Prediction of labor and delivery by transperineal ultrasound in pregnancies with prelabor rupture of membranes at term.
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OBJECTIVE: To evaluate whether engagement of the fetal head or cervical length in women with premature rupture of membranes (PROM) at term, are associated with time from PROM to delivery or need for operative delivery. METHODS: A transperineal ultrasound examination was performed in 152 women with a single live fetus in cephalic presentation after PROM (at > 37 gestational weeks). The shortest distance from the outer bony limit of the fetal skull to the skin surface of the perineum was measured in a transverse view, and the cervical length was measured in a sagittal view. The time from PROM to delivery was tested in a Cox regression analysis with ultrasound measurements, parity, maternal age, body mass index and birth weight as possible predictive factors. RESULTS: The head-perineal distance was associated with the time from PROM to delivery (log rank test, P < 0.001). Thirty-six hours after PROM, 32% (95% CI, 15-49) of women with a short head-perineal distance (< 45 mm) and 43% (95% CI, 24-62) of women with a long distance (> or = 45 mm) were still in labor. Women with a short head-perineal distance had fewer Cesarean sections, less use of epidural analgesia and a shorter time in active labor, and their babies had a higher pH in the umbilical artery. The measured cervical length was not associated independently with time to delivery. CONCLUSION: Transperineal ultrasound measurements of fetal head engagement may help clinicians to predict the course of labor in women with PROM. (+info)
The practice of episiotomy in public hospitals in Hong Kong.
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OBJECTIVE: To review the use of episiotomy during vaginal delivery in Hong Kong public hospitals. DESIGN: Prospective observational survey. SETTING: Public hospitals, Hong Kong. PARTICIPANTS: Women who underwent normal vaginal delivery of a singleton foetus with cephalic presentation. MAIN OUTCOME MEASURES: Number of women having an episiotomy, severe-degree (third- or fourth-degree) tear, other types of tear, blood loss at delivery, postpartum haemorrhage, need for blood transfusion, puerperal pyrexia, wound infection, gaping wound that required suture removal, and drainage or resuturing of a perineal wound. RESULTS: Between 1 January and 31 March 2003, there were 6222 singleton spontaneous normal vaginal deliveries in the public hospitals of Hong Kong. Of the 6167 women in whom the status of the perineum was known, episiotomy was performed in 5274 (85.5%). Primiparous women were more likely to undergo episiotomy at delivery than multiparous women (97.9% vs 71.4%). Women with episiotomy had significantly less perineal tearing of any kind than those without. The occurrence of any type of perineal tear and severe-degree (third- or fourth-degree) tear was significantly lower in primiparous women who had an episiotomy than those without (P<0.05). Women with episiotomy had increased mean blood loss at delivery but other complications were not significantly increased. CONCLUSIONS: In Hong Kong, episiotomy is routinely performed during normal vaginal delivery. It is associated with a significantly lower overall rate of perineal tearing. This study was observational, nonetheless the occurrence of other complications was likely to increase when episiotomy was performed. Firm evidence from several randomised controlled studies shows that routine episiotomy is unjustified and possibly harmful. Routine episiotomy should not be promoted in Hong Kong without further randomised controlled study. (+info)
Case report and summary of literature: giant perineal keloids treated with post-excisional radiotherapy.
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BACKGROUND: Keloids are common benign tumors of the dermis, typically arising after insult to the skin. While typically only impinging on cosmesis, large or recurrent keloids may require therapeutic intervention. While no single standardized treatment course has been established, several series report excellent outcomes for keloids with post-surgery radiation therapy. CASE PRESENTATION: We present a patient with a history of recurrent keloids arising in the absence of an ascribed trauma and a maternal familial history of keloid formation, whose physical examination several large perineal keloids of 6-20 cm in the largest dimension. The patient was treated with surgical extirpation and adjuvant radiation therapy. Radiotherapy was delivered to the scar bed to a total dose of 22 Gy over 11 daily fractions. Acute radiotherapy toxicity necessitated a treatment break due to RTOG Grade III acute toxicity (moderate ulceration and skin breakdown) which resolved rapidly during a 3-day treatment break. The patient demonstrated local control and has remained free of local recurrence for more than 2 years. CONCLUSION: Radiotherapy for keloids represents a safe and effective option for post-surgical keloid therapy, especially for patients with bulky or recurrent disease. (+info)
Postpartum outcomes in supine delivery by physicians vs nonsupine delivery by midwives.
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CONTEXT: Clinically preferred maternal position during childbirth has varied between supine and nonsupine over time and from patient to patient. Preferred maternal birthing position is coming under increasing scrutiny. OBJECTIVE: To compare postpartum maternal and infant outcomes resulting from supine and nonsupine positions maintained during the second stage of labor. DESIGN AND METHODS: Nonrandomized clinical trial comparing low-risk women (N=198) in two separate obstetrics practices. In one practice, parturients (n=100) used only the supine position as their birthing position. In the other practice, parturients (n=98) used any or all of three nonsupine positions (sitting, squatting, or kneeling/hands-and-knees). Data collection took place immediately after birth by provider survey and included: Apgar scores, demographics, estimated blood loss, neonatal weight, perineal integrity, position during second-stage labor and birth, and vulvar edema. RESULTS: Infants born to mothers in nonsupine positions were delivered with significantly less tearing of the perineum (P<.001) and less vulvar edema (P<.001). Although the length of second-stage labor was shorter among the women who were nonsupine, this result lacked statistical significance. There did not appear to be increased risk to the infant from the mother's nonsupine posture. CONCLUSION: Nonsupine positions during labor and delivery were found to have clinical advantages without risk to mother or infant. Enhanced maternal outcomes included improved perineal integrity, less vulvar edema, and less blood loss. (+info)
Urethral duplication with a perineal opening in a four-year-old boy.
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Urethral duplication (UD) is a rare congenital anomaly. In UD, there is in addition to a normally positioned urethra an accessory urethra arising from the bladder, bladder neck or the proximal urethra and terminating anywhere between the base of the penis along the ventral surface and the glans penis. The embryologic development of UD remains to be clearly elucidated and the etiology of the condition is unknown. We present our experience with a 4 year old boy who presented with urethral duplication. (+info)
Mucinous adenocarcinoma arising from chronic perianal fistula.
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Perianal mucinous adenocarcinoma is a rare tumor which may be associated with long-standing chronic perianal sepsis. Early diagnosis is challenging and is based on a high index of clinical suspicion and specific histological features. Definitive treatment is surgical, in the form of an abdomino-perineal resection. We hereby describe a case of a perianal mucinous adenocarcinoma arising from long-standing recurrent perianal fistula and complement this with a brief review of the literature pertaining in particular to the management of this condition. (+info)
Perineal sensation: an important predictor of long-term outcome in open spina bifida.
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OBJECTIVES: To see if perineal sensation in infants with open spina bifida is associated with a better long-term outcome, particularly in terms of survival, renal-related deaths and incontinence. METHODS: We conducted a prospective cohort study on a complete cohort of 117 consecutive patients with open spina bifida, whose backs were closed non-selectively at birth between 1963 and 1971. A meticulous neurological examination in infancy showed that 33 (28%) of them had perineal sensation, defined as intact sensation to pinprick in at least one dermatome on one side in the saddle area (S2-4). Data recorded within 48 h of birth and during six reviews between 1972 and 2002 were used. Details of deaths were obtained from medical records and from the Office of National Statistics. RESULTS: By December 2005, 57% (67/117) of the cohort had died. There were 50 survivors with a mean age 38 years (range 35-41). More of those with perineal sensation survived than those without (23/33 v 27/84, p<0.001). This difference was mainly caused by 19 renal deaths in those lacking perineal sensation. Crucially there were no renal-related deaths in those with perineal sensation (0/33 v 19/84, p = 0.003). Among the survivors, those with perineal sensation were more likely than the remainder to be continent of urine and faeces (10/23 v 1/27, p<0.001 and 18/23 v 9/27, p = 0.002 respectively). They were also more likely to be able to walk at least 50 m (11/23 v 5/27, p = 0.027) and never to have had pressure sores (15/23 v 9/27, p = 0.025). CONCLUSIONS: A simple assessment of perineal sensation in infancy predicts long-term outcome in terms of survival, renal prognosis and incontinence in open spina bifida. (+info)
"The sponge perineum:" an innovative method of teaching fourth-degree obstetric perineal laceration repair to family medicine residents.
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BACKGROUND: Fourth-degree perineal lacerations are an uncommon, unpredictable injury that family physicians may face. METHODS: After a needs assessment and feasibility review, we developed goals, objectives, instructional tools, and a feedback survey for a curriculum using a novel model to simulate perineal laceration repair. RESULTS: Fifty-six learners evaluated the session, expressing increased confidence with perineal laceration repair, the usefulness of the model, and their desire to see it included in the Advanced Life Support in Obstetrics course. CONCLUSIONS: The "sponge perineum" is an inexpensive, effective tool to teach perineal laceration repair. Further study is needed with actual patient experiences. (+info)