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Practice bulletins > #198 Prevention and Managment of Obstetric Lacerations at Vaginal Delivery > Flashcards

#198 Prevention and Managment of Obstetric Lacerations at Vaginal Delivery Flashcards

1
Q

What is the most common site of laceration during childbirth?

A

Perineal body

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2
Q

What is the perineal body?

A

Mass of dense connective tissue that includes superficial and deep muscles of the perineal membrane including transverse perineal muscles and attachments of the bulbocavernosus muscles

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3
Q

What is included in the anal sphincter complex?

A

Internal and external sphincters, which circle the distal anus

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4
Q

What type of muscle is the external anal sphincter?

A

Skeletal muscle

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5
Q

Is the external muscle voluntary or involuntary?

A

Voluntary control

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6
Q

What type of control is the internal anal sphincter under?

A

Autonomic control

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7
Q

Does internal or external anal sphincter responsible for the majority of the resting pressure of the anal canal?

A

Internal anal sphincter

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8
Q

The internal anal sphincter provides up to what % of the resting pressure of the anal canal?

A

Up to 80%

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9
Q

Do the external and internal anal sphincters overlap?

A

Yes, for a distance of 1-2cm

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10
Q

For how long does the anal sphincter complex extend up the anal canal?

A

Approximately 4cm

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11
Q

What % of women will experience some type of laceration during vaginal delivery?

A

53-79%

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12
Q

What is a first degree perineal laceration?

A

Injury to perineal skin only

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13
Q

What is a second degree perineal laceration?

A

Injury to perineum involving perineal muscles but not involving anal sphincter

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14
Q

What is a third degree perineal laceration?

A

Injury to perineum involving anal sphincter complex

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15
Q

What is a 3a degree perineal laceration?

A

Less than 50% of external anal sphincter thickness torn

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16
Q

What is a 3b degree perineal laceration?

A

More than 50% external anal sphincter thickness torn

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17
Q

What is a 3c degree perineal laceration?

A

Both external and internal anal sphincters torn

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18
Q

What is a fourth degree perineal laceration?

A

Injury to perineum involving anal sphincter complex and anal epithelium

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19
Q

What is the reported incidence of third-degree lacerations in the US?

A

3.3% [another systematic review reports approximately 11% incidence of sphincter injury]

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20
Q

What is the reported incidence of fourth-degree lacerations in the US?

A

1.1% [another systematic review reports approximately 11% incidence of sphincter injury]

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21
Q

What % of vaginal births include an episiotomy (based on 2012 US hospital dc data)?

A

Approximately 12%

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22
Q

Does routine episiotomy use offer benefit in perineal laceration severity, pelvic floor dysfunction (including urinary or fecal incontinence), or pelvic organ prolapse over a restrictive use of episiotomy?

A

No

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23
Q

Do women with vaginal delivery c/b obstetric anal sphincter injury associated with increased/decreased incidence of anal incontinence symptoms compared to cesarean section without sphincter laceration?

A

Increased risk after vaginal delivery c/b OASIS

24
Q

How does the incidence of poor bowel control compare between women with third or fourth degree laceration?

A

Women with hx of 4th degree laceration at first delivery reported worse bowel control 10 times more frequently than women with a 3rd degree laceration

25
Q

Compared to cesarean delivery what is the hazard ratio of pelvic organ prolapse surgery after noninstrumented vaginal delivery, VAVD, FAVD?

A

NSVD: HR 9.3
VAVD: HR 8.9
FAVD: HR 20.9

26
Q

What are the strongest risk factors for obstetric anal sphincter injury? What are additional risk factors?

A

Strong risk factors: Forceps delivery, vacuum-assisted delivery, midline episiotomy, increased fetal birth weight
Additional: primiparity, asian, labor induction, labor augmentation, epidural anesthesia, persistent occiput posterior position

27
Q

What is the effect of digital perineal massage from 34 wks of gestation onward in regards to perineal trauma at time of delivery?

A

Modest reduction in perineal trauma that required repair with suture and decreased episiotomy (primips)

28
Q

What is the effect of digital perineal massage during second stage of labor?

A

Reduced third degree and fourth degree tears when compared with “hands off” the perineum, but was not associated with significant changes in the rate of birth with an intact perineum

29
Q

Has perineal support shown to have an effect of rates of intact perineum at birth or rates of OASIS?

A

Conflicting evidence. Insufficient evidence to recommend a specific practice

30
Q

How does warm compress on the perineum during second stage of labor affect rates of intact perineum with delivery and rates of OASIS?

A

Significant reduced 3rd and 4th degree lacerations. Did not increase the rate of woman having intact perineum after delivery.

31
Q

Does delayed pushing (between 1-3 hours after fully dilated) affect the rates of perineal laceration or use of episiotomy?

A

No

32
Q

What are the indications for an episiotomy?

A

Based on existing evidence, there are no specific situations in which episiotomy is essential. Perform based on clinical considerations, restrict use.

33
Q

Which type of episiotomy has an increased risk of OASIS?

A

Midline

34
Q

What is associated with mediolateral episiotomy?

A

Limited data suggest may be associated with increased likelihood of perineal pain and dyspareunia

35
Q

Which labial, periclitoral, and periurethral lacerations should be repaired after delivery?

A

Lacerations that are bleeding or distort anatomy

36
Q

Which first degree perineal lacerations need to be repaired?

A

Those that are bleeding or distort anatomy

37
Q

Can surgical glue be used to repair perineal lacerations after delivery?

A

Yes, either standard suture or adhesive glue may be used to repair a hemostatic first-degree laceration or the perineal skin of a second degree laceration

38
Q

Are continuous or interrupted sutures preferable for second degree and episiotomy repairs, why?

A

Continuous repairs are associated with less pain for up to 10 days postpartum, less analgesia use, and a lower risk of having suture material removed postpartum.

39
Q

What type of suture is recommended for repair of first degree and second degree perineal lacerations, why?

A

Absorbable synthetic suture such as polyglactin (vicryl) recommended. Compared with catgut it is associated with less pain up to 3 days after delivery and less analgesia up to 10d postpartum. More women with catgut suture require resuturing (although number in both groups are small)

40
Q

How does suture compare to use of adhesive glue for closing perineal skin over episiotomy after suture closure of subcutaneous tissue and muscle?

A

No difference in reported pain. Application of skin adhesive takes less time.

41
Q

What is the method for closing a cervical laceration after delivery?

A

Only need to repair if bleeding. Use 2-0 chromic or polyglactin suture, either interrupted or continuous locking suture starting above the apex of the laceration, incorporate entire thickness of the cervix

42
Q

What suture technique is recommended for repair of anal mucosa?

A

Based on expert opinion:
Subcuticular running repair with transvaginal approach and interrupted sutures with knots tied in the anal lumen have been described. Absorbable 4-0 or 3-0 polyglactin or chromic suture. Some experts recommend second suture layer placed through rectal muscularis using 3-0 polyglactin suture in running or interrupted fashion

43
Q

What technique is recommended for repair of the internal anal sphincter?

A

Either as a part of the distal portion of the reinforcing second layer of the rectal muscularis using a 3-0 polyglactin suture or separately from the external anal sphincter using a 3-0 monofilament polydioxanone suture (PDS).

44
Q

What are the two methods of external anal sphincter repair? How do outcomes compare?

A

End-to-end and overlap repair. No difference at 36mo with incontinence symptoms or quality of life, overlapping had a lower risk of anal incontinence over first 12 mo.

45
Q

What is important to incorporate in your external anal sphincter repair?

A

Important to suture the fascial sheath and not just the muscle

46
Q

What suture is recommended for repair of the external anal sphincter based on expert opinion?

A

3-0 polyglactin, 3-0 polydioxanone, or 2-0 polyglactin suture

47
Q

Should antibiotics be administered in the setting of OASIS repair?

A

A single dose of antibiotic at the time of repair is reasonable in the setting of OASIS, but more studies are needed to see if it should be routine

48
Q

How can you decrease the risk of retained sponges at the time of vaginal delivery and laceration repair?

A

Count all sponges and needles before and after. Use radiography detectable sponges. The sponge count should be recorded in the permanent medical record

49
Q

During the first 6 wks postpartum, what % of women with OASIS will have wound breakdown and what % will have wound infection?

A

25% with wound breakdown

20% with wound infection

50
Q

In the US, what % of rectovaginal fistulas are associated with obstetric trauma?

A

9%

51
Q

The decrease in rectovaginal fistula repair has been decreasing (assumably due to decreased formation), why is it decreasing (related to obstetrics)?

A

Decreases in episiotomy, anal sphincer lacerations, and operative vaginal delivery

52
Q

What should be considered postpartum for women who had OASIS?

A

Pain control, avoidance of constipation, and evaluation for urinary retention

53
Q

How should you manage a postpartum patient with perineal laceration repair with superficial breakdown that does not involve the rectum or anal sphincter?

A

Expectant management with perineal care, may allow spontaneous healing to occur over a period of several weeks.
For more extensive breakdowns or logistics prevent many follow-up visits may be prohibitive, primary closure of the defect may be attempted

54
Q

What post-OASIS strategies prevent the development of anal incontinence?

A

No strategies are proven to prevent development of anal incontinence

55
Q

What is the risk of OASIS in women who had an OASIS at a previous delivery compared to those without (odds ratio) and what is the absolute risk?

A

OR 4.2. Absolute risk 3%

56
Q

What % of patients with previous OASIS undergo subsequent vaginal delivery?

A

67-90%

57
Q

In which patients with history of OASIS should you offer a cesarean delivery in subsequent pregnancies?

A

If any of the following is noted: experienced anal incontinence after the delivery, had complications including wound infection or a need for repeat laceration repair, or expresses suffering psychological trauma and requests scheduled cesarean delivery

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