2021年2月2日星期二

preparation h hemorrhoids,Correct understanding of prenatal episiotomy

    Episiotomy (episiotomy) is one of the simplest, commonly used and effective procedures in obstetrics. The department will cut the vagina to make the fetus easier to deliver, and avoid excessive stretching or tearing of the soft tissues of the perineal pelvic floor, which may cause pelvic floor relaxation syndrome in the future.

    There are three incision methods: oblique perineum incision, midline incision, and lateral incision. The first two are commonly used. Lateral oblique incision will not involve the rectum due to the lengthening of the incision, but more tissues need to be cut, and there will be more bleeding, and the tissue will swell and pain after suture. The median incision is less tissue, less bleeding, easy to fit, and less pain after surgery. The disadvantage is that rectal injury may occur. The former has more clinical applications.

    【Indications】

    1. It is estimated that perineal laceration is inevitable, such as the perineal body is too long, too short and poorly stretched (perineal toughness, tightness, edema or scar formation, etc.), vaginal bleeding before delivery of the fetal head, persistent posterior occipital position, fetal head Larger, narrow or low pubic arch, etc.

    2. Primipara requires vaginal delivery, such as forceps, fetal head suction and full-term breech delivery.

    3. Maternal or fetal conditions need to shorten the second stage of labor, such as prolonged labor, uterine contractions, mild cephalopelvic disproportion, fetal distress, pregnancy-induced hypertension, and heart disease.

    4. Avoid excessive resistance and prevent intracranial hemorrhage, such as giant babies, premature babies, and fetal growth restriction.

    5. Occasionally used in transvaginal surgery to expand the surgical field of vision.

    【Contraindications】

    1. People who have pelvic abnormalities or disproportionate head and pelvis who cannot deliver vaginally.

    2. Those who have genital herpes, condyloma acuminatum, etc. who are not suitable for vaginal delivery.

    3. In the previous delivery, the perineum is intact or the incision is healed well, generally, no incision is required.

    4. Stillbirths and non-surviving teratogenesis should not be incised as far as possible.

    5. There is a bleeding tendency that is difficult to control.

    【Position】

    The parturient takes the supine knee bent position or the bladder lithotomy position. Routinely disinfect the vulva, catheterize, and spread sterile towels.

    【anesthesia】

    Adopt pudendal nerve block and local infiltration anesthesia. Block anesthesia, including pain relief and relaxation of pelvic floor muscles. Operation steps: The surgeon puts one hand and two index fingers into the vagina to touch the ischial spine as a guide, and the other hand holds a syringe with a long needle containing 20ml of 0.5%-1% procaine, or 0.5% lidocaine 5~10ml. Insert the needle at the midpoint of the connection between the anus and the ischial tuberosity (2cm inside the ischial tuberosity), first subcutaneously inject a skin mound, pierce the needle to the pudendal nerve passing through the tip of the sciatic spine, draw back without blood, and inject the medicine Liquid 1/2, block the pudendal nerve. Then return the needle to the subcutaneous area, and perform fan injections along the labia and perineum of the incision side. If you are preparing for vaginal delivery, you should perform the same block anesthesia on the opposite side to relax the pelvic floor muscles better. In the case of a midline incision, local infiltration anesthesia is performed on the perineal body. Be careful not to inject the liquid into the blood vessel or rectum.

    【Surgery method and procedure】

    (1) Oblique incision of the perineum can be performed on either left or right. In clinical practice, oblique incision on the left is more common.

    1. The incision operator uses the left hand and index finger to extend between the vagina and the presenting part, prop up the left vaginal wall, and hold the perineal incision scissors or blunt-ended straight scissors in the right hand. One leaf is placed in the vagina and the other leaf is placed Outside the vagina, press the scissors to cut the line and the post-perineum joint midline and place it at a 45° angle to the side. Under the guidance of the left hand, cut the full thickness of the vagina by 4 to 5 cm (including vaginal mucosa, hymen, and scaphoid). Fossa, skin, subcutaneous tissue, bulbocavernosum muscle, superficial transversus perineum, deep transversus perineum, inner fiber of levator ani muscle).

    Precautions:

    (1) The incision time should be 5 to 10 minutes before the fetus is delivered when the fetal head has been crowned and the perineum becomes thin at the beginning of contraction. Premature wounds lose a lot of blood and increase the chance of infection; the perineum has been torn after cutting and loses its protective significance.

    (2) The scissors should be placed perpendicular to the skin, and the size of the skin and mucosal incision should be the same.

    (3) If the perineum is highly swollen, the oblique angle should be about 60°-70°, otherwise the rectum may be injured or suture difficult due to the small angle.

    (4) Press gauze to stop bleeding immediately after incision, and clamp and ligate to stop bleeding if small arteries are bleeding.

    2. Suture Before suturing, the placenta and fetal membranes should be completely delivered. Check other parts for lacerations, and then insert gauze into the upper part of the vagina to prevent blood flow down the uterine cavity, so as not to hinder the surgical vision. After washing the wound with metronidazole, suture it in different levels.

    (1) Suture the vaginal mucosa: use the left hand and index finger to open the vaginal wall, expose the top of the vaginal mucosa incision and the entire incision, use 2-0 absorbable thread, start from 0.5-1cm above the top of the incision, intermittently or continuously suture the vaginal mucosa And submucosal tissues, directly outside the hymen ring. Pay attention to align the wound edge with the hymen as a mark, and leave no dead space.

    (2) Suture the muscle layer (levator ani muscle): Suture the muscle layer intermittently with the same thread to close the dead space to achieve hemostasis. The suture needles should not be too dense, the muscular layer incision edge should be aligned and sutured, the lower musculature of the incision will often be slightly staggered downwards, and the alignment should be pulled to restore the anatomical relationship. Be careful not to sew through the rectum when sewing the deep inside.

    (3) Suture subcutaneous and skin tissue: Intermittent suture of subcutaneous fat and skin with No. 1 silk thread. Or continuous intradermal suture with 4-0 absorbable thread, no stitch removal.

    Note that the stitches should not be too dense, and the stitches should not be too tight, so as to prevent the stitches from embedding in the tissue after tissue edema, which may affect wound healing or cause difficulty in stitch removal.

    (2) Median perineal incision and suture

    The advantage is that the damaged tissue is less than the oblique incision, less bleeding, easy suture, better healing, and less postoperative pain; the disadvantage is that if the incision extends downward, it may damage the anal sphincter and even the anal canal, resulting in a perineal Ⅲ° laceration. Therefore, it is not suitable for those who assist in delivery, large fetus or unskilled delivery technology.

    1. After incision and local infiltration anesthesia, make a vertical incision along the midpoint of the posterior perineum to the anus, about 2 to 3 cm in length. The cut tissues are the mucosa of the posterior vaginal wall, the skin and subcutaneous tissue of the perineal body, and the central tendon of the perineum. Be careful not to damage the anal sphincter.

    2. Stitching

    (1) Suture the vaginal mucosa: intermittently suture the vaginal mucosa and submucosa. Do not penetrate the rectal mucosa. If necessary, place a finger in the anus for guidance.

    (2) Suture subcutaneous fat and skin: Suture subcutaneous tissue and skin intermittently, or use absorbable thread for continuous intradermal suture without removing the suture.

    (3) Post-suturing treatment

    Take out the tuck in the vagina and carefully check the suture for bleeding or hematoma. Make sure that the orifice of the hymen ring is not less than two transverse fingers, and there is no suture penetrating the rectal mucosa during routine anal examination. If so, it should be removed immediately and re-sterilized and sutured.

    【Postoperative care】

    1. Keep the vulva clean and advocate lying on the healthy side. Within 5 days after the operation, scrub the vulva with iodophor cotton ball twice a day; after every bowel movement, scrub the vulva; change the vulva pad frequently.

    2. For patients with obvious edema and pain in the vulvar wound, within 24 hours, use 95% alcohol wet compress or cold compress, after 24 hours, use 50% magnesium sulfate gauze wet or hot compress, or perform ultrashort wave or infrared radiation, once a day, each time 15 minutes. The suture was removed 5 days after the operation.

    3. Check the incision every day after the operation. If infection and suppuration are found, the suture should be removed immediately, and the wound should be thoroughly debrided, drained, and dressing changed.

    4. If the incision is dehisced, the sinus tract should be widened, and the local area should be cleaned. After the granulation has grown, a secondary suture should be performed. The secondary repair of episiotomy can be performed under sacral anesthesia, pudendal nerve block or local anesthesia. First trim the edges of the wound neatly and gently scrape the granulation surface to create a rough surface. The mucous membrane is sutured with 1-0 absorbable thread intermittently, the skin, subcutaneous and muscle are interrupted by the 7th silk thread, and the exposed line can be passed through a thin skin tube to protect the skin. 5-7d stitches are removed.

    In recent years, with the continuous improvement of suture technology and suture materials, the clinical episiotomy rate has increased significantly. A foreign study found that although the episotomy has no effect on female sexual arousal and orgasm, more pain during intercourse and vaginal lubrication will occur within 12-18 months after delivery. In addition, since the incidence of incision dehiscence after episiotomy and suture is not very low in clinical practice, the operation must strictly grasp the indications, and the surgeon must be skilled in midwifery technology. It must not be used as a routine operation.

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