Endometriosis refers to an estrogen dependent disease in which endometrial tissue (including glands and stroma) with growth function occurs outside the mucous membrane and muscular layer of the uterine cavity. In recent years, the incidence rate has increased year by year. As a common disease among women of childbearing age, the main manifestation is cyclic pain in the perineum closely related to the menstrual period; Pain will gradually increase, and there may be local swelling or stabbing sensations at the scar site of the perineal incision. There may be itching or tenderness, and the pain can be relieved or even disappear after menstruation. The use of anti-inflammatory drugs and physical therapy have poor effects, and a few reports of sexual pain, anal prolapse during menstruation, and other discomfort. In recent years, with the increase of episiotomy rate, perineal endometriosis has had a serious impact on patients' daily life and sexual activity.
The prevention and management of endometriosis in perineal episiotomy mainly focus on the following three stages in clinical practice: prenatal, intrapartum, and postpartum.
1. Pre marital education should be vigorously provided to the general public to enhance their understanding of this disease and raise their awareness of prevention. Accurate and appropriate contraceptive measures should be taken to reduce the chances of pre marital intrauterine operations and intrauterine infections; Reduce operations such as vaginal surgery or vaginal flushing during menstruation that may cause endometrial damage or menstrual blood reflux. Pregnancy education is also an important part of preventing this disease. In addition to prenatal care and weight control, it is also important to pay attention to proper perineal massage during the later stages of pregnancy to improve perineal muscle elasticity. It is recommended that starting from 34 weeks of pregnancy, primiparous women without pregnancy complications or other high-risk factors can perform 1-3 times a week of perineal expansion massage on their own or with the assistance of a partner to reduce perineal lacerations during childbirth, provided that the external genitalia is thoroughly cleaned and lubricated. Seek help from medical staff when necessary; Massage daily or when conditions permit; When massaging with a partner, use the index and middle fingers; Avoid pressing the urethra to prevent infection; Play light music, coordinate with breathing, etc.
2. During labor
(1) It is required that medical staff enhance their understanding of this disease, improve their sense of responsibility, and enhance their personal professional skills. They should regularly receive training on correct perineal incision surgery, birth canal assessment and examination, cultivate strict compliance with relevant operating procedures, establish awareness of protective isolation and prevention, and reduce soft birth canal injuries.
(2) Strictly adhere to the indications for episiotomy and vaginal delivery surgery. Currently, restrictive or selective episiotomy is advocated, which means unconventional episiotomy to protect the integrity of the perineum and avoid serious perineal lacerations. If episiotomy is necessary, the risk of anal sphincter injury is lower compared to episiotomy; At the same time, medical staff should weigh the advantages and disadvantages of vaginal delivery and cesarean section in both mother and child, carefully choose treatment methods to improve the prognosis of mother and child; Finally, obstetricians and midwives should constantly evaluate the success rate of vaginal delivery and abandon vaginal delivery procedures if necessary. Especially when it is difficult to lower the fetal head, it is not recommended to use instruments such as forceps and fetal head attractants to assist in delivery.
(3) Pay attention to process management during childbirth. In the second stage of labor, sterile hot towels are used for hot compress and perineal massage, which has a significant effect on preventing severe perineal lacerations. This method is simple and easy to implement, and is worthy of clinical promotion and wide application. Regarding the management of the third stage of labor, it is recommended that natural childbirth patients do not intervene in the third stage too early to avoid placental residue and the outcome of uterine curettage. If necessary, attention should also be paid to protecting the perineal incision during uterine curettage. Gloves should be replaced promptly after the operation. If the placenta and membranes are intact, it is not necessary to regularly wipe the uterine cavity during delivery.
(4) Reduce the opportunities for intrauterine operations during and after childbirth, and try to avoid excessive vaginal examinations, improper fetal rotation, and manual placental removal. Pay attention to protecting the perineal incision; At the same time, attention should be paid to the technique of delivering the placenta to reduce the chance of the placenta contacting the perineal wound; Before suturing the perineum, the vagina should be filled with sterile gauze with a tail to prevent contamination of the wound by uterine blood. The wound should then be washed with physiological saline before suturing, and if necessary, iodine can be used to wipe and rinse the incision thoroughly.
3. Postpartum care
(1) Pay attention to perineal wound care. For those with perineal injuries, it is recommended to lie on the healthy side after delivery, and change underwear and sanitary napkins frequently to prevent residual or detached endometrium from being transplanted to the perineal incision site.
(2) Pay attention to postpartum education, encourage breastfeeding, promote effective contraception after childbirth through education, and cautiously perform postpartum curettage to reduce the phenomenon of endometrial tissue remaining, spreading, and implantation.
(3) Follow up should be conducted for high-risk individuals after their menstrual cycle resumes, including the age of the disease, whether medication has been used after surgery, whether there is recurrence after surgery, the patient's pregnancy status after surgery, whether they are breastfeeding and the duration of breastfeeding per parity, and the time of postpartum recurrence per parity.
Endometriosis, as a "modern difficult to treat" disease, needs to be prevented as much as possible from the source, especially in obstetrics and gynecology, which is a high-risk area for iatrogenic endometriosis, and should be controlled from the source. In the current era of big data, it is recommended to use training methods and health education to improve the correct understanding of diseases among medical staff and the public, implement the obstetrics and gynecology patient management plan, and enhance the scientific cognitive ability of medical staff regarding disease progression. Early identification of cases of perineal endometriosis can improve medical efficiency through effective treatment, ultimately benefiting patients.