Perineal body length as a risk factor for ultrasound-diagnosed anal sphincter tear at first delivery.

INTRODUCTION AND HYPOTHESIS: Shortened perineal body (PB) is associated with an increased risk of ultrasound-detected obstetric anal sphincter tear. The objective was to determine if shortened perineal body length (<3 cm) is a risk factor for ultrasound-detected anal sphincter tear at first delivery. METHODS: Pregnant nulliparous women were recruited over 18 months. At 35-37 weeks' gestation and 6 weeks' postpartum perineal body length (PB) was measured and subjects completed quality of life questionnaires. Primary outcome was ultrasound-diagnosed anal sphincter tear at 6 weeks postpartum. Secondary outcomes were also assessed. A priori power analysis determined that 70 subjects were needed to detect a difference in anal sphincter tear based on a PB cut-off of 3 cm. RESULTS: Seventy-three subjects completed the study. Mode of delivery was 69.9% spontaneous vaginal, 15.1% operative vaginal, and 15.1% labored cesarean. There were 25 anal sphincter abnormalities (34.2%) seen on ultrasound: 11 (15.1%) internal or external sphincter tears, 3 (4.1%) internal sphincter atrophy, 6 (8.2%) external sphincter thinning, and 7 (9.6%) external sphincter scarring. Only the 11 sphincter tears qualified as abnormal for the primary outcome. In the vaginal delivery group 16.4% (10 out of 61) had a sphincter tear, compared with 8.3% (1 out of 12) in the labored cesarean group (p = 0.68). Women with PB < 3 had a significantly higher rate of ultrasound-diagnosed anal sphincter tear (40.0% vs 11.1%, p = 0.038). When comparing women with and without sphincter tear, there was a significant difference in mean antepartum PB (3.1 vs 3.7 cm, p = 0.043). CONCLUSIONS: A shortened perineal body length in primiparous women is associated with an increased risk of anal sphincter tear at the time of first delivery.

Vaginal hysterectomy: the original minimally invasive surgery.

Hysterectomy is one of the most commonly performed procedures in the United States. It is a unique procedure with multiple routes of access and multiple operative techniques. While focus has shifted towards minimally invasive techniques, the vaginal hysterectomy should be ranked first in this category, as it represents an original natural orifice surgery. Vaginal hysterectomy offers the least invasive approach to hysterectomy, with the lowest associated risks and costs. Despite these benefits, vaginal hysterectomy has experienced a decline in the last two decades. This decline is likely due to both the prevalence of fibroid uterus as a major indication for hysterectomy, and the decline of vaginal surgical skills among gynecologic surgeon due to more recent focus on laparoscopic proficiency. While vaginal hysterectomy is not risk-free, and is not the best option for all diagnoses, it should be given first-line consideration when planning to perform a benign hysterectomy. The purpose of this review is to understand the origins and evolution of the vaginal hysterectomy, the evidence-based benefits of this route of surgery, and best practice methods to ensure that patients receive safe and effective surgical treatment.

Neonatal outcomes associated with planned vaginal versus planned primary cesarean delivery.

OBJECTIVE: To determine whether planned route of delivery leads to differences in neonatal morbidity. STUDY DESIGN: Analysis was based on planned route of delivery, not actual route of delivery. A total of 4048 subjects were divided into two groups: planned vaginal delivery and planned cesarean delivery. Primary outcomes were neonatal intensive care unit (NICU) admission, respiratory morbidity and neurologic morbidity. RESULT: There were 3868 planned vaginal and 180 planned cesarean deliveries. Planned vaginal delivery had decreased NICU admission (P<0.0001), oxygen resuscitation (P=0.001) and jaundice (P<0.0001) but increased meconium passage (P<0.0001) and 1 min Apgar