- Guillermo
Carroli , Luciano
Mignini. Episiotomy for vaginal birth. Cochrane Database Syst Rev
2009
Jan21;(1):CD000081.DOI: 10.1002/14651858.CD000081.pub2
- Hong
Jiang, Xu
Qian, Guillermo
Carroli, and Paul
Garner. Selective versus routine use of episiotomy for vaginal birth.
Cochrane
Database Syst Rev 2017. 2017(2): CD000081. Feb
8. doi: 10.1002/14651858.CD000081.
- R
McCandlish, U
Bowler, H
van
Asten, G
Berridge, C
Winter, L
Sames, J
Garcia, M
Renfrew, D
Elbourne. A randomized controlled trial of care of the perineum
during the second stage of normal labor. Br J Obstet Gynaecol 1998
Dec;105(12):1262-72.
doi: 10.1111/j.1471-0528.1998.tb10004.x.
- Margarita
Manresa, Ana
Pereda, Josefina
Goberna-Tricas, Sara
S
Webb, Carmen
Terre-Rull, Eduardo
Bataller. Postpartum perineal pain and dyspareunia
related to each superficial perineal muscle injury: a cohort study.
Int Urogynecol J 2020 Nov;31(11):2367-2375. doi:
10.1007/s00192-020-04317-1.
- Shiow-Ru
Chang , Kuang-Ho Chen , Chien-Nan
Lee , Ming-Kwang
Shyu , Ming-I
Lin , Wei-An
Lin. Relationships between perineal pain and postpartum depressive
symptoms: A prospective cohort study. Int J Nurs Stud 2016
Jul;59:68-78. doi:10.1016/j.ijnurstu.2016.02.012.
- Fernando RJ, Sultan AH, Freeman RM, Williams AA, Adams EJ. The
Management of Third‐ and Fourth‐Degree Perineal Tears (Green‐top
Guideline No. 29). RCOG, 2015 June.
- Sorbye IK, Bains S, Vangen S, Sundby J, Lindskog B, Owe KM. Obstetric
anal sphincter injury by maternal origin and length of residence: a
nation-wide cohort study. BJOG. 2021 Oct 28. doi:
10.1111/1471-0528.16985. Epub ahead of print. PMID: 34710268.
- Rathfisch G, Birsen
Kucuk Dikencik BD,
Beji
NK, Comert N, Tekirdag AI, Kadioglu A. Effects of perineal trauma on
postpartum sexual function. J Adv Nurs 2010 Dec;66(12):2640-9. doi:
10.1111/j.1365-2648.2010.05428.x. Epub 2010 Aug 23.
- Larsson
PG, Platz-Christensen
JJ, Bergman
B, G
Wallstersson G. Advantage or disadvantage of episiotomy compared with
a spontaneous perineal laceration. Gynecol Obstet Invest
1991;31(4):213-6. doi: 10.1159/000293161.
- Ferreira-Valente
MA,
Pais-Ribeiro
JL,
Jensen
MP. Validity of four pain intensity rating scales. Clinical Trial.
2011 Oct;152(10):2399-2404. doi: 10.1016/j.pain.2011.07.005.
- Garner DK, Akash
B Patel
AB, Hung
J, Castro
M, Segev TG, Plochocki
JH, Hall
MI. Midline and Mediolateral Episiotomy: Risk Assessment Based on
Clinical Anatomy. Diagnostics (Basel) 2021 Feb 2;11(2):221.doi:
10.3390/diagnostics11020221.
- Ostrzenski A. Modified Posterior Perineoplasty in Women. J Reprod Med
2015;60:109-116.
- Woolley RJ. Benefits and risks of episiotomy: a review of the
English-language literature since 1980. Part I. Obstet Gynecol Surv
1995 Nov;50(11):806-820.
- Sarfati R, Maréchaud M, Magnin G.
Comparison of blood
loss during cesarean section and during vaginal delivery with
episiotomy]. J Gynecol Obstet Biol Reprod (Paris). 1999
Feb;28(1):48-54.
- Macarthur AJ., Macarthur C. Incidence, severity, and determinants of
perineal pain after vaginal delivery: a prospective cohort
study. American Journal of Obstetrics and
Gynecology 2004;191(4):1199‐204.
- McCandlish R, Bowler U, Asten H, Berridge G, Winter C, Sames L, et
al. A randomized controlled trial of care of the perineum during the
second stage of normal labor. British Journal of Obstetrics and
Gynaecology 1998;105(12):1262‐1272.
- Andrews V, Thakar R, Sultan AH, Jones PW. Evaluation of postpartum
perineal pain and dyspareunia ‐ a prospective study. European Journal
of Obstetrics & Gynecology and Reproductive Biology 2007;137:152‐156.
- Reid A J, Beggs AD, Sultan AH, Roos AM, Thakar R. Outcome of repair of
obstetric anal sphincter injuries after three years. International
Journal of Gynecology & Obstetrics 2014;127(1):47‐50.
- Boyles SH, Li H, Mori T. Effect of a mode of delivery on the incidence
of urinary incontinence in primiparous women. Obstetrics &
Gynecology 2009;113(1):134‐41.
- Signorello LB, Harlow BL, Chekos AK, Repke JT.
Midline episiotomy
and anal incontinence: retrospective cohort study. BMJ. 2000 Jan
8;320(7227):86-90.
- Sultan A.H., Thakar R. Lower genital tract, and anal sphincter
trauma. Best Practice & Research. Clinical Obstetrics &
Gynaecology 2002;16(1):99‐115.
- De Vogel J, van der Leeuw-van Beek A, Gietelink D, Vujkovic M, de
Leeuw J.W., van Bavel J, Papatsonis
D. The effect of a
mediolateral episiotomy during operative vaginal delivery on the risk
of developing obstetrical anal sphincter injuries. Am J Obstet
Gynecol. 2012 May;206(5):404.e1-5.
- Ostrzenski A. Pelvic
Organ Prolapse Quantification (POP-Q) system needs revision or
abandonment: The anatomy study. Eur J Obstet Gynecol Reprod Biol.
2021 Oct 20;267:42-48. doi: 10.1016/j.ejogrb.2021.10.016.
- Fernando RJ, Sultan AH, Kettle C, Thakar R, Radley S. Methods of
repair for obstetric anal sphincter injury. Cochrane Database of
Systematic Reviews 2006, Issue 3. [DOI:
10.1002/14651858.CD002866.pub2]Figures legends Figure 1. Discovery of the vaginal outlet anatomy and
histologyA. The yellow arrow represents the hymeneal membrane and its
tags. Upon dissecting the hymen membrane, the hymeneal ring is white
and indicated by the orange arrow. The low segment of the hymeneal
ring fuses with the hymeneal plate, creating the crease and
protuberance (the blue arrow).B. The excised fragment of the vaginal outlet without
posterior perineal muscles. The yellow arrow refers to the hymeneal
membrane; the orange denotes the hymeneal ring; the blue arrow points
out the hymeneal plate.C. The histology (Hematoxylin & Eosin stained, and 40x
magnification) of the vaginal outlet structure consists of the three
histological layers: superficial (the green arrow), middle (the orange
arrow deep layer (the blue arrow) of the excised strip of the vaginal
outlet obtained during parturition. The vaginal outlet consists of the
three histological layers: superficial (the green arrow), middle (the
orange arrow, and deep layer (the blue arrow). The first histological
layer (the hymeneal membrane) is the superficial layer (the green
arrow), consisting of multilayer flat squamous cells of the
epithelium, loose fibrous connective tissue, collagen fibers, numerous
network of capillary blood vessels, and multiple nerve endings. The
second or the middle layer (the hymeneal ring) is well-organized,
compressed fibers of the collagen fibers, a network of blood vessels
of a larger caliber than in the superficial layer, heavily distributed
nerve endings more than in the superficial layer (the orange arrow).
Finally, the third layer (the hymeneal plate) is less organized and
compact collagen fibers than the hymeneal ring (the blue arrow). In
this layer, the smooth vaginal muscles fuse with the hymeneal plate,
and it is the only connection of the vaginal wall with the vaginal
outlet. A significantly smaller number of nerve endings is present in
this stratum when compared to the hymeneal ring—none of the
microscopic specimens from the V-shape excision shows perineal
skeletal muscle.
Figure 2. The implementation of Ostrzenski’s vaginal outlectomy
at the time of fetal head crowning.A. The side of local anesthetic injection before the vaginal
outlet excision,B. The fragment V-shape excision that includes tissue of the
transitional vulvar skin, hymeneal membrane,
hymeneal ring, and hymeneal plate,C. The minimal amount of bleeding is associated with a vaginal
outlectomy.
Figure 3. Crowning of the fetal head through the vaginal outlet
(“belt-like”) is depicted. The vaginal outlet anatomy consists of a
hymeneal membrane (stretched to the point that is almost invisible); the
next layer is the hymeneal ring, and under it is the upper crease that
separates the next layer of the hymeneal plate, seen as the protuberant
configuration. The lower part of the hymeneal plate and the inner
surface of the labium minus create a well-visible lower crease.
Figure 4. Post outlectorrhaphy, the suture line (the black
arrow) is almost invisible, and the vagina orifice is not gapping.
Figure. 5. Comparison of vaginal outlectomy bleeding with
vaginal outlectomy extension and midline episiotomy bleedingA. Amount of bleeding associated with vaginal outlectomy,B. Vaginal outlectomy extension to the posterior
perineum, bleeding is heavier than from an uncomplicated
vaginal outlectomy,C. Midline episiotomy (the black arrow) divides the skin,
posterior-distal vaginal wall, the perineal body, posterior perineal
fascia, and five surgically separated muscles (1- the bulbospongiosus
muscle, 2- the urethrovaginal sphincter muscle, 3- the superficial
transverse perineal muscle, 4- superficial external anal sphincter
muscle, 5- the perineal body muscle located under the posterior-distal
vaginal wall. The white on blue numbers represent the separated
posterior perineum musculatures. The white on green no. 5 depicts the
perineal body, and no. 6 describes the levator ani defect.