The usual suspect: cross-sectional study of fundal pressure at second stage of delivery and the association with pelvic floor damage.

INTRODUCTION AND HYPOTHESIS: Uterine fundal pressure is applied to accelerate birth by increasing the expulsive force of the uterus in the second stage of delivery. The aim of the study was to evaluate the effect of using uterine fundal pressure during the second stage of delivery on the rate of pelvic floor damage among primiparous women using three-dimensional transperineal ultrasonography. METHODS: The women were divided into two groups: the fundal pressure group included women where the fundal pressure maneuver was applied (n = 39); the control group included women who delivered spontaneously without fundal pressure (n = 47). 3D-TPU was performed within 48 h of delivery, and LAM biometry, LAM defect and loss of tenting were determined. RESULTS: Anteroposterior hiatal dimensions on resting, maximal Valsalva and maximal PFMC were found to be higher in the fundal pressure group (p < 0.0001, p = 0.008, p = 0.007, respectively). The mean hiatal area at rest was larger in the fundal pressure group than in the control group (p = 0.04). The rate of LAM defect was significantly higher in the fundal pressure group (p = 0.001). The rate of loss of tenting was significantly higher in the fundal pressure group (p < 0.0001). According to multivariate regression models, the fundal pressure was the only independent factor associated with LAM defect (OR = 5.63; 95% CI = 12.01-15.74) and loss of tenting (OR = 8.74; 95% CI = 2.89-26.43). CONCLUSIONS: Fundal pressure during the second stage of delivery is associated with a higher risk of LAM defect and loss of anterior vaginal wall support. CLINICAL TRIAL REGISTRATION: NCT03752879.

Total colpocleisis technique in huge neglected ulcerated uterovaginal prolapse.

INTRODUCTION AND HYPOTHESIS: We present a video describing the technical considerations for performing a total colpocleisis in the management of significant, neglected, ulcerated, and symptomatic complete uterovaginal prolapse. METHODS: A 79-year-old debilitated woman presented with a large, ulcerated pelvic bulge. A previous attempt at pessary treatment failed because of a disproportion of the pessary with the prolapse size. She had a history of liver insufficiency and hypertension. Obliterative colpocleisis surgery was selected because the healing of a large ulcerated vagina was not likely within a short timeframe. Sharp dissection with scissors and de-epithelialisation of the remaining non-eroded vaginal mucosa with the friction of a sharp-edged surgical knife were performed. Closely located purse strings were used to obliterate potential spaces. Two mirror image triangles in the anterior and posterior vaginal walls were removed. After the formation of a new perineal body, the diamond-shaped vaginal incision was closed vertically to narrow introitus. RESULTS: The patient was discharged on the first postoperative day and an uncomplicated postoperative course ensued. At the 4-week follow-up, there was no evidence of infection, recurrent prolapse, de novo stress incontinence, or voiding with difficulty. CONCLUSIONS: Total colpocleisis is an excellent surgical option in women with multiple, large cervicovaginal ulcers and multiple comorbidities with no desire for penetrative vaginal function.