The Prevalence of Pelvic Floor Hematoma After Vaginal Delivery

Oxytocin augmentation and neurotransmitters in prolonged delivery: An experimental appraisal

The uterus is a highly innervated organ, and during labor, this innervation is at its highest level. Oxytocinergic fibers play an important role in labor and delivery and, in particular, the Lower Uterine Segment, cervix, and fundus are all controlled by motor neurofibers. Oxytocin is a neurohormone that acts on receptors located on the membrane of the smooth cells of the myometrium. During the stages of labor and delivery, its binding causes myofibers to contract, which enables the fundus of the uterus to act as a mediator. The aim of this study was to investigate the presence of oxytocinergic fibers in prolonged and non-prolonged dystocic delivery in a cohort of 90 patients, evaluated during the first and second stages of labor. Myometrial tissue samples were collected and evaluated by electron microscopy, in order to quantify differences in neurofibers concentrations between the investigated and control cohorts of patients. The authors of this experiment showed that the concentration of oxytocinergic fibers differs between non-prolonged and prolonged dystocic delivery. In particular, in prolonged dystocic delivery, compared to non-prolonged dystocic delivery, there is a lower amount of oxytocin fiber. The increase in oxytocin appeared to be ineffective in patients who experienced prolonged dystocic delivery, since the dystocic labor ended as a result of the altered presence of oxytocinergic fibers detected in this group of patients.

Measurement of perineal tears as an additional tool for laceration assessment during vaginal birth

INTRODUCTION

Spontaneous lacerations at vaginal birth are everyday events, but their classification and management still challenge midwifery care. This study aims to measure and describe first-degree and second-degree perineal lacerations resulting from vaginal birth, describe their repair, and the education provided for care.

METHODS

A descriptive study was conducted in a public maternity hospital in São Paulo, Brazil, with 87 parturients. Data were collected between October 2017 and June 2018 using a structured instrument containing obstetric variables and a description of lacerations. The obstetricians and nurse midwives assisted with births, determining the degree of laceration and intervention, and the researchers measured and reported them.

RESULTS

The majority of parturients (82.7%) had lacerations only in the anterior region, 8% had them in the posterior region, and 9.2% in both regions. The lacerations were classified as first-degree (78.1%) or second-degree (21.8%). Among the 32 nulliparous parturients, 27.6% had first-degree lacerations, and 9.2% had second-degree. Of the 55 multiparous parturients, 50.6% had first-degree, and 12.6% had second-degree. Among the lacerations assessed as first-degree, 25% had deeper tissue layers compromised in addition to the skin and mucosa. There were 180 lacerations, with an average length of 33.1 mm, depth of 19.8 mm, and width of 23.8 mm. Half of the parturients did not receive guidance on laceration care. There was no association between parity and size, number, location, or degree classification of lacerations.

CONCLUSIONS

This study provides a broad description of the characteristics of perineal lacerations and presents measurement techniques as a complementary resource for evaluating lacerations.

Management of large paravaginal hematomas with the Zhukovsky vaginal catheter

OBJECTIVE

To ameliorate the treatment of large paravaginal hematomas postpartum using the Zhukovsky vaginal catheter.

METHODS

A retrospective, controlled study including puerperas with large paravaginal hematomas. To assess the effectiveness of the proposed treatment, a group of patients underwent traditional obstetric surgery. A second group of puerperas underwent an integrated approach: the surgical stage (pararectal incision) and the application of the Zhukovsky vaginal catheter. The effectiveness of treatment was assessed according to the following criteria: blood loss volume and hospital admission time.

RESULTS

In total, 30 puerperas were included in the study; 15 in each treatment group. Large paravaginal hematomas were reported most often in primiparas (50.0%), in 36.7% were combined with rupture of the vagina and the cervix, and in 10.0% of cases an episiotomy was performed during delivery. In 40.0% of primiparas, the blood loss volume was more than 1000 mL, whereas in multiparous and in multiple pregnancies, blood loss did not exceed 1000 mL (r = -0.49; P = 0.022). In 25.0% of puerperas with a blood loss of up to 1000 mL there were no obstetric injuries; in the group with a blood loss of more than 1000 mL, 83.3% of patients had obstetric injuries. An integrated approach reduced the blood loss volume (r = -0.22; P = 0.29), compared with the traditional surgery, and reduced the hospital admission time from 12 (11.5; 13.5) days to 9 (7.5; 10.0) days (P < 0.001).

CONCLUSION

In patients with large paravaginal hematomas treated by an integrated approach we reported a decrease in bleeding, less risk of postoperative complications, and a reduction in the time of the hospital stay.

Correlation between pelvic floor ultrasound parameters and vaginal pressures in nulliparous women: a subanalysis of the SUM-AN study

INTRODUCTION AND HYPOTHESIS

Pelvic floor ultrasound is used as a validated technique for measuring levator ani dimensions. Vaginal manometry has been used in the past as a method to assess levator ani muscle (LAM) strength. Whether the combination of both methods can contribute to our understanding of pelvic floor pathophysiology has not yet been described. We hypothesized that as female pelvic floor muscular hiatus increases, the vaginal pressure and strength decrease.

METHODS

We recruited 20 asymptomatic nulliparous women ages 18-85 years. Minimal levator hiatus (MLH) area, anteroposterior/left-right (AP/LR) diameter ratio, the distance between levator plate and the pubic symphysis (LP-PS) while at rest and squeeze were measured using endovaginal ultrasound (US). Vaginal pressure at rest, squeeze (Kegel) and Valsalva were measured using 3D manometry. Logistic and linear regression analysis was performed to assess correlations.

RESULTS

MLH area was negatively correlated with the sum of all the squeeze pressures produced on the four walls of the vagina (p = 0.049, R² = 0.197). There was also a borderline negative correlation between MLH and the sum of rest pressures (p = 0.09, R² = 0.15). AP/LR ratio was negatively correlated with the sum of squeeze pressures (p = 0.056, R² = 0.197). LP-PS distances, both while at rest and during squeeze, were negatively correlated with the vaginal squeeze pressure (p = 0.046, R² = 0.21; p = 0.011, R² = 0.31, respectively). LP-V distance, both at rest and during squeeze, was negatively correlated with the sum of squeeze pressures on four vaginal walls (p = 0.02, R² = 0.25; p = 0.005, R² = 0.36, respectively).

CONCLUSIONS

Stronger levator ani muscles, smaller MLH area and a more oval shape of pelvic floor hiatus as assessed by pelvic floor ultrasound are associated with higher squeeze vaginal pressures as assessed by 3D manometry.

Large concealed paravaginal haematoma: A case report of an occult postpartum haemorrhage

Paravaginal haematomas are common but rarely do they cause severe postpartum haemorrhage. While surgical evacuation is classically recommended for large haematomas, conservative management may be an appropriate strategy. We present the case of a 30-year-old primiparous woman with a large paravaginal haematoma causing a postpartum haemorrhage managed conservatively. The patient became hypotensive to 80/40 mmHg three and a half hours after forceps delivery, despite minimal vaginal bleeding. On examination she had a palpable mass at the right vaginal wall and uterine fundus deviated to the right, above the umbilicus. A computerised tomography examination of the pelvis demonstrated two paravaginal haematomas, the largest measuring 7 cm × 8 cm × 12 cm, extending superiorly into the supralevator and extraperitoneal space. The patient's haemoglobin fell from 13.2 g/dL to 7.1 g/dL. She was managed conservatively with analgesia, intravenous fluid resuscitation and one unit of packed red blood cells, and was discharged home three days postpartum. This case supports the conservative management of even large paravaginal haematomas, which may extend into the supralevator space, making surgical evacuation technically difficult.