![]() Clinical Implications of Basic Neuroscience.Challenges in Clinical Electrocardiography. ![]() The following variables were adjusted for in the model: type of insurance, race, maternal age, year of delivery, primiparity, obstetric comorbidity index score, marital status, rural vs urban location, hospital teaching status, hospital bed size, geographic region, precipitous labor, prolonged second stage, other labor abnormalities, induction of labor, fetopelvic disproportion, suspected macrosomia, postdates pregnancy, placental abruption, pregestational diabetes, gestational diabetes, maternal congenital cardiac disease, other maternal cardiovascular disease, human immunodeficiency virus, obesity, gestational hypertension, mild or unspecified preeclampsia, and severe preeclampsia or eclampsia. There were 510 hospitals included in the analysis. Each vertical line parallel to the y-axis represents an individual hospital with 95% CI in the adjusted model after accounting for hospital factors, medical and demographic variables, and labor diagnoses. ![]() 6 Risk factors for OASIs based on a meta-analysis of 22 studies are described in Table 62-2.Hospitals are arranged from lowest to highest rates of episiotomy along the x-axis. 5 Unfortunately, OASIs are sometimes unavoidable, with estimates of third- and fourth-degree lacerations complicating 3.3% and 1.1% of vaginal deliveries, respectively. 4 Furthermore, evidence suggests that the severity of the perineal tear directly affects the frequency of loss of anal continence, with women who sustained a fourth-degree laceration reporting decreased control of their bowels 10 times more frequently than those who sustained a third-degree laceration (30.8% vs. Third- and fourth-degree perineal lacerations, also known as obstetric anal sphincter injuries (OASIS), have been associated with dramatically increased rates of anal incontinence 5 to 10 years after delivery compared with a cesarean control group. Injury to the perineum during vaginal delivery can be classified into four degrees of laceration, 3 as described in Table 62-1 and demonstrated in Fig. The aim of this chapter is to provide an overview of current best practices related to both episiotomy and perineal laceration repair. The roles of the OB/GYN hospitalist as an expert physician in difficult or emergent deliveries and as a leader in perinatal quality and safety necessitate familiarity with current recommendations in both complex laceration repair and the use of episiotomy. For reasons that will be explored in detail later in this chapter, routine episiotomy has fallen out of favor, but the procedure is still an important tool in the obstetric and gynecological (OB/GYN) hospitalist’s arsenal. 1 Episiotomy, more precisely termed perineotomy, refers to the enlargement of the distal birth canal via incision of the perineum in order to facilitate delivery of the fetus. This fact, along with other theoretical benefits, led to the popularization of routine episiotomy in the United States in the 1920s and 1930s. ![]() The risk of complications associated with perineal lacerations increases dramatically with the increased levels of anatomy affected. Laceration of the perineum may occur with any vaginal delivery, and it is so common that repair of such lacerations is considered a routine part of immediate postpartum care.
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