Obstetric laceration repair in the United States: is there a common practice?

OBJECTIVE: To assess practice preferences in the repair of severe obstetric lacerations among obstetrician/gynecologists in the United States. STUDY DESIGN: A survey detailing third and fourth degree laceration repair techniques was distributed to 634 obstetrician/gynecologists from demographically diverse areas of the United States. Categorical outcomes were compared among respondents using chi2 or Fisher's exact test where appropriate. RESULTS: Of the 266 respondents, there were 124 self-reported "experts" (47%) and 106 physicians-in-training (40%). Repair techniques were compared between experts versus nonexperts and trainees versus practicing physicians. There were no significant differences found between either comparison group on the type and size of suture utilized or preferred method of closure for repair. CONCLUSION: There is little variation in the practice pattern of complex laceration repairs among obstetrician-gynecologists in the United States. This commonality should encourage the design of standard teaching models and techniques for physicians in training.

A case-control study of risk factors for ileus and bowel obstruction following benign gynecologic surgery.

OBJECTIVE: To identify risk factors leading to the development of postoperative ileus and small-bowel obstruction (SBO) after benign gynecologic surgery. METHODS: In a multicenter case-control study across the United States, data were examined from women with International Classification of Diseases 9 (ICD-9) and Current Procedural Terminology (CPT) codes who underwent benign gynecologic surgery between January 2005 and June 2010 and subsequently developed an ileus or SBO. Each patient with ileus or SBO was matched to 2 control women who underwent the same benign gynecologic procedure but did not develop ileus or SBO. RESULTS: During the study period, 144 cases and 288 controls were identified. By conditional multivariate logistic regression, risk factors for ileus or SBO included cystotomy (odds ratio [OR], 8.7; 95% confidence interval [CI], 1.48-51.47), concomitant bowel surgery (OR, 4.3; 95% CI, 1.18-15.78), perioperative transfusion (OR, 2.9; 95% CI, 1.44-5.95), and lysis of adhesions (OR, 1.7; 95% CI, 1.03-2.83). CONCLUSION: Lysis of adhesions, concomitant bowel surgery, and perioperative complications such as blood transfusion and cystotomy were found to be risk factors for the development of ileus and/or SBO after benign gynecologic surgery.

Management of ileus and small-bowel obstruction following benign gynecologic surgery.

OBJECTIVE: To describe practice preferences for the diagnosis and management of ileus and small-bowel obstruction (SBO) following benign gynecologic surgery. METHODS: A secondary descriptive analysis was performed on data from a multicenter case-control study of patients who underwent gynecologic surgery and subsequently developed ileus or SBO. Information was collected regarding interventions such as type of imaging ordered for diagnosis, diet alterations, antiemetic administration, and need for reoperation. RESULTS: In total, 144 cases were identified. Abdominal X-ray was the most common imaging modality, occurring in 54 (37.5%) cases. Sixty-nine (65.1%) of the 106 women who underwent imaging were given definitive radiologic diagnoses of either ileus (50 [72.5%]) or SBO (19 [27.5%]); 57.9% (n=11) of the SBO diagnoses and 90.0% (n=45) of the ileus diagnoses were managed conservatively. Eighteen (12.5%) patients underwent reoperation for bowel obstruction. There were no significant differences in rate of reoperation between cases involving the use of single antiemetics and those involving the use of multiple antiemetics (P=0.18), or between diet statuses on postoperative day 1 (P=0.08). CONCLUSION: Most study centers initially performed an abdominal X-ray for diagnostic purposes. The majority used a multimodal treatment approach. None of the management options decreased the likelihood of reoperation.

Transmural vaginal-to-bladder injury from an obstructed labor pattern.

BACKGROUND: A vesicovaginal fistula, among other devastating sequelae, is a complication that can arise from obstetric trauma such as prolonged obstructed labor patterns. These are rarely seen as obstetric-related complications in well-developed countries. They are thought to arise from direct ischemic injury that can occur between the fetal head and the adjacent tissues. CASE: A patient presented to the emergency room in obstructed labor. Examination revealed a crowning fetal head, no fetal heart tones, and purulent vaginal discharge. Postpartum, the patient experienced irritative voiding symptoms, vaginal stenosis, and cystoscopic evidence of injury to the bladder base. CONCLUSION: These findings may provide evidence of the transmural vaginal-to-bladder damage that can occur from obstructed labor.