulvar wound is not healing with conservative measures. Cyclosporine can be considered as an alternative to steroids for treatment.

The obstetric consequences of female genital mutilation/cutting: a systematic review and meta-analysis.

Various forms of female genital mutilation/cutting (FGM/C) have been performed for millennia and continue to be prevalent in parts of Africa. Although the health consequences following FGM/C have been broadly investigated, divergent study results have called into question whether FGM/C is associated with obstetric consequences. To clarify the present state of empirical research, we conducted a systematic review of the scientific literature and quantitative meta-analyses of the obstetric consequences of FGM/C. We included 44 primary studies, of which 28 were comparative, involving almost 3 million participants. The methodological study quality was generally low, but several studies reported the same outcome and were sufficiently similar to warrant pooling of effect sizes in meta-analyses. The meta-analyses results showed that prolonged labor, obstetric lacerations, instrumental delivery, obstetric hemorrhage, and difficult delivery are markedly associated with FGM/C, indicating that FGM/C is a factor in their occurrence and significantly increases the risk of delivery complications. There was no significant difference in risk with respect to cesarean section and episiotomy. These results can make up the background documentation for health promotion and health care decisions that inform work to reduce the prevalence of FGM/C and improve the quality of services related to the consequences of FGM/C.

Fibrin Sealant for Management of Complicated Obstetric Lacerations

Department of Obstetrics and Gynecology, Dartmouth Medical School, Dartmouth-Hitchcock Medical Center, Lebanon, NH

Characteristics Associated With Severe Perineal and Cervical Lacerations During Vaginal Delivery

To characterize potentially modifiable risk factors for third- or fourth-degree perineal lacerations and cervical lacerations in a contemporary U.S. obstetric practice. The Consortium on Safe Labor collected electronic medical records from 19 hospitals within 12 institutions (228,668 deliveries from 2002 to 2008). Information on patient characteristics, prenatal complications, labor and delivery data, and maternal and neonatal outcomes were collected. Only women with successful vaginal deliveries of cephalic singletons at 34 weeks of gestation or later were included; we excluded data from sites lacking information about lacerations at delivery and deliveries complicated by shoulder dystocia; 87,267 and 71,170 women were analyzed for third- or fourth-degree and cervical lacerations, respectively. Multivariable logistic regressions were used to adjust for other factors. Third- or fourth-degree lacerations occurred in 2,516 women (2,223 nulliparous [5.8%], 293 [0.6%] multiparous) and cervical lacerations occurred in 536 women (324 nulliparous [1.1%], 212 multiparous [0.5%]). Risks for third- or fourth-degree lacerations included nulliparity (7.2-fold risk), being Asian or Pacific Islander, increasing birth weight, operative vaginal delivery, episiotomy, and longer second stage of labor. Increasing body mass index was associated with fewer lacerations. Risk factors for cervical lacerations included young maternal age, vacuum vaginal delivery, and oxytocin use among multiparous women, and cerclage regardless of parity. Our large cohort of women with severe obstetric lacerations reflects contemporary obstetric practices. Nulliparity and episiotomy use are important risk factors for third- or fourth-degree lacerations. Cerclage increases the risk for cervical lacerations. Many identified risk factors may not be modifiable.

Hospitalizations for Extreme Conditions Mean Extreme Expenses, Study Verifies

NEW STATISTICS CONFIRM WHAT anyoneinhealthcarecouldguess: hospital care for the very sick or vulnerable intheUnitedStates isveryexpensive and often futile. In certain instances, however, some say such costly episodesmightbeminimizedorevenprevented by quality hospital care. According to a statistical brief issued in October by the Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project (HCUP), the top 0.5% of the most expensive hospital stays in 2008 averaged $568 040 in total charges, with a mean charge per day of $17 224 and an average length of stay of 48.4 days. Septicemia; live-born infant; respiratory failure; complication of device, implant, or graft; and acute cerebrovascular disease were the most common principal diagnoses leading to the highest hospitalization charges (http://www .hcup-us.ahrq.gov/reports/statbriefs /sb97.pdf). And while the care is expensive, it does not always guarantee successful outcomes. HCUP found that in the top 0.5% of expensive stays, 30.5% of those admitted for septicemia died in the hospital, as did about 24.9% of patients admitted for respiratory failure and about 20.4% admitted due to a complication of device, implant, or graft. Taking a broader view, HCUP estimated that the mean total charge for the 5% of the most expensive hospitalizations was $191 984 compared with a mean of $20 804 for the other 95%. The most common principal diagnoses for the top 5% were septicemia; coronary atherosclerosis; acute myocardial infarction; complication of device, implant or graft; and respiratory failure. For the remaining 95%, the most common principal diagnoses were liveborn infant, pneumonia, congestive heart failure, osteoarthritis, and childbirth trauma to perineum and vulva. Among the top5%ofexpensive stays, the most common procedures were bloodtransfusion;respiratoryintubation and mechanical ventilation; diagnostic cardiac catheterization, coronary arteriography; enteral and parenteral nutrition;anduseofheart-lungmachineduring surgery. For the bottom 95%, the most common procedures were blood transfusion; prophylactic vaccinations and inoculations; cesarean delivery; repair of current obstetric laceration; and diagnosticcardiaccatheterization,coronary arteriography. HCUP made its estimates using its National Inpatient Sample, a database of inpatient stays sampled from all types of hospitals. The sampling frame represents about 95% of all US discharges. The charges are what a hospital billed for a case and do not include professional fees. They also do not reflect any discounts negotiated by insurers covering patient hospital costs. The high costs of certain hospitalizations could be seen as a sign of unnecessary charges in the delivery of health care in a hospital setting, but Bernard Friedman, PhD, the brief’s lead author and a senior economist with HCUP, said he was fairly confident the totals reflect honest efforts to treat patients with extreme conditions. “We did some statistical testing to try to determine which of the charges were suspiciously high, and we found about 12% of cases to be—a low statistical percentage,” Friedman said. “So that indicates to me that maybe none of them were truly wrongfully high.” While the high charges may be legitimate, that does not mean that nothing can be done to try to reduce such expenses. Friedman said the appearance of septicemia at the top of categories for highest hospital expenses spotlights a condition that can be prevented or minimized by quality hospital care. “People are way up in arms as to how serious this is and how frequent it has become,”

Perimenopausal Amenorrhea with Cervical Atresia and Hematotrachelos

Obstruction of the lower female genital tract leading to proximal dilatation and development of hematotrachelos is most commonly a result of congenital abnormalities such as an imperforate hymen, a complete transverse vaginal septum, or rarely, cervical atresia. Acquired hematotrachelos is rare, and the possible etiology includes iatrogenic trauma to the uterocervix such as cervical surgery, dilation and curettage, obstetric laceration, cervical or endometrial carcinoma, and radiation therapy. We report an unusual case of a patient in who spontaneously acquired hematotrachelos developed in the perimenopausal period. Combined speculum inspection of the cervix and recognition of transvaginal echographic features assisted the diagnosis. In addition, we tried a new treatment method, using the firm plastic end of an Ipas Karman cannula (6 mm diameter and 6 cm length) with nylon fixation retained for I month that resulted in a patent cervical canal.

Non-Oral Poster 33

OBJECTIVES: To review our experience pertaining to the surgical repair of rectovaginal fistulae during a medical mission at Hospital Escuela in Tegucigalpa, Honduras. Included are the scope of the problem, surgical repair, and the opportunity for resident learning experience during the mission. MATERIALS AND METHODS: In May 2009, a MEDRETE (medical readiness mission) involving urogynecologic surgical care was undertaken for two weeks at the Hospital Escuela in Tegucigalpa, Honduras. Two attending urogynecologists, 2 OB/GYN senior residents, 4 aneshtesia providers, and OR staff were deployed to Tegucigalpa from Brooke Army Medical Center and Wilford Hall Medical Center in San Antonio, Texas. Seventy-two patients were evaluated for surgery with problems including pelvic organ prolapse, urinary incontinence, and rectovaginal fistula. Sixty-one surgical procedures were performed over 9 operating days. Eleven patients were identified as having rectovaginal or anovaginal fistulae. The average age of these patients was 26 years and average parity was 3. Nine of these patients sustained injury during childbirth which was not attended by physician or mid-wife or not properly repaired. The average time these patients waited for evaluation was 18 months. Hospital Escuela in Tegucigalpa, Honduras is the main teaching hospital and also provides free care to patients with little means. There are approximately 65 deliveries per day in this hospital with an average of 2 attending obstetricians and 2 residents each day. RESULTS: Eleven patients underwent surgical repair of rectovaginal or anovaginal fistulae. Eight of these underwent sphincteroplasty, and three underwent perineoplasty alone. Each spent one night in the hospital and were discharged the next day. Each case was staffed by an attending urogynecologist with a senior level OB/GYN resident. At the conclusion of the mission, the senior resident was acting as primary surgeon with attending assistance. Prior to the mission, each resident reported exposure to 2 4th degree repairs and no rectovaginal fistulae procedures. To date, there were no major complications reported with only one patient with a perineal skin separation. Ten of the eleven patients were seen in follow up by the Honduran Gynecologist. At the conclusion of the mission, there were approximately 50 patients with the similar condition waiting for evaluation. CONCLUSION: Recto-vaginal fistula is a devastating condition in 3rd world countries where it is a common complication of childbirth resulting from obstructed labor or either poorly or unrepaired obstetric lacerations. It is exceedingly rare in developed countries. Social, emotional and psychological consequences incurred by women with obstetric fistulas can lead to stigmatization, isolation and loss of social support and in some cases divorce or separation. In the United States, with diminishing use of episiotomy and fewer operative vaginal deliveries utilizing forceps, the opportunity to train Obstetric and Gynecology residents this important skill has decreased. Other than the obvious benefit of providing surgical care to the impoverished population of a Third World country, it provided a robust learning experience for OB/GYN residents.

Fibrin Sealant for Management of Complicated Obstetric Lacerations

Fibrin sealant commonly is used topically for hemostasis in cardiovascular surgery. Complicated vulvar and vaginal bleeding after vaginal delivery can be difficult to manage using traditional techniques. A 21-year-old primipara, after a spontaneous vaginal delivery of a twin gestation, was found to have expanding right labial swelling and ecchymosis extending from the superior part of the labia majora to the ischial fossa that was approximately 10 cm wide. Surgical exploration was pursued, but poor tissue quality limited the effectiveness of traditional hemostatic techniques. Prompt hemostasis was achieved with application of fibrin sealant. Fibrin sealant may be useful for hemostasis when traditional techniques fail in complicated lacerations of the vulva and vagina associated with obstetric delivery.

Objective structured assessment of technical skills for repair of fourth-degree perineal lacerations

The objective of this study was to assess the reliability and validity of an objective structured assessment of technical skills (OSATS) for repair of fourth-degree obstetric lacerations on a surgical model. Three blinded judges reviewed recordings of 20 junior and 20 senior obstetrics-gynecology residents performing simulated perineal repairs using a beef tongue model. Judges completed task-specific OSATS and global rating scales for each repair. Six recordings were rereviewed after 2 weeks. Inter- and intrarater reliability and construct validity were assessed. Interrater reliability was 0.80 for task-specific OSATS and 0.59 for the global rating scale. Intrarater reliability was poor. Construct validity was demonstrated, with senior residents scoring higher than junior residents on task-specific OSATS (13.0 vs 10.5; P = .007) and the global rating scale (24.0 vs 19.3; P = .001). We found good interrater reliability and construct validity using a task-specific OSATS for fourth-degree perineal laceration repair. This instrument shows promise as a tool for competency-based evaluations.

Episiotomy and Increase in the Risk of Obstetric Laceration in a Subsequent Vaginal Delivery

Episiotomy and Increase in the Risk of Obstetric Laceration in a Subsequent Vaginal Delivery

Episiotomy and Increase in the Risk of Obstetric Laceration in a Subsequent Vaginal Delivery

Episiotomy and Increase in the Risk of Obstetric Laceration in a Subsequent Vaginal Delivery

The use of blunt needles does not reduce glove perforations during obstetrical laceration repair

The objective of the study was to compare the rate of glove perforation for blunt and sharp needles used during obstetrical laceration repair. A secondary aim was to assess physician satisfaction with blunt needles. This was an institutional review board-approved, randomized, prospective trial. Patients with obstetric lacerations were randomized to repair with either blunt or sharp needles. Patient demographics, operator experience, and other clinical variables were collected. Physicians reported any percutaneous injuries and were surveyed regarding satisfaction with the assigned needles. Glove perforation was determined using a validated water test method. There were 438 patients enrolled in the trial: 221 in the control group and 217 in the study group. There was no statistical difference between groups in patient demographics, clinical variables, severity of laceration, or experience level of the surgeon. There was no difference in the glove perforation rate between blunt and sharp needles (risk ratio, 0.79; 95% confidence interval, 0.2-2.95). There was poor correlation between reported perforations and those detected by water test (R(2) = 0.33). The physicians reported that blunt needles were more difficult to use than sharp needles (P = .0001). There was no difference in the rate of surgical glove perforation for blunt, compared with sharp, needles used during vaginal laceration repair. Physicians also reported increased difficulty performing the repair with blunt needles.

Episiotomy and Increase in the Risk of Obstetric Laceration in a Subsequent Vaginal Delivery

To examine whether episiotomy at first vaginal delivery increases the risk of spontaneous obstetric laceration in the subsequent delivery. 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. 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. 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. II.

Risk and Outcome of Obstetrical Anal Sphincter Injury

In Brief Objective: To describe risk factors for sustaining anal sphincter injury during vaginal delivery and to describe the frequency of short-term complications. Methods: A case-control review of 83 patients sustaining third or fourth degree obstetrical lacerations and a group of 166 controls. Univariate and multivariate logistic regression analyses were performed. The frequency of wound complications and perineal/anal symptoms was calculated. Results: The presence of chorioamnionitis, use of forceps, midline episiotomy, first delivery, larger birth weight, and longer second stage of labor (P < 0.02) had increased odds ratios for association with anal sphincter lacerations using univariate analysis. Only use of forceps and midline episiotomy (P < 0.02) demonstrated significantly increased odds ratios using a logistic multivariate model. Following repair of anal sphincter lacerations, the rate of wound breakdown was 2% and the rate of wound infection was 5%, which were unrelated to the degree of laceration. Of 62 patients with follow-up documentation, 21% complained of some degree of anal incontinence, pain with defecation, dyspareunia, or anal urgency. Conclusions: Risk factors for anal sphincter injury include use of forceps and midline episiotomy. Wound breakdown and infection frequencies were not different between third and fourth degree lacerations. Risk factors for recognized obstetrical anal sphincter injury include use of forceps and midline episiotomy. In the short term, one-fifth of patients complained of some degree of adverse symptoms related to third or fourth degree laceration.

Minimizing Genital Tract Trauma and Related Pain Following Spontaneous Vaginal Birth

Genital tract trauma is common following vaginal childbirth, and perineal pain is a frequent symptom reported by new mothers. The following techniques and care measures are associated with lower rates of obstetric lacerations and related pain following spontaneous vaginal birth: antenatal perineal massage for nulliparous women, upright or lateral positions for birth, avoidance of Valsalva pushing, delayed pushing with epidural analgesia, avoidance of episiotomy, controlled delivery of the baby's head, use of Dexon (U.S. Surgical; Norwalk, CT) or Vicryl (Ethicon, Inc., Somerville, NJ) suture material, the "Fleming method" for suturing lacerations, and oral or rectal ibuprofen for perineal pain relief after delivery. Further research is warranted to determine the role of prenatal pelvic floor (Kegel) exercises, general exercise, and body mass index in reducing obstetric trauma, and also the role of pelvic floor and general exercise in pelvic floor recovery after childbirth.

Does Epidural Analgesia Affect the Rate of Spontaneous Obstetric Lacerations in Normal Births?

The precise relationship between epidural use and genital tract lacerations in normal childbirth is unclear. Data from a clinical trial on measures to lower genital tract trauma in vaginal birth were used for a secondary analysis. The goal was to assess whether epidurals affect the rate of spontaneous obstetric lacerations in normal vaginal births. Maternal characteristics and intrapartum variables were compared in women who did and did not use an epidural in labor, and also in those with and without any sutured lacerations following vaginal birth. Variables that were statistically different in both cases were entered into regression equations for simultaneous adjustment. Epidural use was not an independent predictor of sutured lacerations. Predictors of sutured lacerations included nulliparity, a prolonged second stage, being non-Hispanic white, and an infant birthweight greater than 4000 grams. Elements of midwifery management need further research.

Acquired Hematometra and Hematotrachelos in an Adolescent With Dysfunctional Uterine Bleeding

Obstruction of the lower female genital tract leading to proximal dilatation and development of hematocolpos, hematotrachelos, and hematometra is most commonly a result of congenital abnormalities. 1-3 These conditions include an imperforate hymen, a complete transverse vaginal septum, and vaginal and, rarely, cervical atresia. 1-3 Acquired obstruction of the lower female genital tract is rare. Etiologies of such acquired lesions include iatrogenic trauma to the uterine cervix such as cone biopsies, loop electrosurgical procedures, dilation and curettage, obstetric lacerations, cervical or endometrial carcinoma, and radiation therapy. 4-8 Spontaneous obstruction is extremely rare yet has been reported recently. 9 We describe an unusual case in which sonographic findings of marked spontaneous hematometra and hematotrachelos were depicted in an adolescent with dysfunctional uterine bleeding.

Prolonged Second Stage of Labor and Risk of Adverse Maternal and Perinatal Outcomes: A Systematic Review

Safe and effective management of the second stage of labor presents a clinical challenge for laboring women and practitioners of obstetric care. This systematic review was conducted to evaluate evidence for the influence of prolonged second stage of labor on the risk of selected adverse maternal and neonatal outcomes. Articles were searched using PubMed, Cochrane Library, and CINAHL from 1980 until 2005. Studies were included according to 3 criteria: if they reported duration of the second stage of labor, if they reported maternal and/or neonatal outcomes in relation to prolonged second stage, and if they reported original research. Our systematic review found evidence of a strong association between prolonged second stage and operative delivery. Although significant associations with maternal outcomes such as postpartum hemorrhage, infection, and severe obstetric lacerations were reported, inherent limitations in methodology were evident in the studies. Recurrent limitations included oversimplified categorization of second stage, inconsistency in study population characteristics, and lack of control of confounding factors. No associations between prolonged second stage and adverse neonatal outcomes were reported. The primary findings of our review indicated that most of the studies are flawed and do not answer the important questions for maternity caregivers to safely manage prolonged second stage. Meanwhile, approaches for promoting a normal second stage of labor are available to caregivers, such as maternal positioning and pain relief measures and also promoting effective pushing technique.