دانلود کتاب Pelvic Floor, Perineal, and Anal Sphincter Trauma During Childbirth: Diagnosis, Management and Prevention

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Foreword
Preface
Contents
1: Anatomy of the Pelvic Floor, Perineum and Anal Sphincter
1.1 Introduction
1.2 Embryology
1.3 Muscles of the Perineum
1.3.1 The Urogenital Triangle
1.3.1.1 Superficial Transverse Perineal Muscle
1.3.1.2 Bulbospongiosus Muscle
1.3.1.3 Ischiocavernosus Muscle
1.3.2 The Anal Triangle
1.3.2.1 Anal Canal
1.3.2.2 Anal Sphincter Complex
External Anal Sphincter
Internal Anal Sphincter
The Longitudinal Layer and the Conjoint Longitudinal Coat
1.3.2.3 Innervation of the Anal Sphincter Complex
1.3.2.4 Vascular Supply
1.3.2.5 Lymphatic Drainage
1.3.2.6 Ischioanal Fossa
1.4 Perineal Body
1.5 The Pelvic Floor
1.5.1 Innervation of the Levator Ani
1.5.2 Vascular Supply
1.6 The Pudendal Nerve
1.7 Conclusion
Appendix: MCQ
Questions
Answers
References
2: Pathophysiology and Effects of Pregnancy on the Pelvic Floor
2.1 Introduction
2.2 Pelvic Floor Anatomy
2.3 Pelvic Floor Changes
2.3.1 Pelvic Floor Changes in Preparation for Birth
2.3.2 Pelvic Floor Injury During Birth
2.3.2.1 Levator Ani Muscle Injury
Incidence, Risk Factors, and which Muscle Is Injured
Mechanism of Injury and Concept of Injury Spectrum
What Is the Cause of Levator Ani Injury?
Stretching and Tearing Is the Cause of Injury
2.3.3 Recovery After Vaginal Birth
2.3.3.1 How Do the Hiatuses Recover?
2.4 The Hiatus and Pelvic Floor Disorders
2.4.1 How Does High Pressure Zone Contribute to Providing Support?
2.4.2 An Enlarged Hiatus Is One Cause of Pelvic Organ Prolapse
2.4.3 Factors Affecting Hiatus Size
2.4.4 The Perineal Complex
2.5 Pelvic Floor Dysfunctions in Relation to Birth Injuries
2.5.1 Pelvic Organ Prolapse
2.5.1.1 Levator Ani Injury at Birth and Prolapse
2.5.1.2 Load Sharing Between Levator Ani and Connective Tissue
2.5.2 Urinary Incontinence
2.5.2.1 Urethral Support and Birth
2.5.2.2 Levator Ani Injury Associated Urethral Sphincter Dysfunction
2.5.3 Anal Incontinence
2.5.3.1 Ultrasound Studies and Anal Incontinence
2.6 Summation
Appendix: MCQ
Questions
Answers
References
3: Diagnosis of Obstetric Anal Sphincter Injuries (OASIs)
3.1 Introduction
3.2 Classification of Perineal Trauma
3.2.1 Steps to Making an Accurate Clinical Diagnosis of OASIS
3.3 Undiagnosed OASIs
3.4 Can Routine Anal Sonography Immediately After Delivery Improve Accuracy of Detection of OASIs?
3.5 Conclusions
Appendix: MCQ
Questions
Answers
References
4: Episiotomy, First and Second Degree Tears
4.1 Introduction
4.2 Definition
4.3 Prevalence
4.4 Episiotomy Rates: Is There an ‘Ideal’?
4.5 Classification of Perineal Trauma
4.6 Indications for Episiotomy
4.7 Non-suturing of First and Second Degree Tears
4.8 Suturing Methods
4.9 Suture Materials
4.10 Management of Perineal Trauma
4.10.1 Basic Surgical Principles
4.10.2 First Degree Tears and Labial Lacerations
4.10.3 Repair of Episiotomy and Second Degree Tears
4.10.4 The Continuous Suturing Technique
4.10.4.1 Suturing the Vagina
4.10.4.2 Suturing the Muscle Layer
4.10.4.3 Suturing the Perineal Skin
4.10.5 Training
4.11 Conclusion
Appendix: MCQ
Questions
Answers
References
5: Management of Acute Obstetric Anal Sphincter Injuries (OASIs)
5.1 Introduction
5.2 Historical Perspective
5.3 Prevalence
5.4 Repair Techniques
5.4.1 Principles and Technique of Repair
5.5 Rectal Buttonhole Tears
5.6 Outcome of Primary Repair of OASIs
5.7 Post-Operative Management
5.7.1 Antibiotics
5.7.2 Bladder Catheterisation
5.7.3 Post-Operative Analgesia
5.7.4 Dietary Advice and Stool Softeners
5.7.5 Patient Information
5.7.6 Follow-Up
5.8 Management of Subsequent Pregnancies After OASIs
5.8.1 What Is the Risk of Sustaining a Recurrent OASIs (rOASIs)?
5.8.2 What Is the Risk of Anal Incontinence After Another Vaginal Birth?
5.8.3 What Is Recommended Practice?
5.8.3.1 Asymptomatic Women Post OASIs
5.8.3.2 Symptomatic Women Post OASI
5.8.4 What Is the Risk of Worsening anal Incontinence Symptoms After Recurrent OASIs?
5.8.5 How Safe Is Caesarean Birth?
5.8.6 Can Objective Assessments Predict Who Will Develop Incontinence?
5.9 Who Should Be Performing Acute Primary Obstetric Sphincter Repairs?
5.10 Education and Training
5.11 Conclusions
Appendix: MCQ
Questions
Answers
References
6: Short and Long-term Maternal and Neonatal Outcomes of Caesarean Section
6.1 Introduction
6.2 Short-term Implications of CB
6.2.1 Bleeding
6.2.2 Surgical Site Infection and Wound Complications
6.2.3 Return to Theatre
6.2.4 Venous Thromboembolism (VTE)
6.2.5 Visceral Injury
6.2.6 Maternal Mortality
6.2.7 Neonatal Implications
6.2.8 Recovery Time
6.3 Long Term Implications of CB
6.3.1 Future Pregnancies
6.3.1.1 Birth Complications
6.3.1.2 Uterine Rupture
6.3.1.3 Placenta Praevia
6.3.1.4 Placenta Accreta Spectrum (PAS)
6.3.1.5 Preterm Labour (PTL)
6.3.1.6 Spontaneous Abortion and Ectopic Pregnancy
6.3.1.7 Caesarean Scar Ectopic Pregnancy (CSEP)
6.3.1.8 Fetal Demise
6.3.2 Gynaecological Issues
6.3.2.1 Fertility
6.3.2.2 Chronic Pelvic or Abdominal Pain
6.3.2.3 Development of Endometriosis
6.4 Emotional and Psychological Wellbeing and Birth Satisfaction
6.5 Childhood Wellbeing Implications
6.5.1 Cerebral Palsy and Neuropsychological Development
6.5.2 Development of Physical Health Conditions
6.6 Implications to Perineal Problems, Prolapse and Incontinence
6.6.1 Perineal and Anal Sphincter Injury
6.6.2 Pelvic Organ Prolapse (POP) and Incontinence
6.7 Conclusion
Appendix: MCQ
Questions
Answers
References
7: Sexual Dysfunction After Childbirth
7.1 Introduction
7.2 Sexual Function and Dysfunction in Women
7.3 Risk Factors
7.3.1 Mode of Childbirth
7.3.2 Perineal Trauma and Episiotomy
7.3.2.1 Obstetric Anal Sphincter Injuries
7.3.2.2 Episiotomy
7.3.3 Breast Feeding
7.3.4 Postpartum Depression
7.3.5 Other Contributing Factors
7.3.5.1 Fatigue
7.3.5.2 Body Image
7.3.5.3 Interpersonal Relationships
7.3.5.4 Obstetric Trauma/Post-Traumatic Stress Disorder
7.3.5.5 Pelvic Floor Disorders
7.4 Natural History of Sexual Dysfunction Postpartum
7.5 Screening for Sexual Dysfunction
7.6 Clinical Evaluation of Sexual Dysfunction
7.7 Screening and Diagnostic Questionnaires
7.8 Physical Exam
7.9 Clinical Counseling and Addressing Patient Goals
7.10 Therapeutic Strategies
7.11 Conclusions
Appendix: MCQ
Questions
Answers
References
8: Impact of Pregnancy and Childbirth on Pre-existing Bowel Conditions
8.1 Introduction
8.1.1 The Changing Physiology of Pregnancy and the Consequences for the Gastrointestinal Tract
8.2 The Gastrointestinal Microbiome and Pregnancy
8.3 Inflammatory Bowel Disease (IBD)
8.4 IBD and Pregnancy
8.4.1 Pre-conception Planning (and Fertility)
8.4.2 Biologic Medications
8.4.3 Managing IBD Flares During Pregnancy
8.4.4 The Post-surgical Abdomen and Pregnancy in IBD
8.4.5 Managing Stomas in Pregnancy
8.4.6 Birth Modality
8.5 Other Gastrointestinal Disorders and Pregnancy
8.5.1 Irritable Bowel Syndrome
8.5.2 Constipation
8.5.3 Haemorrhoids
8.5.4 Acid Reflux and Peptic Ulcer Disease
8.5.5 Coeliac Disease
8.5.6 Gallstone Disease
8.6 Conclusions
Appendix: MCQ
Questions
Answers
References
9: Perineal and Anal Sphincter Wound Healing Complications
9.1 Introduction
9.2 Normal Wound Healing
9.3 Perineal Wound Infection
9.3.1 Definition
9.3.2 Pathophysiology
9.3.3 Microbiology
9.3.4 Incidence
9.3.5 Risk Factors
9.4 Perineal Wound Dehiscence
9.4.1 Definition
9.4.2 Pathophysiology
9.4.3 Incidence
9.4.4 Risk Factors
9.5 Objective Assessment of Wound Healing Complications
9.5.1 Advanced Wound Assessment
9.6 Management
9.6.1 Principles and Technique of Repair
9.6.1.1 Perineal Repair
9.6.1.2 Anal Sphincter Repair
9.7 Common Complications of Disrupted Perineal Healing
9.7.1 Granulation Tissue
9.7.2 Perineal Pain/Dyspareunia
9.7.3 Fistula
9.7.4 Psychological Impact
9.8 Prevention of Wound Complications
9.8.1 Other Treatments
9.9 Conclusions
Appendix: MCQ
Questions
Answers
References
10: Post-partum Problems and the Perineal Clinic
10.1 Introduction
10.2 Perineal Concerns
10.2.1 Perineal Pain
10.2.1.1 Treatment of Perineal Pain
Local Treatment
Systemic Treatment
Oral Analgesics
Suppositories
10.2.2 Perineal Haematoma
10.2.3 Perineal Wound Healing Complications
10.3 Bowel Concerns
10.3.1 Anal Fissures
10.3.2 Haemorrhoids
10.3.3 Anal Incontinence
10.3.4 Constipation
10.4 Bladder Concerns
10.4.1 Postpartum Urinary Retention
10.4.2 Urinary Incontinence
10.5 Sexual Problems
10.6 Pelvic Organ Prolapse
10.7 Maternal Recovery Clinics
10.8 Conclusion
Appendix: MCQ
Questions
Answers
References
11: Management of Subsequent Pregnancy After Incontinence and Prolapse Surgery
11.1 Introduction
11.2 Safety Concerns During Pregnancy
11.2.1 Previous Surgery for SUI
11.2.2 Previous Sacral Neuromodulation
11.2.3 Previous Surgery for POP
11.3 Mode of Delivery
11.3.1 Previous Surgery for SUI
11.3.2 Previous Sacral Neuromodulation
11.3.3 Previous Surgery for POP
11.4 Efficacy of Prior Surgical Treatment After Subsequent Birth
11.4.1 Surgical Treatment for SUI
11.4.2 Previous Sacral Neuromodulation
11.4.3 Previous Treatment for POP
11.5 Conclusions
Appendix: MCQ
Questions
Answers
References
12: Prevention of Perineal Trauma
12.1 Introduction
12.2 Risk Factors
12.2.1 Perineal Trauma Including Anal Sphincter Injury
12.2.2 Levator Injury
12.3 Interventions to Prevent Perineal Trauma (Not Involving the Anal Sphincter)
12.3.1 Antenatal
12.3.1.1 Perineal Massage
12.3.2 Intrapartum
12.3.2.1 Maternal Position During Labour and Birth
12.4 Interventions to Prevent OASI
12.4.1 Antenatal
12.4.1.1 Perineal Massage
12.4.2 Intrapartum
12.4.2.1 Second Stage Perineal Massage
12.4.2.2 Second Stage Perineal Warm Compress
12.4.2.3 Manual Perineal Protection
12.4.2.4 Episiotomy
12.4.2.5 Assisted Vaginal Birth
12.4.2.6 Prediction Models
12.5 Interventions to Prevent Levator Avulsion
12.5.1 Intrapartum
12.5.1.1 Mode of Birth
12.5.1.2 Prediction Models
12.6 Conclusions
Appendix: MCQ
Questions
Answers
References
13: Female Genital Mutilation
13.1 Definition
13.2 Historical Perspective
13.3 Why Is FGM practiced?
13.4 Incidence
13.5 Classification of FGM Types
13.6 Type 3 FGM
13.7 FGM Type 4
13.8 Classification Challenges
13.9 Difficulties Associated with Classification of FGM
13.10 Differential Diagnosis
13.11 Clinical Presentation, Management and Complications
13.12 FGM and Psychological Consequences
13.13 Women with FGM Presenting to a Gynaecological Setting
13.14 Deinfibulation
13.15 Management of Pregnant Women Presenting in a Maternity Setting
13.16 Management of Pregnant Women with Type 3 FGM
13.17 Safeguarding and Law
13.18 Safeguarding
13.19 Conclusion
Appendix: MCQ
Questions
Answers
References
14: Anorectal Pathophysiology and Investigations
14.1 Introduction
14.2 Physiology of Defaecation and Continence
14.3 Pathophysiology of Faecal Incontinence
14.3.1 Anal Canal: Impaired ‘Seal’ Function
14.3.2 Anus and Pelvic Floor: Impaired ‘Barrier’ Structure/Function
14.3.2.1 Structural Damage to the Anal Canal and Pelvic Floor
14.3.2.2 Compromised Anal Canal and Pelvic Floor Function
14.3.2.3 Neurological Injury
14.3.3 Rectum: Impaired ‘Reservoir’ Function
14.3.4 Impaired Evacuatory Function
14.3.5 Sigmoid: Impaired ‘Brake’ Function
14.3.6 Colon: Impaired Motility
14.4 Investigations
14.4.1 Diagnostic Testing
14.4.1.1 Tests of Anorectal Motor and Sensory Function
Anorectal Manometry
Anorectal Sensory Testing
Neurophysiological Tests
Electromyography (EMG)
Pudendal Nerve Terminal Motor Latencies (PNTML)
Contemporary Neurophysiological Investigation
14.4.1.2 Imaging of Anal and Pelvic Floor Structure
Ultrasound
Magnetic Resonance Imaging (MRI)
14.4.1.3 Tests of Evacuatory Function
Direct Tests
Balloon Expulsion Test
Defaecography
Indirect Tests (Manometry and Transperineal/Pelvic Floor Ultrasound)
Manometry
Pelvic Floor Ultrasound
14.4.1.4 Other Tests
14.5 Conclusion
Appendix: MCQ
Questions
Answers
References
15: Anal Sphincter Imaging of Obstetric Trauma
15.1 Introduction
15.2 Three-Dimensional Endoanal Ultrasound (3D EAUS)
15.3 Normal Ultrasound Anatomy
15.4 Endoanal Ultrasound in OASIs
15.4.1 Evaluation of OASIS
15.4.2 Missed Tears
15.4.3 Evaluation After OASI
15.4.4 Management of Subsequent Pregnancy
15.4.5 Selection of Patient for Rehabilitation
15.5 Transperineal Ultrasonography (TPUS) and Introital Ultrasonography (IUS)
15.6 Endovaginal Ultrasonography (EVUS)
15.7 Magnetic Resonance Imaging
15.8 Conclusions
Appendix: MCQ
Questions
Answers
References
16: Obstetric Pelvic Floor Trauma
16.1 Introduction
16.2 Functional Anatomy of the Pelvic Floor
16.3 Definition and Prevalence of Obstetric Pelvic Floor Trauma
16.3.1 Connective Tissue Injury
16.3.2 Nerve Injury
16.4 Diagnosis of Levator Trauma
16.4.1 Diagnosis at Birth
16.4.2 Ultrasound Diagnosis
16.4.3 Magnetic Resonance Imaging Diagnosis
16.5 Repair of Levator Trauma
16.6 Consequences of Levator Trauma
16.7 Conservative Treatment of Women with Levator Trauma
16.7.1 Pelvic Floor Muscle Exercise
16.7.2 Vaginal Pessary Treatment of Pelvic Organ Prolapse
16.8 Surgical Treatment of Women with Levator Trauma and Prolapse
16.9 Prevention of Levator Trauma
16.10 Management of Subsequent Pregnancy and Birth
16.11 Conclusions
Appendix: MCQ
Questions
Answers
References
17: Pelvic Floor and Sphincter Neuropathy After Childbirth
17.1 Introduction
17.2 Pelvic Floor Neuroanatomy
17.2.1 Pudendal Nerve
17.3 Incidence of Pudendal Neuropathy
17.4 Risk Factors
17.4.1 Childbirth Related Pudendal Neuropathy
17.5 Mechanism of Pudendal Nerve Injury
17.6 Other Nerve Injuries in Pregnancy
17.6.1 Levator Ani Syndrome
17.7 Clinical Presentation of Pudendal Neuropathy
17.8 Historical Evaluation of Pelvic Floor Neuropathy
17.9 Non -EDX Diagnosis of Pudendal Neuropathy
17.9.1 Nantes Criteria
17.10 Under-Utilisation of EDX Medicine in Cases of Pelvic Floor and Sphincter Neuropathy
17.11 Normal Physiology or Pathology
17.12 Modern EDX Evaluation of Pudendal Neuropathy After Childbirth
17.13 Kinesiological EMG of Sphincter Muscles
17.14 EDX Test Protocols and Methods for Pudendal Nerve Assessment
17.14.1 Needle EMG of EAS
17.15 The Clitoral Anal Reflex (CAR)
17.15.1 Other EDX Tests for Pelvic Floor Neuropathies
17.16 The Diagnostic Accuracy and Interpretation of the EDX Tests
17.17 Clinical Utility of EDX Assessment of Pelvic Floor and Sphincter Neuropathy Associated with Childbirth
17.18 Emerging Technologies for Pelvic Floor Neuromuscular Medicine
17.18.1 Intra-partum Pudendal Nerve Monitoring
17.19 Conclusion
Appendix: MCQ
Questions
Answers
References
18: Physical Therapy After OASIs
18.1 Introduction
18.1.1 Physical Therapy After OASIS
18.1.1.1 The Repair Phase: Early Recovery within 3 Weeks Postpartum
Management of the Acute Muscular Injury
Physical Therapy and Pelvic Floor Muscle training in the Acute Phase
18.1.1.2 The Subacute Postpartum Recovery Phase: 3–12 Weeks Postpartum
Management of the Subacute Muscular Injury
Physical Therapy and Pelvic Floor Muscle Training in the Subacute Phase
18.1.1.3 Late Postpartum Recovery: 3–12 Months Postpartum
Late Management of a Muscular Injury 3–12 Months Postpartum
Physical Therapy and Pelvic Floor Muscle Training in the Late Postpartum Phase
18.1.1.4 Long-Term Postpartum Recovery– Beyond 12 Months after Delivery
Long-Term Management of a Muscular Injury – From 12 Months Postpartum
Long-Term Postpartum Period – From 12 Months Postpartum
The Long-Term Effect of PFMT and Barriers to Physical Therapy
18.2 Conclusions
Appendix: MCQ
Questions
Answers
References
19: Non-surgical Management of Anal Incontinence
19.1 Introduction
19.2 Prevalence of Anal Incontinence
19.3 Impact of Anal Incontinence on Women
19.4 Lifestyle Aspects that Can Affect Anal Incontinence
19.4.1 Body Mass Index (BMI)
19.4.2 Smoking
19.4.3 Physical Exercise
19.4.4 Assessment
19.5 Conservative Treatments
19.6 Education and Empowerment
19.7 Biofeedback
19.8 Diet and Fluids
19.9 Pelvic Floor Muscle Training
19.10 Defaecatory Dynamics
19.11 Femmeze
19.12 Suppositories
19.13 Low Volume Irrigation
19.14 High Volume Irrigation
19.15 Medication Management
19.16 Posterior Tibial Nerve Stimulation
19.17 Living with Anal Incontinence
19.17.1 Coping Strategies
19.18 Conclusions
Appendix: MCQ
Questions
Answers
References
20: Surgical Management of Anal Incontinence
20.1 Introduction
20.2 Evaluation of a Patient Presenting with Fecal or Anal Incontinence
20.2.1 History
20.2.1.1 Key Points
20.2.2 Investigations (See Chap. 14 and 15)
20.2.3 Treatment
20.3 Sphincteroplasty
20.4 Sacral Neuromodulation
20.5 Injectable Therapies
20.6 Historical Repairs
20.7 Regenerative Medicine
20.8 Stoma Formation
20.8.1 Antegrade Continence Enema
20.8.2 End Stoma
20.9 Conclusions
Appendix: MCQ
Questions
Answers
References
21: Obstetric Rectovaginal Fistulas
21.1 Introduction
21.2 Historical Background
21.3 Incidence
21.4 Classification
21.5 Pathophysiology
21.5.1 Obstetrical Fistulas
21.6 Evaluation
21.7 Surgical Technique
21.8 Outcomes
21.9 Conclusions
Appendix: MCQ
Questions
Answers
References
22: Patient Reported Outcomes After Childbirth
22.1 Introduction
22.2 Patient Reported Outcomes (PRO) and Measures (PROM)
22.2.1 Defining PROMs
22.2.2 Types of PROMs
22.2.3 PROM Validation
22.2.4 Evaluation and Selection of a PROM
22.3 Domains of Patient Reported Outcomes Associated with Childbirth-Related Pelvic Floor Trauma (CBRPFT)
22.4 Commonly Used and Validated PROMs
22.4.1 Bowel Function
22.4.2 Urinary Function
22.4.3 Pelvic Organ Prolapse (POP) and Vaginal Symptoms
22.4.4 Sexual Health
22.4.5 Global Pelvic Floor Dysfunction PROMs
22.4.6 Pain
22.4.7 Birth Experience and Perception of Trauma
22.4.8 Emotional Functioning and Mental Health
22.4.8.1 Post-Traumatic Stress Disorder (PTSD)
22.5 Postpartum Recovery
22.6 Generic Pregnancy and Childbirth-Specific PROMs
22.7 Conclusions
Appendix: MCQ
Questions
Answers
References
23: Education and Training in OASIS
23.1 Introduction
23.2 History of Education in OASI
23.3 Importance of Classification and Repair
23.4 National Guidelines on OASIs
23.5 Training for Doctors
23.6 Training for Midwives
23.7 Training Courses
23.8 Training Models and Resources
23.9 Online Training Programmes
23.10 Colorectal Involvement in the Repair of OASIs
23.11 Conclusion
Appendix: MCQ
Questions
Answers
References
24: Litigation After Pelvic Floor and Anal Sphincter Injuries
24.1 Introduction
24.2 Why Do Patients Bring a Claim?
24.3 What Do Claimants Need to Establish to Obtain Damages?
24.4 Burden & Standard of Proof
24.5 Breach of Duty in Relation to Treatment
24.6 The Montgomery Decision and Informed Consent
24.7 Urgent Situations
24.8 What About More Junior Staff?
24.9 Will a Failure to Identify a Tear Always Establish Breach of Duty?
24.10 Causation
24.11 Quantum
24.11.1 First Head of Claim: Pain, Suffering and Loss of Amenity (“PSLA”)
24.11.2 Second Head of Damages: Special Damages
24.11.2.1 Lost Earnings and Pension Claims
24.12 OASI Claims in Practice
24.13 Midwifery Care and OASI
24.14 Avoiding Litigation while Providing Appropriate Treatment
24.15 Case Law Update and the Updated Situation in the United States
24.16 Conclusions
Appendix: MCQ
Questions
Answers
Index