Surgical repair of an obstetric cloaca with review of the literature.

A complete perineal wound breakdown of a fourth degree laceration leading to a cloaca is a rare but devastating complication of vaginal childbirth. A 32-year-old primiparous woman presented with an obstetric cloaca 4 months following delivery. She underwent preoperative evaluation and, following extensive counselling, elected to proceed with operative repair. The procedure is presented in 15 well-defined steps with photos. The repair was performed in standard fashion with three supplementary steps. These included: (1) division of the rectovaginal tissue into three distinct layers; (2) attachment of these layers individually to the reconstructed perineal body and sphincter and (3) incorporation of the levator muscles into the repair. The wound healed well within 6 weeks of repair. Now 3½ years postoperatively, the patient has no faecal incontinence or sexual dysfunction and only minimal defecatory dysfunction. The discussion describes our surgical approach in the context of a review of the literature.

Evidence-based interventions to reduce obstetric-related infections at an army training facility.

BACKGROUND: OBJECTIVE: Obstetric-related infections are a major cause of maternal morbidity and mortality worldwide. Our team implemented an evidence-based infection control bundle aimed at reducing obstetric-related infections at our facility. METHODS: A multidisciplinary team at Tripler Army Medical Center developed, implemented, and evaluated an evidence-based maternal safety infection control bundle (MSICB) on labor and delivery aimed at reducing the incidence of surgical site infections (SSI) and chorioamnionitis. Adenosine triphosphate testing of patient care-related surfaces was performed while behavioral and environmental interventions were implemented. Incidence rates for chorioamnionitis, SSI, and endometritis were compared between pre- and during-MSICB implementation using Fisher exact test and Poisson regression, adjusting for year and quarter. The decision science analysts at US Army Medical Command, Fort Sam Houston, Texas responsible for our facility utilized diagnosis-related group and ICD-10 Procedure Coding to determine infection-related costs. RESULTS: Prior to implementation of the MSICB, the rates of chorioamnionitis, SSI, and endometritis in the first half of 2016 were 6.3%, 3.4%, and 0.4%, respectively. After implementation of the MSICB, in the first 6 months of 2017, the rates of chorioamnionitis and SSI decreased to 1.7% and 1.0%, respectively, with no change in the rate of endometritis. The rate was significantly lower after implementation for chorioamnionitis (P < .001), and there was a statistically nonsignificant decrease for SSI (P = .060) and no difference for postpartum endometritis (P = 1.00). These reductions resulted in an estimated net cost savings of $671,218. CONCLUSIONS: A multidisciplinary approach with evidence-based strategies resulted in a significant decrease (P < .001) in chorioamnionitis and a statistically nonsignificant decrease (P = .060) in the SSI rate, which resulted in a significant cost savings for the hospital. There was no change in our postpartum endometritis rate.