Recent Advances in Obstetrics & Gynecology: Perineal Disorders Dilip Kumar Dutta
INDEX
Page numbers followed by ‘f’ refer to figure
A
Anal sphincter 1
complex 18f
defect 24
Anoscopy 39f
Antenatal perineal massage 13, 13f
Anterior
perineal trauma 1
urogenital triangle 1
Approximation of
bulbocavernosus muscle 12f
levator muscles 10f, 12f
Artificial anal sphincter 25
Assessment of perineal trauma 19
B
Bartholin's duct 2
C
Cardiac disease 7
Classification of perineal tear 5
Combined mechanical and neurologic trauma 19
Complications of perineal trauma 32
D
Direct mechanical injury 19
E
Epidural analgesia 3
Episiotomy 1
incisions 2f
Escherichia coli 41
F
Fecal continence scoring system 34
Female genital mutilation 3
Fetal weight 3
Fistula formation 26
Flexion technique 15, 15f
H
Hemorrhoidectomy 41
Hemorrhoids 37, 37f, 39f
in pregnancy 37, 38
I
Indications of episiotomy 7
Induction of labor 3
Instrumental birth 3
International guidelines in management of constipation in pregnancy 44
L
Loss of rectal tone 19
LUCK study 44
M
Management of
constipation in pregnancy 44
perineal tear 21
Managing constipation in pregnancy 43
Median
episiotomy 9, 10f
incision 10f
Mediolateral
episiotomy 11
incision 12f
Midline toward ischial tuberosity 12f
Muscle transfers 25
N
Needing episiotomy 13
Neurologic injury 19
P
Pelvic floor
exercises 28, 29
neuropathy 26
Performing episiotomy 9, 11f
Perineal
management techniques 15
muscles 1
tears 3, 5f, 6f
techniques 14
trauma 1, 13, 14
Perineotomy 1
Posterior
anal triangle 1
perineal trauma 1
vaginal wall 1
Proximal retraction of tissue with voluntary tightening 19
Pudendal neuropathy 24
R
Reconstruction of urogenital diaphragm 10f, 12f
Repair of
complete perineal tear 23f
vaginal mucosa 12
Ritgen's maneuver 15, 16f
Role of perineal clinic 32, 33
S
Shoulder dystocia 3
Skin closure 10f, 12f
Sphincter
and pelvic floor plication 24
injuries 18
Stimulating laxatives 28
Surgical management of anal incontinence 24
T
Traumatic obstetric injury requiring repair 3
Two methods of anal sphincter repair 22f
W
Water-binding laxatives 28
Wound infection 26
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Chapter Notes

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IntroductionCHAPTER 1

The perineum extends from the pubic arch to the coccyx and is divided into the anterior urogenital triangle and the posterior anal triangle. Anterior perineal trauma is injury to the labia, anterior vagina, urethra or clitoris and is usually associated with little morbidity. Posterior perineal trauma is any injury to the posterior vaginal wall, perineal muscles or anal sphincter (Fernando 2007; Kettle 2008).
Perineal trauma can occur spontaneously or result from a surgical incision of the perineum (episiotomy). The incidence of perineal trauma is reported to be 85% (McCandlish 1998) and the incidence of trauma that affect the anal sphincter is 0.5–7.0% (Sultan 1999), usually between 0.5 and 2.5% of spontaneous vaginal deliveries (Byrd 2005). Anal sphincter or mucosal injuries are identified following 3% to 5% of all vaginal births (Eke us 2008). Around 8% of women experience incontinence of stool and 45% suffer involuntary escape of flatus following anal sphincter injury (Eason 2002). Higher rates of perineal trauma are consistently noted in first vaginal births and with instrumental delivery (Christianson 2003).
There is considerable variation in the number of reported rates of perineal trauma between countries, partly due to differences in definitions and reporting practices (Byrd 2005). Studies with restrictive use of episiotomy report rates of perineal trauma that require suturing between 44% and 79% (Dahlen 2007; Soong 2005).
An episiotomy or perineotomy is a surgically planned incision on the perineum and the posterior vaginal wall during second stage of labor. The use of episiotomy has been said to decrease trauma to the fetus, decrease the frequency of extensive perineal tears, and protect the soft maternal tissues. Episiotomy is done as prophylaxis against soft-tissue-trauma.
There are four main types of episiotomy (Fig. 1.1):
  • Mediolateral: The incision is made downward and outward from midpoint of fourchette either to right or left. It is directed diagonally in straight line which runs about 2.5 cm away from the anus (midpoint between anus and ischial tuberosity).
  • Median: The incision commences from center of the fourchette and extends on posterior side along midline for 2.5 cm.
    2
    zoom view
    Fig. 1.1: Episiotomy incisions
  • Lateral: The incision starts from about 1 cm away from the center of fourchette and extends laterally. There is chance of injury to Bartholin's duct and thus some practitioners have totally condemned it.
  • ‘J’ shaped: The incision begins in the center of the fourchette and is directed posteriorly along midline for about 1.5 cm and then directed downwards and outwards along 5 or 7 o'clock position to avoid the anal sphincter. This is also not done widely.