Case vignette: Four months after spontaneous vaginal delivery, a 34-year-old G4P4 presents with vaginal bulging that interferes with her daily life. With each of her deliveries, she sustained a second-degree laceration, which was repaired.
Diagnosis: Pelvic organ prolapse
Multiple deliveries with spontaneous perineal lacerations have been associated with development of prolapse beyond the hymen.33 Pelvic organ prolapse (POP) surgery is more common in women with a history of both noninstrumented and instrumented vaginal deliveries as compared to women with only cesarean deliveries.34 No preventative strategies have been identified to prevent development of POP. Treatment options are individualized based on a patient’s age, surgical history, and desire for future childbearing. Postpartum pelvic floor muscle training has not been shown to help correct POP.35
Case vignette: A 23-year-old G2P2 presents 1 week postpartum with foul-smelling vaginal discharge and fever. On vaginal examination with speculum, a purulent sponge is found posterior to the cervix and removed with ring forceps.
Diagnosis: Unintended retention of foreign object
When sponges become soaked in blood they can be difficult to identify; the rare complication of unintended retention of foreign object (URFO) is preventable. Retained surgical sponges, needles, or instruments can cause both infection and psychological harm. The average cost related to a URFO is > $200,000, including legal defense, indemnity payments and surgical costs.36 The Minnesota Department of Health reported that in 2006, retained sponges during vaginal delivery were more frequent than all other types of URFOs.37 Findings from an earlier 1996 study also showed that vaginal delivery was the most likely reason for a URFO and in that review, none of the 11 cases of vaginally retained sponges were associated with a sponge count.38
Operating room principles apply to the repair of perineal trauma. These principles include before and after counts of sponges and needles, use of radio-detectable sponges with safety features such as tags, and vaginal examination followed by pelvic radiograph when a retained sponge is suspected.39 Using sponges that are larger, such as 8 inches or 18 inches (mini-laparotomy sponge), rather than the 4×4-inch gauze may also help reduce URFO.37
URFO may also occur if packing is placed for bleeding. When this is done, we recommend placing an arm band on the patient that stays on until the packing is removed. If a foreign body is found, that should be disclosed to the patient as well as to the hospital. The Joint Commission considers URFO a sentinel event and accredited organizations are expected to respond as part of a patient safety program.
Perineal lacerations are common and most resolve without sequelae. Good surgical technique helps prevent URFO and laceration repair should be conducted as any surgical procedure with good lighting, adequate analgesia, and appropriate help and equipment. Rectal examination at the time of vaginal delivery may help prevent missing fourth-degree lacerations. Avoiding routine episiotomy limits perineal trauma, which in turn may limit complications. For women with severe lacerations, including third- and fourth-degree lacerations, postpartum follow-up is important as these patients are at higher risk for FI, pain, and fistulae. Severe complications are rare and providers should be familiar with perineal complications following vaginal delivery.
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