[Ritgen maneuver and its modifications]. / Ritgenuv manévr a jeho modifikace.

OBJECTIVE: To present the Ritgen maneuver, its original description as well as its most common modifications and to demonstrate the heterogenity of descriptions of the maneuver regarding its performance, purpose and published results. DESIGN: A review article. SETTING: Department of Gynecology and Obstetrics, Medical Faculty and University Hospital Pilsen, Charles University in Prague. METHODS: A review article demonstrating the heterogeneity of Ritgen maneuver descriptions based on analysis of present and past obstetrical textbooks and journal articles. CONCLUSION: At present there is a pursuit of finding and analysis of methods for obstetric perineal injury prevention, which could considerably improve quality of life of women after delivery. One of the possible mechanisms of perineal trauma reduction is to ensure that the fetal head passes with its smallest head circumference through the perineal structures. Already in the middle of the 19th century, von Ritgen devised a method allowing to facilitate and control the extension of the fetal head in the end of the second stage of labor. His method quickly spread all over the world, however, the description changed considerably. The Ritgen maneuver today means a variety often very different interventions. This review points out to the need of clarification of terminology, i.e. definition and classification of methods facilitating extension of the fetal head in the end of the second stage of labor.

[Repair of the 3rd and 4th degree obstetric perineal tear]. / Sutura ruptury perinea 3. a 4.stupne.

OBJECTIVE: Summary of the current knowledge of repair of obstetric anal sphincter trauma. DESIGN: Review. SETTING: Department of Gynecology and Obstetrics, Charles University and University Hospital Pilsen. SUMMARY: Review of the current international literature covering the given problem. RCOG classification of obstetrics perineal trauma should always be used as it respects the anatomic structures together with the physiological functions of tissue involved in ano-rectal continence. Two types of procedure: end-to-end approximation and overlapping of torn ends of the anal sphincter are both referred to and they are discussed with regards to the functional outcome of the repair. OPERATING CONDITIONS: Experience of the surgeon, operating theatre and its equipment, asepsis, lighting, operating instruments, anesthesia, material and type of suture, medication is described to increase the effectiveness of the repair. A delay in primary repair of up to 8-12 hours does not seem to be detrimental to the functional outcome of the procedure. Uncommon types of injury mentioned: segmented tear of internal anal sphincter, lateral tear of external anal sphincter.

[Mediolateral episiotomy and anal sphincter trauma]. / Mediolaterální epiziotomie a poranení análního sfinkteru.

OBJECTIVE: A summary of recent knowledge of the correlation between mediolateral episiotomy and anal sphincter injury. DESIGN: Review. SETTING: Department of Gynaecology and Obstetrics, Charles University and University Hospital Pilsen. CONCLUSIONS: The methodology of most studies is not well managed. Four problematical points were identified: definition of the mediolateral episiotomy, practical execution of the mediolateral episiotomy, diagnostics of perineal trauma and classification of the perineal trauma. Mediolateral episiotomy is often deficiently defined. Definitions differ depending on individual textbooks or departments. The majority of studies gives no definition and no description of the practical execution of an episiotomy or describes it inadequately. To the current knowledge there is no international consensual definition, which is used universally. Until 2003, there was no study evaluating adequate implementation of the mediolateral episiotomy. It appears that most of executed mediolateral episiotomies are not truly mediolateral. The angle of inclination between 40-60 degrees was suggested. According to the latest study, the lower limit of the mediolateral episiotomy definition (40 degrees) appears to be insufficient. At the present time, the correlation between mediolateral episiotomy and perineal trauma cannot be precisely evaluated. Before analyzing the benefits and risks of mediolateral episiotomy, an international consensus must be found, that would establish an exact definition of mediolateral episiotomy.