CLINICAL CAS STUDY 1
1. Stress incontinence is the involuntary loss of urine caused by an increase in the intra-abdominal pressure when
the abdominal muscles contract, as in coughing, sneezing, lifting and the like. Compromised urethral sphincters
and/or support are unable to resist this stress, resulting in leakage.
2. Cystocele, also called a prolapsed or dropped bladder, is the bulging or dropping of the urinary bladder into the
anterior wall of the vagina.
Structures that could prolapse and cause a bulge in the posterior wall of the vaginainclude:
a. Loops of the small intestine in the rectouterine pouch may cause a bulge at the posterior fornix (enterocele) and
the rectum may bulge into the lower vagina (rectocele).
3. The uterus is supported by the pelvic diaphragm ( mainly levator ani muscle), the viscera surrounding it (i.e. the
bladder, rectum, etc.), and connective tissue support structures. Several fascial ligaments, including the round
ligament of the uterus and the rectouterine ligaments, and the cardinal ligaments help maintain the orientation of
the uterus and cervix, and aid in supporting the pelvic viscera. As the pelvic diaphragm (floor) weakens due to
aging or injury (like from multiple childbirths), the pelvic organs, including the uterus, will sag if the pelvic
diaphragm tone cannot be maintaine
CLINICAL CAS STUDY 2
1. a. The round ligament of the uterus, which connects to the uterus anterior and inferior to the uterine tube
between the layers of the broad ligament.
b. The ligament of the ovary (proper ovarian ligament), which lies posterior and inferior to the uterine tube.
c. The anterior leaf of the broad ligament and the lateral attachments of the broad ligament.
In addition the surgeon would detach the uterus by cutting below the external os of the cervix and suturing the
four corners of the vaginal wall.
2. The uterine artery is the most significant source of blood to the uterus and therefore requires careful
dissection. It is generally a branch of the internal iliac artery which supplies the uterus and uterine tube.
The other major blood supply to the region is the ovarian artery which a direct branch off the aorta.
3. The ureters pass under the uterine arteries on their way to the bladder - " water" under " bridge" is the term
frequently used to describe their passage.
.
CLINICAL CASE STUDY 3
1. An episiotomy is an incision made in the perineum to enlarge the distal end of the birth canal. Episiotomies
are performed in order to ease delivery, especially in difficult cases like breech and forceps deliveries.
During delivery, as the fetus moves down the vaginal canal, it stretches the perineum, levator ani, and pelvic
fascia. Thepubococcygeus muscle especifically is at risk for stretching to the point of tearing the
pubococcygeus muscle supports the urethra, vagina, and vaginal canal and damage to this muscle could lead
to urinary stress incontinence post delivery whenever the patient coughs or increases her intraabdominal
pressure by bearing down.
2. If the incision tears further during the delivery, a median incision is more likely than a posterolateral
incision to extend posteriorly through the perineal body, the external anal sphincter, the internal anal
sphincter, and the rectum.
3. The integrity of the perineal body is critical to the strength of the entire perineum in women. Unrepaired
injury can cause dysfunction of the external anal sphincter, internal anal sphincter and prolapse of uterus.
CLINICAL CASE STUDY 4
1. The pudendal nerve (from S2, S3, and S4) is the major nerve of the perineum, providing motor and sensory
fibers to the perineum. Its branches in the female include: the perineal nerve, which provides branches to the
posterior labial region and the muscles of the urogenital triangle; the dorsal nerve of the clitoris, which
supplies the prepuce and glans of the clitoris; and the inferior rectal nerves, which supply the perianal region.
2. What other nerves would need to be blocked to provide complete anesthesia to the perineal region?
Complete anesthesia of the perineal region requires anesthetization of the genital branches of
the genitofemoral nerve, the ilioinguinal nerve, and the perineal branch of the posterior femoral cutaneous
nerve. This can be accomplished by making an injection along the outer margin of the labia majora.
3. Where is the best place to deliver anesthetic to perform a pudendal nerve block?
The location to deliver anesthetic to the pudendal nerve is as the nerve wraps around the ischial spine and
before it sends out its branches.
4. What landmarks would an obstetrician use to deliver the anesthetic accurately?
Two different methods may be used for a pudendal nerve block. In the transvaginal procedure, the ischial
spine is palpated through the wall of the vagina and the needle is then passed through the vaginal mucous
membrane toward the ischial spine, at which point the pudendal nerve is bathed with anesthetic. In the
perineal procedure, the ischial tuberosity is palpated through the buttock and the needle is inserted about one
inch deep medial to the ischial tuberosity. The anesthetic can then be injected to bathe pudendal nerve.
5. What other methods of anesthesia might be used to provide pain relief during childbirth?
There are two other methods for delivering anesthetic to reduce the pain of childbirth: spinal
anesthesia and epidural anesthesia. In spinal anesthesia, local anesthetics are injected into the subarachnoid
space in the lower lumbar region. In epidural anesthesia, local anesthetic is infused into the epidural space
through a catheter inserted into the vertebral canal. The methods have the advantage of blocking pelvic pain in
general while allowing the mother to remain awake without interfering with uterine contractions.
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