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分娩时会阴切开术及会阴撕伤的修补

Author
Marc R Toglia, MD
Section Editor
Charles J Lockwood, MD, MHCM
Deputy Editor
Vanessa A Barss, MD, FACOG

引言

经阴道分娩后，应对阴道、会阴和肛门直肠进行检查，以确定是否损伤并修复。特别地，在无其他并发症的分娩过程中经常会发生肛门括约肌复合体的隐匿性损伤，若被忽视，可能会导致肛门和大便失禁[1]。即便损伤被修复，持续的括约肌功能障碍仍被认为是产后肛门失禁最常见的原因[2,3]。

与分娩相关的会阴切开术切口及会阴撕裂伤的评估和修复总结在此。关于阴道撕裂伤的评估和治疗将单独讨论。 (参见“女性下生殖道创伤的评估与处理”，关于‘阴道’一节)

解剖学

女性骨盆底和会阴部肌肉如下图所示(图 1和图 2)。肛门直肠括约肌复合体由两部分组成，这两个结构在维持自制方面具有不同的但又相互重叠的作用(图 3)。肛门外括约肌(external anal sphincter, EAS)是一块环绕肛门的厚实、圆形、主要为横纹肌的肌肉，它负责静息状态及直肠扩张期对固态和液态粪便以及排气的控制。肛门内括约肌(internal anal sphincter, IAS)位于肛门外括约肌和肛管之间，其代表了结肠黏膜下层纵向平滑肌纤维的一个薄且紧密的结构(图 3)。IAS在外括约肌头侧缘上延伸超过1cm[4]，它完全处于非随意控制下，并且有助于维持静息状态的肛门关闭[4]。肛提肌复合体的耻骨直肠肌部分在控制固态粪便中也起着重要的作用，而完整的阴部神经似乎也十分重要。

分类

1999年，Sultan提出改进产科会阴撕裂伤的传统分类体系[5]。修订后的体系为会阴Ⅲ度裂伤提供了一个子分类：

  • 会阴Ⅰ度裂伤仅涉及会阴皮肤和阴道上皮的损伤，会阴肌肉仍保持完整。
  • 会阴Ⅱ度裂伤延伸至会阴体的筋膜和肌肉组织，包括会阴深横肌和会阴浅横肌以及耻尾肌纤维和球海绵体肌纤维。肛门括约肌仍保持完整。
  • 会阴Ⅲ度裂伤贯穿会阴体的筋膜和肌肉组织，并累及EAS和/或IAS的部分或所有纤维。

    会阴Ⅲ度裂伤被再分为以下几类：

                    

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Literature review current through: 2017-06 . | This topic last updated: 2017-06-30.
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