Chart documentation of informed consent for operative vaginal delivery: is it adequate?

OBJECTIVES: To determine the documentation frequency of informed consent for women undergoing a trial of nonemergent instrumental delivery. STUDY DESIGN: A retrospective chart review of instrumented vaginal deliveries from 1992 to 2005 was performed. Cases were identified from a Labor and Delivery database and hospital records were reviewed for documentation of associated risks, general consent for the procedure, indication, and option of cesarean delivery (CD). RESULTS: Three hundred forty six charts were reviewed: 246 were excluded for an emergency delivery (19%), misclassification (25%), or lost notes (27%). In the remaining 100 cases, 61% had a general consent for instrumented vaginal delivery. Documentation of any maternal or neonatal risks was found in 3% and 0%, respectively. The option of a cesarean delivery was documented in 22% of the cases. When comparing 5-year time intervals before and after 2000, there was no increased frequency in documentation of maternal or neonatal risks. CONCLUSIONS: Documentation of informed consent for instrumented vaginal delivery is inconsistent and should be improved.

Anal incontinence in women with and those without pelvic floor disorders.

OBJECTIVE: To compare the prevalence of anal incontinence and anal sphincter injury in women with pelvic floor disorders (cases) with those in a group of normal control subjects and to evaluate the relationship between sphincter injury and anal incontinence in each group. METHODS: We previously reported the results of a cross-sectional study of 100 women with pelvic floor disorders (> or = stage II pelvic organ prolapse and/or urinary incontinence). In this study, we compared those cases with 90 controls (stage 0 or I pelvic organ prolapse and no urinary incontinence) who completed the Rockwood-Thompson fecal incontinence severity index, in which scoring (0-61) is based on the frequency and type of anal incontinence. All women underwent endoanal ultrasonography, and the internal and external anal sphincters were reported as intact versus disrupted. Chi-square test, Student t test, and logistic regression were used for statistical analysis. RESULTS: Women with pelvic floor disorders were significantly more likely to report anal incontinence (54% versus 17.8%, odds ratio [OR] 5.4, 95% confidence interval [CI] 2.8-10.6, P < .001) and had higher mean fecal incontinence severity index scores (22.3 +/- 13 versus 12.7 +/- 6.3, P = .006) than controls. Cases demonstrated higher rates of anal sphincter defects on ultrasound examination than did controls (52% versus 30%, P = .007). Anal incontinence was significantly associated with anal sphincter injury in women with pelvic floor disorders (OR 36.4, 95% CI 12-114, P < .001) and in controls (OR 5.9, 95% CI 3-11, P = .002). CONCLUSION: Anal incontinence was more common in women with pelvic floor disorders than normal controls and may be due to higher rates of anatomic anal sphincter disruption in this group.

Anal sphincter injury in women with pelvic floor disorders.

OBJECTIVE: 1) To estimate the rate of anal incontinence and anal sphincter injury in a group of women with pelvic floor disorders; 2) to evaluate the relationship between anal incontinence and anal sphincter injury as demonstrated by endoanal ultrasonography; 3) to explore any associations between operative vaginal delivery and anal sphincter injury in this population. METHODS: A cohort of 100 women with stage II or greater pelvic organ prolapse and/or urinary incontinence completed the Rockwood-Thompson Fecal Incontinence Severity Index Questionnaire (FISI). Pelvic organ prolapse was recorded using the Pelvic Organ Prolapse Quantification system. Multichannel cystometry and endoanal ultrasonography were performed. Categorical data were compared using the chi(2) statistic. The FISI scores were correlated with degree of anal sphincter injury using the Pearson correlation coefficient (r). RESULTS: Fifteen women with pelvic organ prolapse only, 28 with urinary incontinence only, and 57 with both were evaluated. Mean age (+/- standard deviation) and body mass index were 57.1 +/- 13.2 years and 29.8 +/- 6.8 kg/m(2), respectively. Median parity was 3. Fifty-four percent of those studied had anal incontinence, and 52% had anal sphincter defects. Anal incontinence was significantly associated with sphincter injury (odds ratio 36.4, 95% confidence interval 12-114, P <.001). The FISI scores were positively correlated with increasing degrees of anal sphincter disruption (r = 0.81, P <.001). A history of operative vaginal delivery was significantly associated with anal sphincter injury (P =.023). CONCLUSION: Anal incontinence and anal sphincter injury are common in women with other pelvic floor disorders and are significantly related. Operative vaginal delivery may contribute to unrecognized anal sphincter trauma in this population. LEVEL OF EVIDENCE: III

Thermal balloon endometrial ablation for management of acute uterine hemorrhage.

BACKGROUND: Life-threatening abnormal uterine bleeding can be managed by a variety of techniques, which include intravenous estrogen, dilation and curettage, endometrial ablation, uterine artery embolization, or hysterectomy. Thermal balloon endometrial ablation has been used in the management of chronic dysfunctional uterine bleeding but has not been described in a case of acute uterine hemorrhage. CASE: A 44-year-old woman with end-stage liver disease presented with vaginal bleeding and fever. She was found to have sepsis, coagulopathy, and anemia. No anatomic uterine pathology was identified. Antibiotics, intravenous estrogen, and blood products were administered, but heavy bleeding persisted. Thermal balloon ablation resulted in abrupt cessation of uterine bleeding. CONCLUSION: Thermal balloon ablation appears to be an effective method for management of acute uterine hemorrhage.