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.