Intrapartum ultrasonographic assessment of foetal occiput position a comparison with transvaginal digital examination during the second stage of labor

To compare between digital vaginal examination [DVE], transabdominal sonography [TAS] and transvaginal sonography [TVS] as regards accuracy and time requirements for determination of foetal occiput position during the second stage of labor. Prospective randomized blinded study. 120 laboring patients in the second stage of labor. An informed consent was obtained. A detailed sterile digital vaginal examination was performed immediately before transabdominal and transvaginal examinations. Each sonographer was blinded to the finding of the other as well as to the DVE finding. The findings of digital and ultrasonic examinations were compared with the actual position of the vertex, as determined by direct visualization at vaginal delivery after spontaneous restitution of the foetal head or at cesarean delivery. The foetal head position was assessed by determining the foetal occiput as "the time on a 12-hour clock" into eight categories. The findings of DVE and TAS were considered to be correct if the foetal occiput position was within +/- 45° of TVS finding. The time required by the three methods was recorded. Sensitivity, specificity and diagnostic accuracy of DVE, TAS, combined DVE and TAS and TVS [gold standard] in the determination of the foetal head positions in the second stage of labor were calculated. TVS diagnosed correctly the foetal head position in all cases [100% accuracy] when compared with the actual foetal head position at delivery and thus was considered as the gold standard. The accuracy of DVE in determining foetal head position in the second stage of labor was 72%, being higher for occiput anterior positions. DVE was inaccurate in 26.7% of cases, the majority of which were in occiput posterior positions and was unable to determine 5% of cases. The accuracy of TAS in diagnosing the foetal head position was 80.5%. TAS was inaccurate in 9.16% of cases, the majority of which were in the occiput anterior positions and was unable to determine 4.16% of cases. The accuracy of TVS was significantly higher than DVE and TAS [P= 0.001]. However, combining DVE and TAS increased the sensitivity and diagnostic accuracy than using either alone. The time required for determining foetal head position was significantly shortest for TVS in comparison to TAS or DVE [8.17 +/- 2.15 vs 29.4 +/- 2.81 or 22.27 +/- 3.59 seconds, P= 0.0001]. Transvaginal sonography is the preferred imaging method for the determination of foetal head position in the second stage of labor. However, combining DVE and TAS was more accurate in the assessment of the foetal head position than using either alone and can be used as an alternative to TVS

Successful repair of chronic unhealed rectovaginal septal defect with proper methodical retrieval and repair of the sphincter ani externus

The repair of chronic unhealed rectovaginal septal defect is a problem tackled only by the expert gynaecologic surgeon. Proper preoperative, operative and postoperative measures include vaginal antiseptics, preoperative treatment of any cervicitis, as well as, broad spectrum antibiotics. Postoperative laxatives are a must to keep the stools soft. The surgeon can choose between one of two methods of repair, either dissection at the junction of vagina and rectum or the vaginal flap reflection off the rectal wall. The Levator ani and sphincter ani externus are exposed and repaired ending by building up a perineal body. Over the past 10 years, the author has performed 18 surgical repairs for such perineal tears. Simple as it looks, yet breakdown of the repair may occur. As described in the control group [group 1]. The anal external sphincter, may evade recognition or repair without undue tension. Failure to repair the sphincter ani externus or breakdown of its repair will result in persistence of flatus and loose stool incontinence, a highly embarrasing inconvenience, especially so in the refined and socially conscious lady. For the past 4 years the author has been following a technique for the repair of chronic unhealed complete perineal tears introduced in the early seventies and described in 1978. The sphincter ani externus is properly traced, retrieved, mobilized and sutured without undue tension. The ten cases repaired by the direct dissection between the anorectal canal and vagina, augmented by the method to be shortly described Azab's techinque resulted in complete continence of flatus, soft and hard stools

Packing of the lower uterine segment, following the seperation of theplacenta praevia due to uncontrollled haemorrhage from the opensinuses of the lower uterine segment

In the current obstetric practice, cases of placenta praevia suffering from hemorrhage at term pregnancy or with fetalmaturity, elective lower segment caesarean section is the best treatment.Cases of placenta praevia early in labor with moderate or sever bleeding should be treated by immediate were segment caesarean section.The separation of the praevia placenta may be followed by sever hemorrhage from the open sinuses of the loweruterine segment The treatment followed by us in the last 18 of such cases was firm compression of these sinuses bywarm saline soaked towel for sometime till the ooze stops with clotting of the sinuses. If that measure failed, which itdid in 14 of these cases of sever hemorrhage tight packing of the uterus, particularly the lower uterine segment, theredundant reformed cervix, vaginal fornices and canal, with counter pressure against a vagino- perineal pad. Thatprocedure succeeded in 13 out of these 14 cases, the remaining case was operated upon by subtotal abdominalhysterectomy