Continued part 1, part 2 of ebook Cunningham and Gilstrap’s operative obstetrics provide readers with content about: intrapartum; episiotomy and obstetric anal sphincter lacerations; peripartum hysterectomy; placenta previa and morbidly adherent placenta; urologic and gastrointestinal injuries; postpartum; management of postpartum hemorrhage; genital tract lacerations and hematomas;... Please refer to the ebook for details!
SECTION INTRAPARTUM CHAPTER 20 Episiotomy and Obstetric Anal Sphincter Lacerations INTRODUCTION CLASSIFICATION OF PERINEAL LACERATIONS EPISIOTOMY OBSTETRIC ANAL SPHINCTER INJURIES CONCLUSION INTRODUCTION Injury to the perineum during vaginal childbirth affects millions of women One half to three quarters of parturients undergo some degree of perineal laceration during vaginal childbirth However, rates vary considerably by locale and provider (Low, 2000; Webb, 2002) Some lacerations occur spontaneously during delivery Or, an obstetric provider may cut an episiotomy to increase the vaginal outlet size to aid the birth Either may result in both short- and long-term symptoms and complications Initially, most women experience at least temporary discomfort or pain after perineal lacerations, and one in five will report long-term issues, such as dyspareunia (Glazener, 1995) Additional complications include physical, psychologic, and social problems, which all may affect a woman’s ability to care for her newborn and family (Sleep, 1991) The most severe perineal lacerations involve the anal sphincter, and these are termed obstetric anal sphincter injuries (OASIs) These tears and their consequences are described in detail throughout this chapter Preventively, increasing data are available to guide health-care providers and patients in selecting the optimal perineal strategy for each woman’s delivery No single strategy fits all patients, thus clinicians should devote time during antepartum counseling Topics ideally include discussion of the risks and benefits of episiotomy, strategies that may minimize spontaneous OASIs, and expectations of pelvic floor function following delivery In this chapter, we review current literature and practices for antepartum, intrapartum, and postpartum perineal management Specifically, data regarding risks and possible benefits of episiotomy, repair of obstetric lacerations, and their short- and long-term sequelae are presented CLASSIFICATION OF PERINEAL LACERATION Studies suggest that obstetricians may misclassify anal sphincter injuries This is coupled with an increasing awareness of the association between OASIs and anal incontinence (Fernando, 2006; Sultan, 1995) For these reasons, the traditional classification system for perineal lacerations was modified to include more specific information regarding the anal sphincter complex This updated system now contains internationally accepted nomenclature and is summarized in Table 20-1 and Figure 20-1 (Koelbl, 2009; Royal College of Obstetricians and Gynaecologists, 2007) TABLE 20-1 Classification of Obstetric Lacerations FIGURE 20-1 First-degree perineal laceration: injury only to perineal skin Second-degree perineal laceration: injury to perineum involving the perineal muscles but not to the anal sphincter complex 3a Third-degree perineal laceration: less than 50% of the external anal sphincter (EAS) is torn 3b Third-degree perineal laceration: more than 50% of the EAS is torn, but the internal anal sphincter remains intact 3c Third-degree perineal laceration: external and internal anal sphincters are torn Fourth-degree perineal laceration: injury to the perineum involves the entire anal sphincter complex and the anorectal epithelium By definition, OASIs include only third- and fourth-degree perineal tears Intuitively, these are associated with significantly more maternal morbidity than first- and seconddegree lacerations Moreover, in recent years, litigation related to long-term maternal consequences of OASIs has increased (Eddy, 1999) In the report by the National Health Service Litigation Authority (2012) entitled Ten Years of Maternity Claims, perineal trauma was listed as the fourth most common indication for obstetric claims in the United Kingdom during a 10-year span (Jha, 2015) EPISIOTOMY Historic Evolution Episiotomy is commonly performed in obstetrics and is among the most-debated procedures Episiotomy refers to a surgical incision of the perineum usually performed during the second stage of labor to increase the diameter of the pelvic outlet Episiotomy was thought to prevent perineal lacerations, aid delivery, and reduce the time for neonate delivery Sir Fielding Ould (1742), a Dublin midwife, recommended episiotomy to hasten prolonged labor when the external vaginal opening was deemed too narrow In the United States, the first report of episiotomy was almost 110 years later Namely, Taliaferro (1852) used a scalpel to cut a 1-inch left mediolateral episiotomy to aid delivery and avoid a rectal tear in a 16-year-old eclamptic patient In the 20th century, more women delivered in hospitals, and this was accompanied by an increase in episiotomy rates (Thacker, 1983) DeLee (1920) recommended forcepsassisted vaginal delivery with mediolateral episiotomy for all nulliparas and claimed that episiotomy provided protection for both mother and fetus He believed episiotomy would preserve the pelvic floor and introitus, prevent uterine prolapse and rupture of the vesicovaginal septum, and restore virginal conditions Some also attribute women delivering in lithotomy position to the rise in episiotomy and OASIs during this period Dorsal lithotomy is thought to place additional stress on the perineal body and lead to tears whether or not an episiotomy is cut (Bromberg, 1986; Thompson, 1987) In the 1960s, rates of routine episiotomy decreased as opponents questioned its scientific benefits Investigators argued that widespread use of routine episiotomy did not withstand scientific scrutiny; that episiotomy risks were largely ignored; and that women would likely decline routine episiotomy if adequately informed of the risks and benefits (Kitzinger, 1981; Thacker, 1983) Current Epidemiology Population-based studies from the United States report that episiotomy rates have declined and were approximately 60 percent in 1979, 31 percent in 1997, and 25 percent in 2004 (Frankman, 2009; Weber, 2002) A recent study of vaginal deliveries in more than 500 hospitals found that episiotomy rates continued to decline from 17 percent in 2006 to 12 percent in 2012 That said, hospital-to-hospital variation remains high (Friedman, 2015) For example, the episiotomy rate was 34 percent in the 10 percent of hospitals in which episiotomy was done most frequently This compared with a rate of 2.5 percent in the 10 percent of hospitals that used episiotomy the least Table 20-2 lists patient, practitioner, and delivery factors associated with higher episiotomy rates In a study by Friedman and colleagues (2015), white women had an episiotomy rate of 15.7 percent compared with a rate of percent for black women Notably, factors were not stratified by parity Gravidas with commercial insurance had a rate of 17 percent compared with Medicaid enrollees, whose rate was 11 percent Moreover, rural and teaching hospitals had lower episiotomy rates compared with urban and non-teaching facilities Faculty and private practitioners are two and four times, respectively, more likely than midwives to cut an episiotomy (Gerrits, 1994; Howden, 2004; Robinson, 2000) Likewise, episiotomy use is higher in nulliparas and those receiving epidural anesthesia (Hueston, 1996; Newman, 2001; Robinson, 2000) In contrast, upright or lateral maternal positions are associated with fewer episiotomies (Gupta, 2012) Last, episiotomy is also more common with operative vaginal than spontaneous vaginal deliveries (71 versus 33 percent) (Weber, 2002) TABLE 20-2 Patient, Practitioner, and Delivery Factors Associated with Higher Episiotomy Rates Maternal and Fetal Indications The indications for episiotomy vary widely and include those for the mother or the fetus Of maternal indications, some argue that episiotomy should be considered to reduce spontaneous perineal lacerations and their sequelae To address this, a Cochrane database review by Carroli and Mignini (2009) included eight randomized trials with 5541 women to assess the effects of routine use versus restrictive use of episiotomy Seventy-five percent of women in the routine group had episiotomies compared with 28 percent in the restrictive group Restrictive use of episiotomy was associated with lower rates of severe perineal trauma, suturing, and healing complications No differences were identified in rates of severe perineal or vaginal trauma or later dyspareunia or in several measures of perineal pain Women in the restrictive episiotomy group had a higher incidence of anterior perineal trauma However, this was not associated with greater rates of urinary incontinence or pain These results were consistent regardless of whether midline or mediolateral episiotomies were done That said, no comparative trials that specifically compared midline with mediolateral episiotomy were available for their analysis The authors concluded that episiotomies should be performed in a restrictive manner rather than routinely Regarding long-term effects, a prospective cohort study was designed to examine the effects of episiotomy on women whose first delivery was to 10 years earlier Investigators found that both forceps delivery and perineal lacerations, but not episiotomies, were associated with pelvic floor symptoms (Handa, 2012) Of fetal indications, some recommend episiotomy to shorten second-stage labor for a category III fetal heart rate tracing and lower rates of poor neonatal outcome As a second indication, episiotomy may aid resolution of shoulder dystocia and thereby lower associated fetal acidosis or trauma In addition, proponents assert that episiotomy protects premature fetuses against intracranial hemorrhage during vaginal birth Few published data address these fetal indications Current Recommendations Based in part on the above evidence, the decision to perform an episiotomy should be individualized to each woman with thoughtful consideration of the established risks and potential benefits Routine use of episiotomy is not supported by medical literature and is associated with increased maternal morbidity in most cases Hospitals with high episiotomy rates should consider implementing education and quality improvement programs to educate the health-care team One published literature review found that training courses, audits, a staff champion, and feedback to individual providers regarding their episiotomy rate could help reduce episiotomy rates (Faruel-Fosse, 2006) Most experts now advocate for the restrictive use of episiotomy The American College of Obstetricians and Gynecologists (2015) has concluded that restricted use is preferred to routine use of episiotomy The National Quality Forum reported that limiting the routine use of episiotomy was an important quality and patient safety measure and noted increased rates of pain and anal incontinence with the procedure (Main, 2009) Episiotomy Type There is no international consensus on how to define the different episiotomy techniques, and obstetric textbooks and organization guidelines differ considerably Kalis and associates (2012) have presented a classification of these, and we agree with the need for terminology standardization Midline and mediolateral episiotomies are the two main types and vary by the angle of perineal incision Their specific surgical steps are described and illustrated on page 324 To summarize, the midline episiotomy begins at the fourchette, incises the perineal body in the midline, and ends well before the external anal sphincter is reached The mediolateral episiotomy begins at the midline of the fourchette but is angled toward either the right or the left ischial tuberosity The lateral episiotomy begins at a point to cm lateral from the midline of the fourchette It too is angled toward either the right or the left ischial tuberosity Notably, in older texts, lateral episiotomy formerly described incisions that began at o’clock on the perineum and extended directly laterally This incision is no longer recommended as it fails to provide sufficient perineal relaxation and is associated with bleeding risks from the vestibular bulb and pudendal artery branches (Zuspan, 1988) Comparing midline and mediolateral types, few data support the indicated use of one over the others To date, only one randomized trial has compared midline and mediolateral episiotomies (Coats, 1980) Midline episiotomy was associated with a higher likelihood of OASIs, but with less scarring and a quicker return to sexual intercourse Self-perceived pain scores and dyspareunia were similar in both episiotomy groups Most other comparisons of these two episiotomy types derive from case series and cohort studies These investigations show an increased risk of OASIs with midline compared with mediolateral episiotomy Namely, one metaanalysis identified higher rates of OASIs after midline compared with mediolateral episiotomy in both nulliparas and multiparas undergoing vacuum-assisted delivery (Sagi-Dain, 2015) In comparison, both types result in similar rates of pain Specifically, one prospective cohort study of 300 gravidas found no differences in postpartum pain scores or dyspareunia at months among women receiving midline, mediolateral, or lateral episiotomy techniques (Fodstad, 2014) There are even fewer studies that compare lateral episiotomy to either mediolateral or midline One randomized trial compared lateral and mediolateral types in nulliparas Groups did not differ in pain scores or in vaginal or perineal trauma, including OASIs (Karbanova, 2014a,b) The authors also reported that mediolateral episiotomies required less time and suture for the repair but that they lie closer to the anus In sum, in appropriately counseled women in whom episiotomy is indicated, mediolateral episiotomy may be the preferred incision type based on similar pain and dyspareunia outcomes, but reduced rates of OASIs The American College of Obstetricians and Gynecologists (2015) concludes that mediolateral might be preferable to midline episiotomy in selected cases Operative Vaginal Delivery Vacuum-Assisted Delivery The very conditions that lead to indications for operative vaginal delivery also increase the likelihood of perineal lacerations Episiotomy is reported in up to two thirds of vacuum-assisted deliveries, although rates vary widely In their systematic review that included 350,764 vacuum-assisted deliveries, Sagi-Dain and Sagi (2015) found that the rate of OASIs nearly doubled in nulliparas (59 percent) compared with multiparas (34 percent) Of episiotomy types, lateral episiotomy decreased the risk of OASIs in nulliparas With mediolateral episiotomy, OASIs rates were greater in multiparas, yet for nulliparas, there was a nonsignificant but protective trend Last, midline episiotomy increased OASIs rates during vacuum-assisted delivery regardless of parity Although the quality of evidence in this review was poor, these data suggest that the risk for OASIs during vacuum-assisted delivery varies according to parity and episiotomy type For the fetus, this same review did not ascribe any fetal benefits to any type of episiotomy during vacuum delivery Evaluated indicators included Apgar score, umbilical artery pH and base excess, neonatal intensive care unit (NICU) admission, and need for neonatal resuscitation Of other evidence, a population-based study found that lateral episiotomy was associated with a 46-percent decreased incidence of OASIs in nulliparas who delivered with vacuum assistance (Räisänen, 2012) Similarly, data from the Danish Medical Birth Registry found that in vacuum-assisted deliveries, mediolateral episiotomy was protective compared with no episiotomy (Jangö, 2014) Forceps Delivery Forceps delivery is associated with an increased risk for OASIs that ranges from 10 to 35 percent (Bofill, 1996; de Vogel, 2012; Johnson, 2004) Likewise, in a large prospective cohort study of women who sustained OASIs, two thirds of third- or fourthdegree lacerations were associated with forceps deliveries (Lewicky-Gaupp, 2015) A retrospective study evaluated OASIs rates and fetal head position prior to forceps delivery Bradley and coworkers (2013) showed a lower OASIs rate during forceps delivery if fetuses were rotated from occiput-posterior (OP) to occiput-anterior (OA) head position compared with delivery from an OP position Thus, clinicians may consider rotation of the fetal head to an occiput-anterior position to decrease OASIs rates if forceps are needed Retrospective studies suggest that mediolateral episiotomy may provide protection for the anal sphincter during operative delivery, including forceps delivery (de Vogel, 2012; de Leeuw, 2008) Two recent studies found that mediolateral episiotomy during operative deliveries (forceps and vacuum) decreased the odds of OASIs, with one study showing a sixfold reduction of OASIs (Bharucha, 2014; Jangö, 2014) However, routine use of mediolateral episiotomy has not been shown to reduce risk of OASIs In sum, forceps delivery is a well-established risk factor for OASIs Moreover, as with any vaginal delivery, episiotomy use is restricted unless clinical indications are present, and women are counseled regarding increased risks If episiotomy is done, a mediolateral incision is preferable for many cases (de Leeuw, 2008; de Vogel, 2012; Hirsch, 2008) Surgical Technique Mediolateral Episiotomy Prior to performing an episiotomy, a clinician ensures adequate patient anesthesia from stainless steel, 9) Suturing, needlestick injuries during, 3) Swaged needle, 2) Swage of needle, 2) Sweetheart retractors, 19) Symphysiotomy in shoulder dystocia, 397) Synclitism in operative vaginal delivery, 370)f Systemic Inflammatory Response Syndrome (SIRS) criteria, 92), 93) Systemic lupus erythematosus, 489) T Tapored needle points, 3) Tensile strength, 5) Teratoma, sacrococcygeal, 272) Terbutaline as uterine relaxant, 310) in vaginal breech delivery, 347) Term Breech Trial, publication of, 335), 336) Theca-lutein cysts, 148), 225), 228), 229)f sonographic evaluation of, 228), 229)f Thermal burns, 286) Thermal index (TI), 63) Thermal injury, preterm delivery and, 281) Third-stage labor during cesarean delivery, 494) Third trimester abortions in, 135) falls in, 280) Thoracoamnionic shunting, 269) for congenital cystic adenomatoid malformation, 265)–266 fetal outcomes in, 266) for fetal pleural effusion, 264)–265 technique in, 266) Thoracocentesis, 265) Thoracostomy tube, 285) Thrombocytopenia alloimmune, 219) fetal, 219)–220 gestational, 528) heparin-induced, 519) Thromboelastography (TEG), 98), 99)f, 315) Thromboembolic disease, 515)–521 deep-vein thrombosis, 517)–519, 518)f pulmonary embolism, 519)–521 Thromboembolism, 151) incidence and risk, 297) prevention, 297)–298, 299)–300t, 301)t Thrombophilias, 516) Thrombophlebitis, septic pelvic, 514)–515 Thromboprophylaxis, postpartum, 298) Thyroid scan, 74) Tilt test, 244) Time out, 202) T-incision, 409) Tissue clamps, 20)–22, 20)f, 21)f Tissue forceps, 17)–18, 17)f Tissue reactivity to sutures, 6), 6)t Tocolysis, laparoscopy and, 246) Topical negative pressure (TNP), 25) Torsion adnexal, laparoscopy in diagnosing and treating, 242)–243 diagnosis, 226) incidence and etiology, 225)–226, 225)f treatment, 226) Total breech extraction in vaginal breech delivery, 340)–342, 341)f Total salpingectomy, 525), 526), 530) See also Salpingectomy Tourniquet method, 424) in peripartum hysterectomy, 430) Tracheal intubation, failed, 308) Training See also Simulations of future obstetricians, 361) in preoperative assessment, 372), 372)t, 373)t use of Piper forceps, 361) virtual reality, 83), 83)t Tranexamic acid (TXA), 98), 99), 315) hemorrhages and, 99) Transabdominal cervical cerclage, 500) Transabdominal cervicoisthmic cerclage, 174)–176, 175)f, 176)f, 179), 242)–243 Transabdominal sonography, 440) See also Sonography Transesophageal echocardiography, 103) Transfusion protocols, 314), 431)–432 Translabial sonography, 440) Transthoracic echocardiography, 103) Transurethal cystoscopy, 458) Transvaginal cerclage efficacy, 177)–179, 178)t, 179)t Transvaginal pelvic pressure pack, 479)–480, 479)f Transvaginal sonography, 440), 441), 441)f, 445), 445)f See also Sonography Transversalis fascia, 29) Transverse incisions, 49)–55, 292) Cherney, 52)–53, 53)f Maylard, 50)f, 53)–55, 53)f, 54)f, 55)f Pfannenstiel, 50)–52, 50)f, 51)f, 52)f, 53) supraumbilical, 50)f, 55) Transversus abdominis plane (TAP) block, 30), 313) Trauma abdominal, 282), 286), 287) algorithm in managing, 283)f laparoscopic, 241)–242 perineal, 320) in pregnancy, 276)–288 incidence, 276), 277)f intentional, 278) inimate-partner violence, 281)–282 penetrating trauma, 282) suicide and homicide, 282) management burn, 285)–286 fetal monitoring, 287) imaging, 286), 286)f initial assessment, 282)–284, 283)f laboratory evaluation, 286)–287 minor trauma, 284) motor vehicle crash, 284) pelvic fracture, 285) penetrating wound, 284)–285, 285)f perimortem cesarean delivery, 287)–288 maternal physiologic changes organ systems, 276)–277, 278)t uterus and placenta, 277)–278 myometrial, 444) risk factors, 278) unintentional, 278)–281 accidental poisoning, 281) burns, 280)–281 electric shock, 281) motor vehicle crash, 278)–280, 279)f slips and falls, 280) uterine rupture in, 491) Trendelenburg position, 257) reverse, 257) Trial of labor after cesarean (TOLAC), 456) Trichomoniasis, 189), 198)–199 Trisomy 21), 264) Trocars, 247) wound infections at sites of, 257) Trophotropism, 437) T sign, sonography in identifying, 352) Tubal abortion, 118) Tubal anastomosis, 528) Tubal factor infertility, 113) Tubal interruption, 530) Tubal ligation, anesthesia for postpartum, 315)–316 Tubal peristalsis, 44) Tubal pregnancy, 117) Tubal rupture, 118) Tubal sterilization, 113), 524), 525), 526), 527), 528) reversal of, 528) Tubovarian abscess, 199) Tucker-McLane forceps in operative vaginal delivery, 363)f, 367)f, 368)f, 381) Tumor markers for adnexal masses, 230) Tumors See also Cancer epithelioid trophoblastic, 162) metastatic placental-site trophoblastic, 162) placental-site trophoblastic, 162) Twin Birth Study, 350), 353), 354), 359) Twin gestations, 350)–361 algorithm, 361), 361)f alternative approach to delivery, 360) antepartum management, 352)–353 cesarean delivery in, 354) chorionicity in, 351)–352, 351)f, 352)f coexistent fetus and, 161), 161)f delivery of very preterm twins, 360)–361 delivery preparation in, 353), 354)t first-stage labor in, 353) interval between twins and combined delivery, 353)–354 planned vaginal delivery breech twin A, 357), 359) justification, 359)–360 vertex/breech presentation, 356)–357 vertex/transverse presentation, 357), 358)f, 359)f vertex/vertex presentation, 354)–356, 356)f risks in, 350)–351 training for, 361) vaginal delivery, 310)–311 Twin peak sign, sonography in identifying, 351) Twin reversed arterial perfusion (TRAP) sequence, 243) Twins amniocentesis in, 211) donor, in twin-twin transfusion syndrome, 261)–263, 262)ft recipient, in twin-twin transfusion syndrome, 261)–263, 262)ft Twin-twin transfusion syndrome (TTTS), 243), 316), 352) fetal therapy and, 261)–263, 262)ft Two-hit hypothesis, 268) U Uchida method in puerperal sterilization, 530) Ultrasound, abdominal, 65), 66)f See Sonography Umbilical cord clamping delayed, 410) in low transverse cesarean delivery, 410), 413) in vaginal twin delivery with vertex presentation, 355) Umbilical ligaments, 29) Umbilical cord pH values, 410) Unfractionated heparin in management of deep-vein thrombosis, 518) in management of pulmonary embolism, 521) perioperative indications for, 298) Unintentional trauma, 278)–281 burns, 280)–281 electric shock, 281) Uniparental disomy, 217) Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery, 302) Upper quadrant laparoscopic entry, 253) Urachus, 29)–30 Ureaplasma urealyticum, 196) Ureter, 38)f, 40) See also Ureteral injuries adnexectomy and, 232) dilatation during pregnancy, 44) injury to, risk of, 41) obstructing stone in, 73)f pelvic, 44) in peripartum hysterectomy, 424), 426), 431) placenta accrete syndrome and, 447), 449) preoperative stents placement, 447) Ureteral injuries, 416) cystoscopy, 458) diagnosis, 457)–458 distal ureteral injuries, 458)–460, 459)f incidence and risks, 457) midpelvic, 460), 460)ft in peripartum hysterectomy, 424) psoas hitch or boari flap, 460) ureteral stents, 458) ureteroneocystostomy, 459)–460, 459)f Ureteral stents, 460) placement of, 447) ureteral injuries and, 458) Ureterneocystostomy, 459)–460, 459)f, 460)f Urethra, 33) injuries to, 455)–456 Urinary retention as short-term effect of operative vaginal delivery, 385) urethral injuries and, 455) Urinary tract, injuries to during cesarean delivery, 454)–455, 455)t in peripartum hysterectomy, 431) Urologic injuries, 455)–461 bladder injuries cystomy diagnosis, 456) cystomy repair, 456)–457 incidence and risks, 456) prevention, 457) as common, 450) risk factors, 455)t ureteral injuries cystoscopy, 458) diagnosis, 457)–458 distal ureteral injuries, 458)–460, 459)f incidence and risks, 457) midpelvic, 460), 460)ft psoas hitch or boari flap, 460) ureteral stents, 458) ureteroneocystostomy, 459)–460, 459)f urethral injuries, 455)–456 Urticaria, 295) Uterine artery, 41), 175), 310) ligation of efficacy, 475) in peripartum hysterectomy, 426)–427, 426)f technique, 475)–476 Uterine aspiration, 140)f Uterine atony, 149), 500)–501 as cause of postpartum hemorrhage, 469)–471 Uterine compression sutures, 473)–475 B-lynch method, 473)–474, 474)f complications with, 475) other methods, 474)–475 Uterine incarceration, 47), 47)f Uterine incisional necrosis, 422) Uterine incision in cesarean delivery, 406)–407, 407)f extension of, in low transverse, 409), 409)f Uterine infection following cesarean delivery, 422), 422)f, 505)–508, 506)t, 507)f Uterine inversion, 493)–501 antibiotic prophylaxis, 500) during cesarean delivery, 493) classification, 393)t, 493) defined, 493) diagnosis, 495) etiology, 494) incidence, 493)–494 management general considerations, 495)–500, 496)f nonsurgical, 495)–498, 496)t, 497)f surgical, 498)–500, 499)f maternal morbidity and mortality, 500) reinversion, 500)–501 subsequent pregnancy, 501) Uterine leiomyomas, as indication of peripartum hysterectomy, 422) Uterine malformations, 171) Uterine manipulation in laparoscopy, 254) Uterine myomas, 489) Uterine packing for atony, 470) Uterine perforation, 149) Uterine rupture, 150), 276), 405), 487)–491, 488)t clinical findings and diagnosis, 489)–490, 490)f incidence and predisposing factors, 488)–489 management, 490) outcomes maternal mortality, 490) perinatal morbidity and mortality, 490)–491 pathogenesis, 489), 489)f traumatic, 491) Uterine scar as reason for postpartum hysterectomy, 422) Uterine size, laparoscopy and, 244) Uterine tamponade balloon, 473), 473)f uterine packing, 471)–473, 472)f Uterine tears, 489)–490 Uterine vessel isolation in peripartum hysterectomy, 426), 426)f Uterosacral ligaments, 40) in peripartum hysterectomy, 427)–428 Uterotonic agents, 149) See also Methylergonovine, Misoprostol, Carbopros tromethamine for abortion, 144) for decreasing risk of reinversion, 501) for midtrimester labor induction, 146) in molar pregnancy, 160) for postpartum hemorrhage, 87), 470), 470)t for twin vaginal delivery, 353) in uterine inversion, 495), 496) Uterus, 33)f, 38)–40, 38)f See also specific procedures cervix, 39)–40, 39)f endometrium, 40) myometrium, 40) trauma and, 277)–278 V Vacuum aspiration in first trimester, 136) Vacuum-assisted delivery, 323), 368), 368)t, 376)–377, 376)f, 377)f forceps and, 309)–310, 309)f simulated, 86) Vacuum-assisted wound closure, 25)–26, 25)t efficacy, 26) mechanisms of action, 25)–26, 25)f prophylactic use, 26) Vacuum curette, 139)f Vagina, 33)–34, 33)f See also specific procedures Vaginal birth after cesarean (VBAC), 454), 456) Vaginal bleeding, 210) Vaginal breech delivery, 310), 335)–348 attempted, 337) background, 335)–336 cesarean delivery, 336)t, 337)t, 348) epidemiology maternal morbidity, 336)–337, 336)t neonatal morbidity, 336), 336)t rates, 336) external cephalic version, 347)–348, 348)f first-stage labor, 338) intrapartum simulation in, 86)–87, 86)f preterm breech, 346)–347 second-stage labor, 338)–346 delivery of the arms, 342)–343, 342)f, 343)f delivery of the head, 336)t, 344)–346, 344)f, 345)f, 346)f partial breech extraction, 339)–340, 339)ft, 340)f total breech extraction, 340)–342, 341)f selection criteria, 337)–338, 337)t successful, 337) vertex/breech presentation for twin gestations, 356)–357 Vaginal cuff closure in peripartum hysterectomy, 428)–429, 429)f Vaginal delivery, 36) after cesarean delivery, 406), 454) obstetric simulations in, 84), 84)f operative, 363)–387 Barton forceps in, 382)–384, 382)f, 383)f, 384)f fetus in preoperative assessment, 370)–371, 370)f, 371)f forceps in, 323), 365)–366t, 367)f, 368) history, 363)–365, 363)f, 364)f indications, perquisites, and classification, 369)–370, 369)t instrument choice in, 368)–369 intrapartum simulation in, 85)–86, 86)f Kielland forceps in, 378)–382, 379)f, 380)f, 381)f Luikart forceps in, 373)–376, 373)f, 374)f, 375)f, 376)f malposition of the occiput in, 377) manual rotation in, 377)–378, 378)f maternal morbidity in, 385) morbidity of forceps rotation, 387), 387)t morbidity of midpelvic delivery, 387) neonatal morbidity in, 385)–387, 386)f pelvis in preoperative assessment, 371)–372 sequential use of instruments in, 384) shoulder dystocia and, 393) training in preoperative assessment, 372), 372)t, 373)t trial of, 384)–385 vacuum-assisted delivery, 323) vacuum extraction in, 368), 368)t, 376)–377, 376)f, 377)f puerperal sterilization after, 528)–530, 529)f abdominal entry, 528)–529 fallopian tube identification, 529) fallopian tube interruption, 529)–530, 529)f Irving and Uchida methods, 530) Parkland method, 529), 529)f Pomeroy method, 529), 530)f risk-reducing salpingectomy, 530) wound closure and recovery, 530) simulated, 86) for twins, 310)–311 vertex/vertex presentation, 354)–356, 356)f Vaginal flora, 196) Vaginal lacerations, 483) bilateral, 483) Vaginal septum, 182), 183)f Vaginal spotting, 214) Vaginal surgery, 33)–34, 33)f retractors for, 20), 20)f Vaginosis, bacterial, 196)–197, 197)t Valvuloplasty, percutaneous, 270) Vasa previa, 243), 271) antepartum treatment of, 438) Vascular clamps, 21)f Vascular endothelial growth factor (VEGF), 26) Vascular equator, 263) Vascular injuries from laparoscopy, 256) Vascular pedicle, double-ligation of a, 13)f Vascular steal phenomenon, 272) Vasectomy, 524) Vasopressors for fluid resuscitation, 94) judicial use of, 106) for septic shock, 95) Vena caval thrombosis, 76) Venal caval filters in treating pulmonary embolism, 521) Venography as gold standard, 517) Venous thromboembolism (VTE), 291), 515) risk of, 277) Ventilation-perfusion mismatch, 95) Ventilation-perfusion (V/Q) scanning, 74) in diagnosing pulmonary embolism, 520)–521 Ventral wall defects, 151) Veress needle laparoscopic entry, 251)–253, 252)f, 253)f Vertex/transverse presentation for twin gestations, 356)–357, 358)f, 359)f Vertex/vertex presentation for twin gestations, 354)–356, 356)f Vertical incisions, 49), 55)–57 midline vertical, 55), 55)t, 56)f, 57), 57)f, 58)t paramedian, 57) Vesicoamnionic shunt placement, 220) Vesicouterine peritoneal reflection incision, 407)t, 408), 409)f Vesicouterine space, in peripartum hysterectomy, 424) Vesicovaginal space, 33) Vessel embolization by arteriography, 148) Vestibular bulbs, 32) Vestibule, 31)f, 32) Viability, 135) Vicryl Plus, 6), 324)–325 Violin grip, 15) Virtual reality simulation, 83), 83)t Visceral injuries from laparoscopy, 256) Viscoelastic assays, 98), 99)f Vital signs, 303) Vitamin D deficiency, 419) Volatile agents, 312) Vomiting, postoperative, 256), 303), 314) von Willebrand disease, 485) Vulva, 30)–33, 31)f clitoris, 32), 32)f greater vestibular (Bartholin) glands, 32)–33 mons pubis and labia, 31) paraurethral glands, 33) urethra, 33) vestibular bulbs, 32) vestibule, 31)f, 32) Vulvar abscess, 189)–192, 190)f hidradentis suppurativa, 191)–192 incision and drainage, 189)–190 necrotizing infection, 190)–191, 191)f, 192)t Vulvar hematoma, 486) Vulvovaginal candidiasis, 199) Vulvovaginal hematomas, 485)–487, 486)f Vulvovaginal lacerations, 482)–483, 483)ft repair of, 87)–88 W Warfarin in management of deep-vein thrombosis, 519) Warts, anogenital, 195) White blood cell (WBC) count, 285) Woods maneuver, shoulder dystocia and, 395), 395)f Word catheter placement, 193)–194 Wound(s) clean, 60), 60)t, 294), 295) clean contaminated, 60), 60)t, 294) contaminated, 294)–295 infected, 60), 60)t, 291), 295) penetrating, 282) management, 284)–285, 285)f smoking and infection, 291) Wound closure after puerperal sterilization, 530) in low transverse cesarean delivery, 414), 414)f Wound complications, in peripartum hysterectomy, 432) Wound dehiscence, 331)–332 as postoperative complication, 510)–511, 511)f Wound healing, 59)–61 factors affecting, 61) maturation in, 60) migration in, 60) physiology in, 59)–60 proliferation in, 60) wound classification in, 60), 60)t wound closure in, 60)–61 Wound hematoma and seroma, as postoperative complication, 512), 513)f Wound infections, 60), 60)t, 295), 331)–332 as postoperative complication, 508)–510, 509)t, 510)f Wound security, 12) X X-ray dosimetry, 70), 70)t Y Yankauer suction tip, 22) Yeast infections, 199) Z Zavanelli maneuver in shoulder dystocia, 397) Zeppelin tissue clamp, 21), 21)f Table of Contents Title Page Copyright Page Dedication Editors Contributors Contents Preface Section General Considerations Needles, Sutures, and Knots Surgical Instruments Anatomy Incisions and Closures Perioperative Imaging Clinical Simulation Critical Illness in Pregnancy Section Antepartum Ectopic Pregnancy First- and Second-Trimester Pregnancy Termination 10 Gestational Trophoblastic Disease 11 Lower Genital Tract Procedures 12 Treatment of Lower Genital Tract Infections 13 Invasive Prenatal DiagnosticProcedures 14 Adnexal Masses 15 Diagnostic and OperativeLaparoscopy 16 Fetal Therapy 17 Trauma in Pregnancy 18 Perioperative Considerations 19 Anesthesia for the PregnantWoman Section Intrapartum 20 Episiotomy and Obstetric Anal Sphincter Lacerations 21 Vaginal Breech Delivery 22 Delivery of Twin Gestations 23 Operative Vaginal Delivery 15 18 19 21 52 84 131 164 206 226 269 271 317 370 404 451 480 533 572 618 657 690 720 743 745 778 815 841 24 Shoulder Dystocia 25 Cesarean Delivery 26 Peripartum Hysterectomy 27 Placenta Previa and Morbidly Adherent Placenta 28 Urologic and Gastrointestinal Injuries Section Postpartum 29 Management of Postpartum Hemorrhage 30 Genital Tract Lacerations and Hematomas 31 Uterine Inversion 32 Postoperative Complications 33 Puerperal Sterilization Index 908 941 979 1016 1066 1089 1091 1130 1158 1182 1230 1255 ... nomenclature and is summarized in Table 20 -1 and Figure 20 -1 (Koelbl, 20 09; Royal College of Obstetricians and Gynaecologists, 20 07) TABLE 20 -1 Classification of Obstetric Lacerations FIGURE 20 -1 First-degree... episiotomies (Gupta, 20 12) Last, episiotomy is also more common with operative vaginal than spontaneous vaginal deliveries (71 versus 33 percent) (Weber, 20 02) TABLE 20 -2 Patient, Practitioner, and Delivery... 119(5): 522 , 20 12 Karbanova J, Rusavy Z, Betincova L, et al: Clinical evaluation of early postpartum pain and healing outcomes after mediolateral versus lateral episiotomy Int J Gynaecol Obstet 127 (2) :1 52,