Genital tract injury Flashcards

1
Q

Discuss cervical laceration
-Incidence (1)
-Causes (5)

A
  1. Incidence 0.2%
  2. Causes
    -Rapid cervical dilatation
    -Application of instruments before cervix fully dilated
    -Rapid delivery of head at breech
    -Extension of vaginal tear
    -Extension of uterine angle in CS
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2
Q

Discuss management of cervical laceration (6)

A
  1. Consider if ongoing PPH with good tone
  2. Examine under good anaesthesia
  3. Look at vaginal fornicies
  4. Examine cervix circumferencially with sponge forceps
  5. Suture with interrupted vicryl sutures from apex of laceration
  6. Remember proximately of ureters, bladder and uterine vessels
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3
Q

Discuss episiotomy
-General points (3)
-Indications (5)
-Types (2)

A
  1. General points
    -Routine epis is not recommended
    -WHO recommend epis in <10% of cases
    -Spontaneous tears are associated with shorter pain and faster resumption of intercousre
  2. Indications
    -Soft tissue dystocia with high likelihood of third or fourth degree tear
    -Requirement to accelerate birth
    -Need to facilitate instrumental delivery
    -History of FGM
  3. Types
    Midline
    -More blood loss, perineal pain and dypareunia
    Mediolateral
    -Less blood loss, perineal pain, dyspareunia
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4
Q

Discuss levator avulsion
-Definition (1)
-Incidence (2)
-Risk factors (5)

A
  1. Definition Disruption of puborectalis from boney insertion on the posterior surface of the superior pubic ramus lateral to SP
  2. Incidence
    -13-36%
    -26% with forceps
  3. Risk factors
    -Primiparous
    -Prolonged second stage
    -Macrosomia
    -Forceps delivery
    -Non OA position
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5
Q

Discuss the mechanism of injury of levator avulsion (2)

A
  1. Avulsion from macroscopic trauma
  2. Over distension by the fetal head resulting in microscopic trauma and stretch of the levator ani and the nerves which supply them
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6
Q

How can levator avulsion be diagnosed (4)

A
  1. Asymetry of the genital hiatus
  2. On Valsalva the perineum and anus are displaced towards the healthy side
  3. Space where at the site of puborectalis insertion
  4. Imaging with USS or MRI
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7
Q

Discuss levator avulsion
-Methods to prevent (3)
-Implications of avulsion (3)

A
  1. Methods to prevent
    -Avoid forceps where possible
    -Avoid prolonged second stage
    -Use relaxant analgesia - epidural / pudendal
  2. Implication of avulsion
    -Cannot fix. Must prevent
    -Doubles risk of anterior and apical compartment prolapse
    -Associated with increased recurrence of POP following surgery
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8
Q

Discuss perineal trauma
-Incidence (1)
-Types (2)
-Risk factors (7)

A
  1. Incidence - 85%
  2. Types
    -First degree - perineal skin only
    -Second degree - skin and muscle
  3. Risk factors
    -Primiparous
    -Macrosomia
    -Prolonged second stage
    -Instrumental delivery
    -Malpresentation
    -Precipitous birth
    -FGM
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9
Q

Discuss methods to prevent perineal injury (5)

A

Evidence from Cochrane review
-No difference between hands off and hands poised
-Warm compress reduced rates of 3/4th degree tears but did not impact 1st and second degree tear incidence
-Intrapartum perineal massage increased rates of intact perineum
-Anaesthetic gels, cold compress, oils make no difference
-Antenatal perineal massage stretching devices make no difference

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10
Q

Discuss management of tears
-Labial (3)
-Periurethral (3)

A
  1. Labial
    -Don’t suture if not bleeding
    -Can repair if irregular to avoid skin tags
    -If bilateral opposing grazes suture to avoid fusion
  2. Periurethral tears
    -Often bleed
    -Repair with interrupted 3.0 vicryl rapide
    -Repair with IDC in situ to ensure urethra not breeched
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11
Q

Discuss complications of perineal trauma
-Short term complications (4)
Long term complications (4)

A
  1. Short term complications
    -Pain 10% pain lasts 3-18 months
    -Haematoma
    -Infection
    -Breakdown
  2. Long term complications
    -Dyspareunia (60% at 3 months)
    -Urinary incontinence 30% at 5yrs
    -Faecal incontinence 4% at 9 months
    -Fistulae formation
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12
Q

Discuss third and fourth degree tears
-Incidence (3)
-Types (5)

A
  1. Incidence
    -1% of all vaginal births (3% in Australia)
    -5% of all nulliparious vaginal births
    -30% are occult / missed injuries
  2. Types
    3a - <50% of the EAS
    3b >50% of EAS
    3c EAS+ IAS
    4th inclusion of the anorectal mucosa
    Button hole - through the anal mucosa but anal sphincter intact
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13
Q

Discuss the anatomy of the anal sphincter
-Composition
-Innervation
-Function

A
  1. External anal sphincter
    -Striated muscles
    -Innervated by pudendal nerve
    -Under voluntary control
    -Provides 30% of resting tone
    -Contributes to urge faecal incontinence
  2. Internal anal sphincter
    -Smooth muscle
    -Innervation PNS
    -Provides 70-85% resting tone
    -Contributes to passive soiling and flatus
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14
Q

Risk factors for OASIS injury
-Maternal factors(2)
-Fetal factors (2)
-Labour factors (6)

A
  1. Maternal factors
    -Primiparous RR 7.0
    -South Asian ethnicity RR 2.3
  2. Fetal factors
    -Macrosomia RR 2.0
    -OP presentation RR2.4
  3. Labour factors
    -Induction of labour
    -Epidural anaesthetic Increased risk form 1-2%
    -Prolonged second stage
    -Instrumental delivery esp if no epis
    -Shoulder dystocia RR 2.0
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15
Q

What measures can be used to prevent OASIS injury (9)

A

-Perineal massage after 34/40
-Warm compress in second stage during perineal distension RR 0.46
-Control of head through counter pressure and verbal guidance
-Selective episiotomy use - mediolateral
-PR following birth to detect injury for all women
-Episiotomy should be offered with nullips getting assisted delivery
-Correctly grade any OASIS trauma
-Perineal massage in second stage RR 0.49 for nullips only
-Avoid instrumentals where possible. Opt for ventouse over forceps (forceps 2.5 times more likely to cause damage)

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16
Q

What are the signs of OASI tears (4)

A

-Absence of puckering around the anus
-Visualisation of torn fibers
-Deficient muscle bulk on PR exam
-Unable to squeeze during PR exam

17
Q

Discuss repair of OASI tears
-Types (2)
-Pre-operative
-Repair of anal mucosa
-Repair of internal anal sphincter
-Repair of fully transected EAS
-Repair of partially transected EAS

A
  1. Types
    -Primary repair - performed at time of injury
    -Secondary repair
  2. Pre-operative considerations
    -Do in OT with adequate lighting, sterile field, analgesia
    -Broad spec Abx
    -IDC
  3. Repair of anal mucosa
    -Continuous non-locked suture with 3.0 vicryl
    -Knots in lumen
  4. Internal anal sphincter
    -End to end , interrupted, horizontal mattress sutures with 3.0 PDS
  5. EAS complete transection
    -Overlapping or end to end horizontal interrupted mattress sutures with 3.0 PDS
  6. EAS incomplete transection
    -End to end interrupted horizontal mattress sutures with 3.0 PDS
18
Q

What is the evidence for overlapping vs end to end sutures

A

Cochrane 2013 Meta analysis with 6 trials
-No difference in perineal pain, dyspareunia, flatus incontinence, QoL
-Overlapping technique - lower incidence of faecal urgency and incontinence over 12 months but no difference by 36 months

19
Q

Discuss post op management of OASI repairs

A
  1. Psychological support
    -Debrief
    -Council about expectation and future deliveries
  2. PO Abx 5 days
  3. Avoid opiates for pain management
  4. Laxatives for 2 weeks - lactulose
  5. IDC out after 6 hrs if regional anaesthetic
  6. Follow-up
    -See specialist in 6-12 weeks
    -MDT input - PT, gynaecologist, Continence nurse
    -If symptomatic at FU consider refer for endoanal USS and anorectal manometry
20
Q

Discuss the prognosis of OASI tears
-Incidence of continence achieved (3)
-Risk of recurrence (4)
-Outcomes with second OASIS

A
  1. Incidence
    -Damage to IAS more predictive of Sx of incontinence
    -Primary repair 60-80% continence at 12 months
    -Secondary repair 40% continence at 5 yrs
  2. Risk of recurrence - OR 5.5 5-7%
    -Associated with LGA, South Asian ethnicity, forceps delivery
    -Unclear if OASIS is an independent RF for repeat injury
    -17% risk of worsening sx even without further anal sphincter injury
  3. Outcomes with second OASIS
    -10x increased risk of further OASIS
    -70% chance of anal incontinence
21
Q

Discuss management of subsequent pregnancies in women with OASIS (5)

A
  1. If Asymptomatic offer trial of VB
    -Risk of recurrence of severe tear is same as BL
    -If concern for traumatic delivery have low threshold for offering CS
  2. If transiently symptomatic offer work up with anal manometry and USS. If > 1 quadrant defect or <20mmHg squeeze pressure offer CS
  3. If mild symptoms offer CS
  4. If severe can go for VB then secondary repair or CS
  5. If had secondary repair offer CS