CTS: Labour, delivery, pudendal analgesia, episiotomy, uterine

prolapse

Case 1
A 31 year old woman during the second stage of labour required a medio-lateral episiotomy to
avoid tearing of the perineum. She was given a pudendal nerve block.

1. Which part of the perineum is being cut?
Genitourinary triangle (anterior) separated from anal triangle (posterior) by an
imaginary line between the two ischial tuberosities. (anal triangle)
2. How would the obstetrician locate the pudendal nerve in order to inject local
anaesthetic around it?
Transvaginal method. Before injecting, pull the syringe back. If you extract blood on
pulling back, poke in a different direction because you would have infiltrated an
artery.
3. What parts of the perineum would be anaesthetised by this block?
Clitoris, anal sphincter, levator ani
4. Assuming that the patient suffers a midline tear before the episiotomy can be
performed, which structure is likely to be affected? What muscles are attached here?
What complications might arise if the tear is extended?
Perineal body, perineal and levator ani muscles, anal canal (can causes fecal
incontinence), overlying skin
Case 2
A 28 year old woman receives an epidural anaesthetic during childbirth.
1. Where is the epidural space and what does it contain?
Outside dura mater; contains lympahtics, spinal nerve roots, fat, small arteries,
epidural venous plexus
2. How does the operator know that the epidural space has been reached?
3. Assuming an epidural block at the L3/L4 level what anaesthesia would you expect?
Lateral femoral cutaneous (L2,L3), femoral L2-L4, obturator (L2-L4) all blocked
4. How is epidural anaesthesia administered? How is the height of the epidural block
monitored?
Feel the iliac crests and imagine a horizontal line running between the crests; this level
is the level of the epidural space of L3. Below this level is the space between L3 and L4
5. What is the nerve supply of the uterus? Given this innervation, how would an epidural
work?
Uterovaginal plexus from inferior hypogastric plexus
T12-L1 carries the pain of uterine contractions in childbirth. After giving the injection, you
must change the position of the patient make them head down, feet up, so that the
anaesthetic injected at L3-L4 moves by gravity to T12-L1.
Clinical importance of fat in the epidural space- fat can interfere with the spread of the
anaesthetic. Nb. The epidural space is outside the spinal canal at all levels of the spinal cord.
6. What are the advantages and disadvantages of epidurals?
Advantage- easy way of blocking uterine pain
Disadvantage- since T12-L1 has been paralysed, her bladder will fill up, and the
bladder may block the head of the baby coming out, so therefore you must make a
urinary catheter.

Useful notes:
Stages of labor-1. Regular uterine contractions; ends when cervix is fully dilated
2. stronger contractions up to and including delivery of the baby
3. from delivery of baby to delivery of placenta

Epidural anaesthesia is maintained for c. 12 hours during labor by a catheter
connected to a pump which continually passes anaesthetic agent to the woman.
Case 3
A 50 year old mother of 3 presents with a 6 month history of feeling as if something has come
down. She also has pelvic discomfort increasing by the end of the day especially if she strains
and lifts heavy loads. Her back aches most evenings. She also complains of frequency and
occasionally also burning on urination. Her periods are heavier than they used to be but are still
regular. She has no hot flushes or sweating at night. On pelvic examination there is a bulging of
the anterior vaginal wall that increases on straining. A diagnosis of second degree uterine
prolapse and cystocele is made. After counseling, she agrees to a vaginal hysterectomy and
repair.
1. What is the normal position of the uterus?
2. In what direction does the ostium of the cervix face if the uterus is in its typical position?
3. How do you explain the patients discomfort including heaviness in the lower abdomen
and back?
4. How do you explain the urinary symptoms?
5. What is the cause of the uterine prolapse and the cystocoele?
6. What and where are the cardinal ligaments?
7. What important structures are endangered when the cardinal ligaments are shortened?
8. What position would you expect the patient to be placed in to perform a vaginal
hysterectomy?
9. After removing the uterus through the vagina, what would need to be done surgically to
support the apex of the vagina and repair the prolapse?