UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

会阴切开术方法概述

Author
Julian N Robinson, MD
Section Editor
Charles J Lockwood, MD, MHCM
Deputy Editor
Kristen Eckler, MD, FACOG
Translators
郭毅, 主任医师，教授

引言

会阴切开术是指分娩时由产科医生进行的女性会阴部外科切开术。在胎头即将着冠之前、会阴拉伸扩张之际，通常用剪刀将其切开。其目的是增加软组织骨盆出口的直径，从而避免会阴撕裂伤，辅助分娩，并缩短胎儿娩出时间。

会阴切开术的施行率

会阴切开术是女性最常见的手术之一[1]。产科实践随时代的变化趋势已经影响了人们对会阴切开术的实施决策，致使这一手术的施行率逐渐降低(1979年时60.9%的阴道分娩会实施会阴切开术，而2004年时该比例降为24.5%)[2]。会阴切开术在拉丁美洲的施行率最高[3]，而在欧洲则较低，报告的施行率变化范围很大，从1%(瑞典)到80%(阿根廷)[4,5]。

是否施行会阴切开术似乎受产科医生类型的影响，具体来说，私营诊所医生和学术教学医院中的医生比助产士更有可能使用这种手术(分别是后者的4倍和2倍)[6-8]。母亲的体位、产次及硬膜外麻醉的使用情况似乎也在会阴切开术的决策中起了一定作用。上半身直立或侧卧位的母体分娩姿势比仰卧位或截石位更少进行会阴切开术[9]，而硬膜外麻醉和初产可能会增加会阴切开术的施行率[6,10,11]。阴道助产比阴道自然分娩更常应用会阴切开术(71% vs 33%)[1]。

会阴切开术的理论根据

会阴切开术的可能获益包括[3,12]：

  • 减少Ⅲ、Ⅳ度撕裂伤
  • 易于修复并改善切口愈合
  • 保留盆底肌肉和筋膜的支持作用
  • 减少新生儿创伤，例如早产儿(颅骨较软)或巨大儿(肩难产)的创伤
  • 通过增加软组织盆腔出口的直径，从而减少难产
  • 对胎心率监护图形不良的胎儿加速娩出

                 

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: 2017-06 . | This topic last updated: 2017-03-03.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
References
Top
  1. Weber AM, Meyn L. Episiotomy use in the United States, 1979-1997. Obstet Gynecol 2002; 100:1177.
  2. Frankman EA, Wang L, Bunker CH, Lowder JL. Episiotomy in the United States: has anything changed? Am J Obstet Gynecol 2009; 200:573.e1.
  3. Carroli G, Belizan J. Episiotomy for vaginal birth. Cochrane Database Syst Rev 2000; :CD000081.
  4. Röckner G, Fianu-Jonasson A. Changed pattern in the use of episiotomy in Sweden. Br J Obstet Gynaecol 1999; 106:95.
  5. Routine vs selective episiotomy: a randomised controlled trial. Argentine Episiotomy Trial Collaborative Group. Lancet 1993; 342:1517.
  6. Robinson JN, Norwitz ER, Cohen AP, Lieberman E. Predictors of episiotomy use at first spontaneous vaginal delivery. Obstet Gynecol 2000; 96:214.
  7. Gerrits DD, Brand R, Gravenhorst JB. The use of an episiotomy in relation to the professional education of the delivery attendant. Eur J Obstet Gynecol Reprod Biol 1994; 56:103.
  8. Howden NL, Weber AM, Meyn LA. Episiotomy use among residents and faculty compared with private practitioners. Obstet Gynecol 2004; 103:114.
  9. Gupta JK, Hofmeyr GJ, Shehmar M. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database Syst Rev 2012; :CD002006.
  10. Newman MG, Lindsay MK, Graves W. The effect of epidural analgesia on rates of episiotomy use and episiotomy extension in an inner-city hospital. J Matern Fetal Med 2001; 10:97.
  11. Hueston WJ. Factors associated with the use of episiotomy during vaginal delivery. Obstet Gynecol 1996; 87:1001.
  12. American College of Obstetricians-Gynecologists. ACOG Practice Bulletin. Episiotomy. Clinical Management Guidelines for Obstetrician-Gynecologists. Number 71, April 2006. Obstet Gynecol 2006; 107:957.
  13. Räisänen S, Vehviläinen-Julkunen K, Gissler M, Heinonen S. Hospital-based lateral episiotomy and obstetric anal sphincter injury rates: a retrospective population-based register study. Am J Obstet Gynecol 2012; 206:347.e1.
  14. Bottoms S. Delivery of the premature infant. Clin Obstet Gynecol 1995; 38:780.
  15. Eason E, Labrecque M, Wells G, Feldman P. Preventing perineal trauma during childbirth: a systematic review. Obstet Gynecol 2000; 95:464.
  16. Macarthur AJ, Macarthur C. Incidence, severity, and determinants of perineal pain after vaginal delivery: a prospective cohort study. Am J Obstet Gynecol 2004; 191:1199.
  17. Signorello LB, Harlow BL, Chekos AK, Repke JT. Postpartum sexual functioning and its relationship to perineal trauma: a retrospective cohort study of primiparous women. Am J Obstet Gynecol 2001; 184:881.
  18. Klein MC, Gauthier RJ, Robbins JM, et al. Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation. Am J Obstet Gynecol 1994; 171:591.
  19. Sartore A, De Seta F, Maso G, et al. The effects of mediolateral episiotomy on pelvic floor function after vaginal delivery. Obstet Gynecol 2004; 103:669.
  20. Sleep J, Grant A, Garcia J, et al. West Berkshire perineal management trial. Br Med J (Clin Res Ed) 1984; 289:587.
  21. Thranov I, Kringelbach AM, Melchior E, et al. Postpartum symptoms. Episiotomy or tear at vaginal delivery. Acta Obstet Gynecol Scand 1990; 69:11.
  22. Sleep J, Grant A. West Berkshire perineal management trial: three year follow up. Br Med J (Clin Res Ed) 1987; 295:749.
  23. Fleming N, Newton ER, Roberts J. Changes in postpartum perineal muscle function in women with and without episiotomies. J Midwifery Womens Health 2003; 48:53.
  24. Röckner G, Jonasson A, Olund A. The effect of mediolateral episiotomy at delivery on pelvic floor muscle strength evaluated with vaginal cones. Acta Obstet Gynecol Scand 1991; 70:51.
  25. Handa VL, Blomquist JL, McDermott KC, et al. Pelvic floor disorders after vaginal birth: effect of episiotomy, perineal laceration, and operative birth. Obstet Gynecol 2012; 119:233.
  26. Hartmann K, Viswanathan M, Palmieri R, et al. Outcomes of routine episiotomy: a systematic review. JAMA 2005; 293:2141.
  27. Fritel X, Schaal JP, Fauconnier A, et al. Pelvic floor disorders 4 years after first delivery: a comparative study of restrictive versus systematic episiotomy. BJOG 2008; 115:247.
  28. Borghi J, Fox-Rushby J, Bergel E, et al. The cost-effectiveness of routine versus restrictive episiotomy in Argentina. Am J Obstet Gynecol 2002; 186:221.
  29. Faruel-Fosse H, Vendittelli F. [Can we reduce the episotomy rate?]. J Gynecol Obstet Biol Reprod (Paris) 2006; 35:1S68.
  30. Royal College of Obstetricians and Gynaecologists. Green-top guideline No. 29: The management of third- and fourth-degree perineal tears, 2007. https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg29/ (Accessed on September 26, 2016).
  31. Kalis V, Laine K, de Leeuw JW, et al. Classification of episiotomy: towards a standardisation of terminology. BJOG 2012; 119:522.
  32. Stedenfeldt M, Pirhonen J, Blix E, et al. Episiotomy characteristics and risks for obstetric anal sphincter injuries: a case-control study. BJOG 2012; 119:724.
  33. Coats PM, Chan KK, Wilkins M, Beard RJ. A comparison between midline and mediolateral episiotomies. Br J Obstet Gynaecol 1980; 87:408.
  34. Shiono P, Klebanoff MA, Carey JC. Midline episiotomies: more harm than good? Obstet Gynecol 1990; 75:765.
  35. Labrecque M, Baillargeon L, Dallaire M, et al. Association between median episiotomy and severe perineal lacerations in primiparous women. CMAJ 1997; 156:797.
  36. Helwig JT, Thorp JM Jr, Bowes WA Jr. Does midline episiotomy increase the risk of third- and fourth-degree lacerations in operative vaginal deliveries? Obstet Gynecol 1993; 82:276.
  37. Robinson JN, Norwitz ER, Cohen AP, et al. Episiotomy, operative vaginal delivery, and significant perinatal trauma in nulliparous women. Am J Obstet Gynecol 1999; 181:1180.
  38. KALTREIDER DF, DIXON DM. A study of 710 complete lacerations following central episiotomy. South Med J 1948; 41:814.
  39. Harris RE. An evaluation of the median episiotomy. Am J Obstet Gynecol 1970; 106:660.
  40. Beynon CL. Midline episiotomy as a routine procedure. J Obstet Gynaecol Br Commonw 1974; 81:126.
  41. Eogan M, Daly L, O'Connell PR, O'Herlihy C. Does the angle of episiotomy affect the incidence of anal sphincter injury? BJOG 2006; 113:190.
  42. Legino LJ, Woods MP, Rayburn WF, McGoogan LS. Third- and fourth-degree perineal tears. 50 year's experience at a university hospital. J Reprod Med 1988; 33:423.
  43. Poen AC, Felt-Bersma RJ, Dekker GA, et al. Third degree obstetric perineal tears: risk factors and the preventive role of mediolateral episiotomy. Br J Obstet Gynaecol 1997; 104:563.
  44. Anthony S, Buitendijk SE, Zondervan KT, et al. Episiotomies and the occurrence of severe perineal lacerations. Br J Obstet Gynaecol 1994; 101:1064.
  45. de Vogel J, van der Leeuw-van Beek A, Gietelink D, et al. The effect of a mediolateral episiotomy during operative vaginal delivery on the risk of developing obstetrical anal sphincter injuries. Am J Obstet Gynecol 2012; 206:404.e1.
  46. de Leeuw JW, de Wit C, Kuijken JP, Bruinse HW. Mediolateral episiotomy reduces the risk for anal sphincter injury during operative vaginal delivery. BJOG 2008; 115:104.
  47. Stones RW, Paterson CM, Saunders NJ. Risk factors for major obstetric haemorrhage. Eur J Obstet Gynecol Reprod Biol 1993; 48:15.
  48. Combs CA, Murphy EL, Laros RK Jr. Factors associated with postpartum hemorrhage with vaginal birth. Obstet Gynecol 1991; 77:69.
  49. May JL. Modified median episiotomy minimizes the risk of third-degree tears. Obstet Gynecol 1994; 83:156.
  50. Owen, J, Hauth, JC. Episiotomy infection and dehiscence. In: Gilstrap, LC III, Faro, S (eds) Infections in Pregnancy, Alan R Liss, New York 1990.
  51. Hudelist G, Gelle'n J, Singer C, et al. Factors predicting severe perineal trauma during childbirth: role of forceps delivery routinely combined with mediolateral episiotomy. Am J Obstet Gynecol 2005; 192:875.
  52. Jones KD. Incidence and risk factors for third degree perineal tears. Int J Gynaecol Obstet 2000; 71:227.
  53. Angioli R, Gómez-Marín O, Cantuaria G, O'sullivan MJ. Severe perineal lacerations during vaginal delivery: the University of Miami experience. Am J Obstet Gynecol 2000; 182:1083.
  54. Nager CW, Helliwell JP. Episiotomy increases perineal laceration length in primiparous women. Am J Obstet Gynecol 2001; 185:444.
  55. de Leeuw JW, Struijk PC, Vierhout ME, Wallenburg HC. Risk factors for third degree perineal ruptures during delivery. BJOG 2001; 108:383.
  56. Bodner-Adler B, Bodner K, Kaider A, et al. Risk factors for third-degree perineal tears in vaginal delivery, with an analysis of episiotomy types. J Reprod Med 2001; 46:752.
  57. Hamilton EF, Smith S, Yang L, et al. Third- and fourth-degree perineal lacerations: defining high-risk clinical clusters. Am J Obstet Gynecol 2011; 204:309.e1.
  58. Ramin SM, Gilstrap LC 3rd. Episiotomy and early repair of dehiscence. Clin Obstet Gynecol 1994; 37:816.
  59. Goldaber KG, Wendel PJ, McIntire DD, Wendel GD Jr. Postpartum perineal morbidity after fourth-degree perineal repair. Am J Obstet Gynecol 1993; 168:489.
  60. Ramin SM, Ramus RM, Little BB, Gilstrap LC 3rd. Early repair of episiotomy dehiscence associated with infection. Am J Obstet Gynecol 1992; 167:1104.
  61. Hankins GD, Hauth JC, Gilstrap LC 3rd, et al. Early repair of episiotomy dehiscence. Obstet Gynecol 1990; 75:48.
  62. Arona AJ, al-Marayati L, Grimes DA, Ballard CA. Early secondary repair of third- and fourth-degree perineal lacerations after outpatient wound preparation. Obstet Gynecol 1995; 86:294.