Objective Our aim was to compare two regimens of antibiotic prophylaxis at the time of repair of obstetric anal sphincter injury. Benefit of long regimen of antibiotic prophylaxis in comparison with short regimen of antibiotic administration haven't been till now proven. Material and Methods Women who gave vaginal birth in department of gynaecology and obstetrics of the First Faculty of Medicine of Charles University and Hospital Bulovka from 1.1.2008 to 30.6.2013 and who sustained third - or fourth - degree perineal tears have been enrolled in our trial. All women who fulfilled trial criteria received at the time of repair antibiotic prophylaxis which was cefuroxim (second - generation cephalosporin). This antibiotic has good sensitivity to vaginal gram-positive flora and to rectal gram-negative microorganisms too. Suture technique and following postpartum care have been standardized. All enrolled women were checked 2 weeks and 3 months after delivery. We evaluated subjective and objective parameters of healing of the obstetric perineal injury and 3 months postpartum we looked for symptomps regarding anal incontinence. The Manchester questionnaire was used for evaluation of anal incontince occurance. Results Incidence of third - and fourth - degree perineal tears was 1,4 % during period of our...

Bakgrund: Grad II-bristningar är vanligt förekommande efter vaginal förlossning och kan medföra komplikationer. Svenska myndigheter och föreningar rapporterar brister i eftervården av förlossningsbristningar. Forskning kring kvinnors erfarenheter av eftervård efter uppkommen grad II-bristning är begränsad.  Syfte: Att undersöka kvinnors erfarenhet av eftervård vid uppkommen grad II-bristning. Metod: Strukturerade telefonintervjuer med öppna frågor genomfördes. Femton kvinnor deltog. Intervjumaterialet analyserades med kvalitativ innehållsanalys med induktiv ansats.  Resultat: I resultatet framkommer tre huvudkategorier: ”Stöd postpatum”, ”När eftervården brister” och ”Eftervårdens förändring”. Kvinnornas erfarenheter av eftervården efter uppkommen grad II-bristning är överlag positiva och resultatet visar att eftervården har förbättrats de senaste åren. Kvinnorna tenderar dock att vara otrygga under läkningsprocessen och osäkra på vart de ska vända sig för att få hjälp.  Slutsats: Studiens resultat indikerar att eftervården behöver utvecklas och bygga på bekräftelse och delaktighet. Kvinnorna behöver tydlig information efter uppkommen grad II-bristning eftersom de saknar kunskap. Det finns brister i eftervården under läkningsprocessen och kvinnorna är i behov av en tydlig vårdkedja. Bäckenbottenmottagningen ger kvinnorna en given instans att vända sig till och har en betydande roll i eftervården av grad II-bristningar. / Background: Second degree perineal tears after vaginal childbirth is common and can lead to complications. Swedish authorities and associations report shortage in the postpartum care after perineal trauma. Research about postpartum care after a second degree perineal tear is limited. Aim: To explore women´s experiences of postpartum care in the event of a second degree perineal tear. Method: Data was collected through structured phone interviews with open-ended questions. Fifteen women participated. Inductive qualitative content analysis was applied to the data. Outcome: The result shows three main categories: ”Support postpartum”, ”When aftercare fails” and ”The change of aftercare”. Women’s experiences of post partum care after the onset of a second degree perineal tear are generally positive and the results show that the post partum care has improved in recent years. However, women tend to be insecure during the healing process and unsure of where to turn for help. Conclusion: The results of the study indicate that post partum care needs to be developed and based on confirmation and participation. The women need clear information after the onset of a second degree perineal tear because they lack knowledge. There are shortcomings in the post partum care during the healing process and women are in need of a distinct care chain. The pelvic floor clinic gives women a given instance to turn to and has a significant role in the post partum care of a second degree perineal tear.

Objective Our aim was to compare two regimens of antibiotic prophylaxis at the time of repair of obstetric anal sphincter injury. Benefit of long regimen of antibiotic prophylaxis in comparison with short regimen of antibiotic administration haven't been till now proven. Material and Methods Women who gave vaginal birth in department of gynaecology and obstetrics of the First Faculty of Medicine of Charles University and Hospital Bulovka from 1.1.2008 to 30.6.2013 and who sustained third - or fourth - degree perineal tears have been enrolled in our trial. All women who fulfilled trial criteria received at the time of repair antibiotic prophylaxis which was cefuroxim (second - generation cephalosporin). This antibiotic has good sensitivity to vaginal gram-positive flora and to rectal gram-negative microorganisms too. Suture technique and following postpartum care have been standardized. All enrolled women were checked 2 weeks and 3 months after delivery. We evaluated subjective and objective parameters of healing of the obstetric perineal injury and 3 months postpartum we looked for symptomps regarding anal incontinence. The Manchester questionnaire was used for evaluation of anal incontince occurance. Results Incidence of third - and fourth - degree perineal tears was 1,4 % during period of our...

Obstetric interventions and pelvic floor disorders - Abstract One of the principal objectives of obstetric interventions in the second stage of labor is prevention of pelvic floor trauma and associated pelvic floor disorders. The most commonly used and also most frequently discussed interventions are manual perineal protection and episiotomy. The majority of pelvic floor disorders are of subjective nature. Therefore, tools for objectification and severity quantification of these disorders are the key to reliable comparison and identification of the most effective interventions. The aim of the dissertation was to find the most effective modification of manual perineal protection, to compare two frequently used types of episiotomy regarding all pelvic floor disorders and finally to find a consensus on the most suitable instrument for anal incontinence severity assessment. Our studies concerning manual perineal protection experimentally described the direction and extent of perineal deformation during vaginal delivery. The subsequent studies on biomechanical model demonstrated that the most effective method of manual perineal protection in peak perineal strain reduction is when the fingers are placed on the perineum 6 cm laterally and 2 cm ventrally from the posterior commissure at both sides and are...

Obstetric interventions and pelvic floor disorders - Abstract One of the principal objectives of obstetric interventions in the second stage of labor is prevention of pelvic floor trauma and associated pelvic floor disorders. The most commonly used and also most frequently discussed interventions are manual perineal protection and episiotomy. The majority of pelvic floor disorders are of subjective nature. Therefore, tools for objectification and severity quantification of these disorders are the key to reliable comparison and identification of the most effective interventions. The aim of the dissertation was to find the most effective modification of manual perineal protection, to compare two frequently used types of episiotomy regarding all pelvic floor disorders and finally to find a consensus on the most suitable instrument for anal incontinence severity assessment. Our studies concerning manual perineal protection experimentally described the direction and extent of perineal deformation during vaginal delivery. The subsequent studies on biomechanical model demonstrated that the most effective method of manual perineal protection in peak perineal strain reduction is when the fingers are placed on the perineum 6 cm laterally and 2 cm ventrally from the posterior commissure at both sides and are...

Introduction: Parmi les structures anatomiques impliquées dans les fonctions génitales et urinaires, l’innervation autonome et somatique du rétro-péritoine, du pelvis et du périnée a un rôle contrôle déterminant. Cette innervation reste incomplètement systématisée et elle apparaît vulnérable lors d’interventions chirurgicales ou au cours de maladies neurologiques. Classiquement, deux voies nerveuses se situent de part et d’autre du muscle élévateur de l’anus (MEA) : la voie autonome est supra-lévatorienne ; la voie somatique est infra-lévatorienne. Les nerfs autonomes viennent du plexus hypogastrique supérieur (PHS) (fibres sympathiques) qui se divise en deux nerfs hypogastriques (NHs) s’engageant dans le pelvis. Les NHs reçoivent des nerfs splanchniques pelviens (fibres parasympathiques) qui forment le plexus hypogastrique inférieur (PHI). Les voies somatiques proviennent des nerfs pudendaux. Ces notions établies par la dissection conventionnelle peuvent aujourd’hui être complétées par l’analyse de marqueurs nerveux en Dissection Anatomique Assisté par Ordinateur (DAAO). Celle-ci est susceptible de préciser les connaissances anatomiques et d’éclairer la compréhension des dysfonctions génito-urinaires.Objectifs: L’objectif était de décrire le système nerveux autonome rétro-péritonéal et pelvi-périnéal dans ses aspects morphologiques (origine, topographie, trajet, rapports) et fonctionnels (nature des fibres, terminaisons viscérales) pour mettre en perspective les implications potentielles dans les dysfonctions génito-urinaires.Matériel et méthodes: Des coupes histologiques sériées de 5 µm d’épaisseur ont été effectuées dans les régions lombaire et pelvienne de onze fœtus humains âgés de 14 à 31 semaines de gestation, et au niveau pénien chez cinq sujets anatomiques adultes masculins. Pour chaque niveau de coupe, des lames ont été colorées puis traitées en immunohistochimie pour détecter : l’ensemble des fibres nerveuses (anticorps anti-protéine S100), les fibres nerveuses somatiques (anti-PMP 22), les fibres autonomes adrénergiques (anti-TH), les fibres autonomes cholinergiques (anti-VAChT), les fibres autonomes nitrergiques (anti-nNOS), et les fibres musculaires lisses (anti-actine lisse). Les coupes ont ensuite été numérisées par un scanner de haute résolution optique et les images ont été reconstruites en 3D avec le logiciel Winsurf®.Résultats: Au niveau rétro-péritonéal, le PHS est formé de fibres adrénergiques, cholinergiques et nitrergiques. Ses fibres proviennent à la fois du plexus mésentérique inférieur, des ganglions sympathiques voisins et des nerfs splanchniques lombaires. Au niveau pelvien, le PHI se systématise en : une portion supérieure recevant ses fibres du PHS et innervant détrusor, uretères et vésicales séminales ; une portion inférieure recevant ses fibres des nerfs splanchniques pelviens et innervant trigone, prostate et corps érectiles. La jonction uretéro-vésicale est une zone richement innervée par des fibres adrénergiques, cholinergiques et nitrergiques provenant du PHI et des NHs. En outre, le PHI fournit un contingent nerveux autonome au MEA par voie supra-lévatorienne, tandis que le nerf pudendal (NP) lui fournit un contingent somatique par voie infra-lévatorienne. Au niveau pénien, la composante autonome prédomine dans les 2 tiers proximaux quand, en distalité, l’innervation est presque exclusivement somatique. Trois niveaux de communication entre les voies autonome et somatique ont été observés : pré- trans- et post-lévatorien.Conclusion: L’intrication des voies autonomes et somatiques rétropéritonéo-pelvi-périnéales, la diversité de leurs origines, leurs communications et répartition depuis les plexus jusqu’aux viscères s’établissent par DAAO. Ces voies méritent d’être au mieux préservées au cours d’interventions chirurgicales ou instrumentales. Elles représentent de potentielles voies de modulation, de plasticité ou de régénération à explorer. / Introduction: The autonomous and somatic innervations of the retro-peritoneum, the pelvis and the perineum have a determining control role among the anatomical structures involved in the genital and urinary functions. The innervations remain incompletely systematized and appear vulnerable during surgical procedures or during neurological diseases. Normally, two nerve pathways are located on both side of levator ani muscle (LAM): the autonomic pathway is supra-levatorian and the somatic pathway is infra-Levatorian. The autonomic nerves come from the superior hypogastric plexus (SHP) (sympathetic fibers) which divides into two hypogastric nerves (HNs) engaging in the pelvis. The HNs receive pelvic splanchnic nerves (parasympathetic fibers) which form the inferior hypogastric plexus (IHP). The somatic pathways come from the pudendal nerves. These notions which are established by conventional dissection can now be supplemented by the analysis of nerve markers in computer-assisted anatomic dissection (CAAD). This is likely to clarify anatomical knowledge and illuminate the understanding of genitourinary dysfunction.Objectives: The objective of this study was to describe the retro peritoneal and pelvic -perineal autonomic nervous system, its morphological (origin, topography, path and relationships) and functional (nature of fibers, visceral endings) aspects and to put into perspective the potential implications on genitourinary dysfunction.Materials and methods: Serial histological sections of 5 μm of thickness were performed in the lumbar and pelvic regions of eleven human fetuses aged 14 to 31 weeks of gestation and at the penile level in five male adult anatomical subjects. For each level, slides were stained and then treated in immunohistochemistry to detect: general nerve fibers (anti-protein S100), somatic nerve fibers (anti-peripheral myelin protein 22), autonomic adrenergic fibers (anti-tyrosine hydroxylase), autonomic cholinergic fibers (anti-VAChT), autonomic nitrergic fibers (anti-nNOS), and smooth muscle fibers (anti-actin). The slides were then digitized by a high-resolution optical scanner and the images were reconstructed in 3D using the Winsurf® software.Results: At the retroperitoneal level, the SHP is composed of adrenergic, cholinergic and nitrergic fibers. Its fibers come from inferior mesenteric plexus, the adjacent ganglions and the lumbar splanchnic nerves. At the pelvic level, the IHP is systematized into: a superior portion receiving its fibers of the SHP and innervating detrusor, ureters and seminal vesicles, a inferior portion receiving its fibers from the pelvic splanchnic nerves and innervating trigone of bladder, prostate and erectile bodies. The ureterovesical junction is an area richly innervated by adrenergic, cholinergic and nitrergic fibers from the IHP and the HNs. In addition, the IHP provides an autonomic nervous to the LAM via the supra-levatorian route, while the pudendal nerve provides a infra-levatorian somatic nervous. At the penile level, the autonomic component predominately innervates in the proximal two thirds where, in distal third, the innervation is almost exclusively somatic. Three levels of communications between the autonomic and somatic pathways were observed: pre- trans- and post-levatorian.Conclusions: The interaction of the autonomic and somatic retroperitoneo-pelvic-perineal pathways, the diversity of their origins, their communications and distribution from the plexus to the viscera are established by CAAD. These pathways deserve to be best preserved during surgical or instrumental procedures. They represent potential pathways of modulation, plasticity or regeneration to be explored in future studies.

Knowledge of the course of the pudendal nerve (PN) is important when performing perineal surgery. Distances between landmarks were measured after PN dissections in 71 cadavers and after perineal procedures on 30 cadavers. Separate inferior rectal nerve (IRN) entry and medial position of the PN/IRN with shortened sacrospinous ligaments were often seen in black individuals. A PN block should therefore be placed more proximally and medially. The Richter’s stitch should be placed further from the ischial spine. During ischioanal procedures the IRN is at risk in white females, as it was more superficial. The dorsal nerve of the clitoris/penis (DNC/DNP) is in danger during the outside-in procedures in white or obese individuals, as it was closer to the inferior pubic ramus. The dorsal penile nerve block should be administered deeper in white and obese individuals, as the DNP was deeper. The above-mentioned findings should be verified in a clinical setting. / Dissertation (MSc)--University of Pretoria, 2013. / gm2014 / Anatomy / Unrestricted

Den sexuella hälsan och sexualiteten utgör centrala faktorer i kvinnans livsvärld. Historiskt sett har bilden av kvinnans sexualitet varit belagd med olika tabu vilket ännu idag återspeglas i samhället. Förlossningsbristningar kan leda till fysiska och psykiska konsekvenser som kan påverka kvinnans sexuella hälsa. Barnmorskan kan hjälpa kvinnan till en bättre sexuell hälsa genom att inneha god kunskap om förlossningsbristningar. Stöd och information före och efter förlossning kan bidra till en ökad Känsla av Sammanhang, KASAM, och främja den sexuella hälsan. Caritativt vårdande kan bidra till att lindra lidande samt använda lidandet som motivation till förändring. Förlossningsbristningar kan påverka kvinnans sexuella hälsa och därmed hennes livsvärld. Syftet med studien var att belysa kvinnors upplevelser av hur deras sexuella hälsa har påverkats efter att de drabbats av förlossningsbristningar. Studien utfördes som en kvalitativ intervjustudie med induktiv ansats där 10 kvinnor intervjuades. Resultatet visar att förlossningsbristningar begränsar kvinnors sexuella frihet. Kvinnorna upplevde en försämring av den sexuella hälsan men ibland även en förbättring då nya aspekter av det sexuella livet framtonades. Dock upplevde kvinnorna sig som begränsade även när deras sexuella hälsa förbättrats. Känslor av att vara trasig, smutsig, ha ett påverkat självförtroende, en påverkad relation och/eller svårigheter att träffa någon ny framkom. Sjukgymnastik, tydlig information från vården samt att utforska nya sätt att utöva sexualiteten till exempel med hjälp av sexleksaker och icke-penetrerande sex främjade den sexuella hälsan. Skamkänslor, nonchalans från vårdens sida samt bristande information upplevdes som försämrande faktorer. Det krävs en större öppenhet kring att tala om sexualitet inom vården samt en bättre samordnad och koordinerad vårdkedja i kombination med förbättrad information, utbildning och uppföljning. Sexuella hjälpmedel behöver lyftas och implementeras i vården. Barnmorskeledd utbildning av olika yrkeskategorier i att tala om sexuell hälsa kan vara av stor nytta. / Sexual health and sexuality are central factors in a woman's life world. Historically, the image of women's sexuality has been covered with various taboos, which are still reflected in society today. Perineal tears can lead to physical and psychological consequences that can affect a woman's sexual health. The midwife can help the woman to a better sexual health by having good knowledge about perineal tears. Support and information as well before as after childbirth can help increase the Sense of Coherence, SOC, and promote sexual health. Caritative care can contribute to alleviate suffering and use the suffering to generate motivation for change. Perineal tears can affect a woman's sexual health and thus her life world. The purpose of the study was to describe women's experiences of how their sexual health has been affected after they suffered from perineal tears. The study was conducted as a qualitative interview study with an inductive approach where 10 women were interviewed. The results show that perineal tears caused a limitation to women’s sexual freedom. Women experienced a deterioration in sexual health, but sometimes also an improvement when new aspects of sexual life emerge. However, the women felt restricted regardless of whether their sexual health had improved. Feelings of being broken, dirty and having affected self-confidence, affected relationships and/or difficulties meeting someone new emerged. Physiotherapy, clear information from healthcare and exploring new ways of exercising sexuality, for example with the help of sex toys and non-penetrative sex, promoted sexual health. Feelings of shame and nonchalant treatment from healthcare professionals as well as a lack of information were perceived as limiting. There is a need for greater openness in talking about sexuality in healthcare as well as a better coordinated chain of care in combination with improved information and follow-up. Sexual aids such as sex toys need to be lifted and implemented in care. Midwife-led training of various professional categories in talking about sexual health can be of great benefit.

La presente tesis fue financiada por el Fondo de Investigación Sanitarias del Instituto Carlos III, dependiente del Ministerio de Ciencia e Innovación, con el registro PI09/90257 y el proyecto de investigación titulado "Estudio experimental controlado y aleatorizado para evaluar la efectividad y seguridad del uso de la pelota de parto durante el trabajo del parto y el parto.