Introduction
In 1742, Fielding Ouled from Ireland was the first who described episiotomy.1 Traditional episiotomy is an obstetrical, surgical concept to widen the vaginal canal by incision of the posterior-distal vaginal wall and the posterior perineum. Its purpose is to facilitate the passing a fetus’s head during birth. Those women who undergo episiotomy or experience perineal tear(s) suffer from moderate to severe perineal pain that requires pain medication and other forms of therapy. In addition, severe short- and long-term complications from this obstetrical surgical intervention are well-documented in the medical literature. In general, a traditional episiotomy can result in a) moderate or severe perineal pain immediately after delivery; b) blood lost during and post-episiotomy that is compatible with Cesarean section; c) wound infections; d) wound separation; e) long-term postpartum moderate or severe perineal pain; f) urinary or fecal incontinence, or both: g) urogenital and rectovaginal fistulas; h) pelvic floor dysfunction and pelvic organ prolapse; i) persistent superficial dyspareunia.2-5 The most severe episiotomy complications are associated with an incision extension responsible for the risk of third or fourth degrees of perineal lacerations - obstetrical anal sphincter injuries (OASIS).6 It has been postulated that primiparous women from Asia and Sub-Saharan Africa are more predisposed to developed OASI.7 Additionally, it has been documented that the most common maternal injury during birth is the vaginal outlet.1
The concept of Ostrzenski’s vaginal outlectomy does not include the posterior perineum or the posterior-distal vaginal wall to avoid postpartum symptoms. Other studies showed that intact posterior perineum does not produce postpartum perineal pain, superficial dyspareunia, or other symptoms.8, 9 Therefore, the question arises whether the posterior perineum incision is necessary to widen the vaginal opening for vaginal parturition? In addition, does the hymeneal ring and hymeneal plate risk of injuries exist during fetal head delivery? Therefore, the present study will develop the surgical concept of vaginal outlectomy surgical anatomy without including the posterior perineum and posterior-distal vaginal wall.
The hypothesis of the current study is to test whether vaginal outlectomy provides sufficient widening of the vaginal outlet to overcome the tissue resistance force on the fetal head during delivery? Therefore, the objectives were a) to show anatomical structures of the vaginal outlet and resist a fetal head passing through; b) to establish a new gross, topographic, and surgical anatomy of the vaginal outlet; c) assess the postpartum perineal pain perception and superficial dyspareunia; d) to develop a surgical intervention (vaginal outlectomy) to widen the vaginal outlet without incorporating the posterior-distal wall and the posterior perineum and develop a new episiotomy. The primary maternal outcome measures postpartum posterior perineum pain associated with vaginal outlectomy. The secondary outcomes measure a) complication of vaginal outlectomy; b) occurrence of superficial dyspareunia after vaginal outlectomy; c) results of Ostrzenski’s vaginal outlectomy; d) neonatal outcome measured by an APGAR score.