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\begin{document}

\title{New episiotomy: A prospective case series study}



\author[1]{Adam Ostrzenski}%
\affil[1]{Institute of Gynecology, Inc.}%


\vspace{-1em}



  
  \date{June 09, 2024}


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\selectlanguage{english}
\begin{abstract}
Objectives To establish anatomical structures responsible for a
resistance force on a fetal head during vaginal delivery; assess the
postpartum perception of perineal pain and superficial dyspareunia;
develop a new episiotomy. Design A prospective observational case series
study. Setting International sites. Population Eighteen pregnant women
in labor Methods Small V-shape excision was made on the
posterior-lateral vaginal outlet without incising the posterior perineum
or vaginal wall. Simple interrupted sutures were used to repair the
surgical defect (outlectorrhaphy). Histological examinations were
performed on excised specimens. Main Outcome Measures The primary
maternal outcome measured postpartum perineal pain; the secondary
outcome measured occurrences of superficial dyspareunia, results of
Ostrzenski's vaginal outlectomy, and APGAR scores measured the neonatal
outcome. Results The small V-shape excision widened the vaginal outlet
sufficiently for a vaginal delivery. Outlectorrhaphy required two-three
simple interrupted sutures. All subjects were delivered vaginally with
median newborns' weight of 3,550 gm \selectlanguage{ngerman}±250gm and median APGAR scores of 9
±1 at 5 minutes. One patient experienced a grate II extension tear with
bleeding heavier than an uncomplicated vaginal outlectomy. Postpartum
patients reported no moderate or severe perineal pain and no superficial
dyspareunia. Histology showed that the vaginal outlet was deferred from
the vaginal walls. Conclusions The vaginal outlet is responsible for
resistance force on a fetal head. No moderate or severe perineal pain or
dyspareunia occurred in this study group. Ostrzenski's vaginal
outlectomy widens the vaginal outlet sufficiently for a fetal vaginal
birth, and it is easy to repair.%
\end{abstract}\selectlanguage{ngerman}%



\sloppy


\textbf{New episiotomy: A prospective case series study}

Adam OSTRZENSKI, M. D., Ph. D., Dr. Habil.

\textsuperscript{1}Institute of Gynecology, Inc., USA

\textsuperscript{2}Padua University, Italy, (Visiting Professor), Italy

\textbf{Corresponding Author:}

Prof. Dr. Adam Ostrzenski

Institute of Gynecology, Inc., 7001 Central Ave.~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~
~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ St. Petersburg, FL 33710

USA Tel. ~(727) 458 6060

Fax: (727) 341-0121

E-mail:~ao@baymedical.com~\textbf{Running title:} Ostrzenski's vaginal
outlectomy

\textbf{Disclosure statement:} The author declares no conflict of
interest\textbf{. Registration:} N/A

\textbf{The number of abstract words:} 244

\textbf{The number of text words:} 2, 887

\textbf{New episiotomy: A prospective case series study}

\textbf{Abstract}

\textbf{Objectives} To establish anatomical structures responsible for a
resistance force on a fetal head during vaginal delivery; assess the
postpartum perception of perineal pain and superficial dyspareunia;
develop a new episiotomy.\emph{} \textbf{Design} A prospective
observational case series study.\textbf{Setting} International
sites.\textbf{Population} Eighteen pregnant women in
labor\textbf{Methods} Small V-shape excision was made on the
posterior-lateral vaginal outlet without incising the posterior perineum
or vaginal wall. Simple interrupted sutures were used to repair the
surgical defect (outlectorrhaphy). Histological examinations were
performed on excised specimens. \textbf{Main Outcome Measures} The
primary maternal outcome measured postpartum perineal pain; the
secondary outcome measured occurrences of superficial dyspareunia,
results of Ostrzenski's vaginal outlectomy, and APGAR scores measured
the neonatal outcome.\textbf{Results} The small V-shape excision widened
the vaginal outlet sufficiently for a vaginal delivery. Outlectorrhaphy
required two-three simple interrupted sutures. All subjects were
delivered vaginally with median newborns' weight of 3,550 gm \selectlanguage{ngerman}±250gm and
median APGAR scores of 9 ±1 at 5 minutes. One patient experienced a
grate II extension tear with bleeding heavier than an uncomplicated
vaginal outlectomy. Postpartum patients reported no moderate or severe
perineal pain and no superficial dyspareunia. Histology showed that the
vaginal outlet was deferred from the vaginal walls.\textbf{Conclusions}
The vaginal outlet is responsible for resistance force on a fetal head.
No moderate or severe perineal pain or dyspareunia occurred in this
study group. Ostrzenski's vaginal outlectomy widens the vaginal outlet
sufficiently for a fetal vaginal birth, and it is easy to repair.

\textbf{Funding:} The author did not receive any findings or grants for
the present study.

\textbf{Keywords:} Vaginal delivery; Episiotomy; Episiotomy tears;
Vaginal outlet; Ostrzenski's vaginal outlectomy; Vaginal orifice.

\textbf{New episiotomy: A prospective case series study}

\textbf{Tweetable abstract}

Ostrzenski's vaginal outlectomy reduces postpartum moderate-to-severe
perineal pain and eliminates superficial dyspareunia

\textbf{New episiotomy: A prospective case series study}

\textbf{Graphical Abstract}\selectlanguage{english}
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\textbf{Introduction}

In 1742, Fielding Ouled from Ireland was the first who described
episiotomy.\textsuperscript{1} Traditional episiotomy is an obstetrical,
surgical concept to widen the vaginal canal by incision of the
posterior-distal vaginal wall and the posterior perineum. Its purpose is
to facilitate the passing a fetus's head during birth. Those women who
undergo episiotomy or experience perineal tear(s) suffer from moderate
to severe perineal pain that requires pain medication and other forms of
therapy. In addition, severe short- and long-term complications from
this obstetrical surgical intervention are well-documented in the
medical literature. In general, a traditional episiotomy can result in
a) moderate or severe perineal pain immediately after delivery; b) blood
lost during and post-episiotomy that is compatible with Cesarean
section; c) wound infections; d) wound separation; e) long-term
postpartum moderate or severe perineal pain; f) urinary or fecal
incontinence, or both: g) urogenital and rectovaginal fistulas; h)
pelvic floor dysfunction and pelvic organ prolapse; i) persistent
superficial dyspareunia.\textsuperscript{2-5} The most severe episiotomy
complications are associated with an incision extension responsible for
the risk of third or fourth degrees of perineal lacerations -
obstetrical anal sphincter injuries (OASIS).\textsuperscript{6} It has
been postulated that primiparous women from Asia and Sub-Saharan Africa
are more predisposed to developed OASI.\textsuperscript{7} Additionally,
it has been documented that the most common maternal injury during birth
is the vaginal outlet.\textsuperscript{1}

The concept of Ostrzenski's vaginal outlectomy does not include the
posterior perineum or the posterior-distal vaginal wall to avoid
postpartum symptoms. Other studies showed that intact posterior perineum
does not produce postpartum perineal pain, superficial dyspareunia, or
other symptoms.\textsuperscript{8, 9} Therefore, the question arises
whether the posterior perineum incision is necessary to widen the
vaginal opening for vaginal parturition? In addition, does the hymeneal
ring and hymeneal plate risk of injuries exist during fetal head
delivery? Therefore, the present study will develop the surgical concept
of vaginal outlectomy surgical anatomy without including the posterior
perineum and posterior-distal vaginal wall.

The hypothesis of the current study is to test whether vaginal
outlectomy provides sufficient widening of the vaginal outlet to
overcome the tissue resistance force on the fetal head during delivery?
Therefore, the objectives were a) to show anatomical structures of the
vaginal outlet and resist a fetal head passing through; b) to establish
a new gross, topographic, and surgical anatomy of the vaginal outlet; c)
assess the postpartum perineal pain perception and superficial
dyspareunia; d) to develop a surgical intervention (vaginal outlectomy)
to widen the vaginal outlet without incorporating the posterior-distal
wall and the posterior perineum and develop a new episiotomy.\emph{} The
primary maternal outcome measures postpartum posterior perineum pain
associated with vaginal outlectomy. The secondary outcomes measure a)
complication of vaginal outlectomy; b) occurrence of superficial
dyspareunia after vaginal outlectomy; c) results of Ostrzenski's vaginal
outlectomy; d) neonatal outcome measured by an APGAR score.

\textbf{Methods}

Padua University, Italy, Ethics Committees approved the clinical study's
vaginal outlectomy protocol and informed consent (No. 23445/2019). The
Warsaw Medical University Bioethics Committee, Poland, approved the
experimental anatomical dissections of the urogenital tract on fresh
human female adult cadavers and practiced the newly developed vaginal
outlectomy procedure \textbf{(} No. AKBE 146/12). The anatomical
dissections were conducted at the Forensic Medicine Department, and the
author executed all the anatomical macro and micro (3.5 -- 4.00
magnifying loupe) dissections. Additionally, he practiced a new vaginal
outlectomy surgical intervention. The anatomical dissections were
conducted at the Forensic Medicine Department, and the author executed
all the anatomical macro and micro (3.5 -- 4.0 magnifying loupe)
dissections. Additionally, the author practiced a new vaginal outlectomy
surgical intervention on female corps.

Eighteen pregnant at term women were recruited, and the case series
study was conducted on this cohort subjects. These patients underwent a
clinical assessment in the supine position with the legs on stirrups.
The posterior-distal vaginal wall, posterior perineum, and anal external
and internal sphincters were evaluated by visual inspections and digital
vaginal and anal examination.

The most stretch vaginal outlet resistant force on the fetal head at
delivery was used as a reference point to determine the small V-shape
vaginal outletlectomy excision location. After outlectorrhaphy (V-shape
excision's defect repairs), blood loss was subjectively assessed by
inspecting the excision site, posterior perineum skin blood smear, and
clots.

On the first postpartum day, perineal pain perception levels and at
three months postpartum, superficial dyspareunia perception levels were
measured using a validated Numeric Rating Scale
(NRS).\textsuperscript{10} an 11-point scale for patients self-reporting
that is based on daily living activities and pain raging 1) no pain - 0;
2) mild pain from 1-3 on the NRS scale (nagging, annoying, and little
interfering with activities of daily living; 2) moderate pain from 4-6
on the NRS scale (interferes significantly with activities of daily
living); 3) severe pain from 7-10 on the NRS (disabling; unable to
perform daily living activities).

Generally accepted indications for traditional episiotomy, Tabl.1, were
closely followed and used in the selection process for the present
study. This study included singleton fetuses pregnancy in the vertex
presentation with occiput anterior and sonographically estimated fetal
weight between 2,629gm and 3,999 gm.

Patients who presented with prior episiotomy scar or perineal obstetric
- gynecologic surgery or perineal trauma were excluded from the current
study. Furthermore, those subjects who reported superficial dyspareunia,
dyschezia, or pain in the crotch were also excluded from this study. In
addition, abnormal fetal presentations (malpresentation) and breech
presentation were excluded from the present study.

The goal of the current research was to develop a new episiotomy
procedure that would exclude the posterior perineum. Ostrzenski's
vaginal outlectomy first step is identifying the ``belt-like'' structure
embracing the fetal head circumference; a midwife or obstetrician numbs
the area between 7 and 8 o'clock with plain lidocaine 1\%. At the
I-stage of parturition, the lidocaine skin test is performed by placing
lidocaine-soaked gauze under the right breast, and the skin reaction is
determined one hour later. Next, the V-shape partial excision of the
hymeneal membrane, hymeneal ring, and the hymeneal plate is executed
(the vaginal outlet). The size of the V-excision is approximately 1.5 cm
between the V-arms, and V-shape arms incisions are connected at the
bottom. The excision does not incorporate the posterior peritoneum or
posterior-distal vaginal wall. Finally, the vaginal outlectomy excised
tissue is submitted to the histological, routine examination and is
stained with hematoxylin and eosin (H-E), Fig. 1C.

\emph{Literature Search}

The medical literature was searched electronically and manually for the
gross and topographic anatomy of the vaginal introitus, vaginal
vestibule, vaginal orifice, and vaginal outlet. In addition, anatomy
articles, conference proceedings, and specializing websites were also
included. The Medical Subject Headings (MeSH) were applied. The
following keywords or phrases were used: vaginal delivery, episiotomy,
episiotomy tears, episiotomy extension, episiotomy laceration, vaginal
outlet; Ostrzenski's vaginal outlectomy, vaginal orifice, the human
vagina, vaginal outlet gross human, vaginal outlet topographic anatomy,
human vaginal introitus gross anatomy, human vaginal topographic
anatomy, human vaginal orifice gross anatomy, human vaginal orifice
topographic anatomy, perineal body location, vaginal posterior-distal
laceration, vaginal outlet histology, posterior vaginal colporrhaphy.

\textbf{Results}

The cohort of eighteen pregnant women completed the study and delivered
vaginally live neonates with implementing a newly developed Ostrzenski's
vaginal outlectomy. All pregnancies were singleton with a fetus in a
longitudinal lie, a cephalic presentation,~and occiput anterior. A
summary of the maternal demographic profile is presented in Tabl. 2, and
maternal clinical characteristics summarized in Tabl. 3. Vaginal
outlectomy outcome measures are reported in Tabl. 4. The neonatal
clinical outcome is encapsulated in Tabl. 5. The neonatal APGAR score at
5 minutes was between 8 and 10 (median 9 \selectlanguage{ngerman}±1), and median birth weight of
3.314 gm ± 684 gm. Neonatal clinical characteristics are summarized in
Tabl. 5.

When a fetal head is crowning, the fragment of the visible belt-like
structure of the vaginal outlet can be identified, Fig.1A and Fig. 1B,
Fig. 2B, and Fig. 3. A small V-shape excision of the vaginal outlet
structure reduced the tissue's resistance force on the fetal head during
birth enough. Immediately postpartum, none of the subjects from this
study group reported moderate or severe postpartum perineal pain.
Additionally, at three months follow up, including the patient who had
experienced vaginal outlectomy extension tear, did not report
superficial or deep dyspareunia.

The outlectorrhaphy required two or three interrupted absorbable sutures
to close the surgical defect. Esthetically, the wound closure resulted
in fine scar formation and no complications in wound healing in this
study group, Fig. 4. Additionally, the postpartum vaginal opening was
not gaping following outlectorrhaphy in every subject of the present
study, Fig. 4.

Utilizing the Validated Numerical Pain Rating Scale to record perineal
pain intensity on the first postpartum day showed no moderate or severe
perineal pain in all subjects who underwent Ostrzenski's vaginal
outlectomy. The mild perineal discomfort subsided spontaneously without
pain medication on the second and third postpartum days. Furthermore, no
woman in this group reported dyspareunia at twelve-week.

One case out of 18 subjects experienced vaginal outlectomy excision tear
that included the vulvar skin, perineal fascia, right bulbospongiosus
muscle (the second degree) with the increased amount of bleeding
compared to uncomplicated Ostrzenski's vaginal outlectomy, and the
neonatal birth weight was 3,390 gm. However, the vaginal wall,
corrugator muscle, and external anal sphincter were intact in this case,
Fig. 5B. In addition, this pregnant woman presented at full-term being
in active labor, and no malpresentation was diagnosed.

\textbf{Discussion}

\emph{Main Findings}

The present clinical research showed that vaginal outlectomy is a simple
obstetrical procedure with a short learning curve, negligible blood
loss, mild postpartum perineal discomfort, and no dyspareunia.
Approximately 1,5 cm V-shape excision is made on the vaginal outlet (the
hymeneal membrane, hymeneal ring, and continued within the hymeneal
plate). It was enough to reduce tissue resistance forces on the fetal
head at birth. During a fetal head delivery, the perineal muscle would
naturally be stretched by the forces of uterine contractions and
progressing fetal head that compresses the crotch from inside;
therefore, the posterior perineum has limited contribution in widening
vaginal outlet and will not require to be included into vaginal
outlectomy. Thus, the too-tight vaginal outlet is the cause that
inhibits the fetal head from passing through the vaginal outlet and
removes this tissue's natural resistance by small excision of the
fragment of the transitional skin, hymeneal ring, hymeneal plate without
perineal muscles incisions will overcome the resistance force.

Garner et al. developed the injury risk map during parturition and
determined that the posterior perineum was at low risk for trauma during
fetal head vaginal delivery.\textsuperscript{11} Therefore, the
posterior perineal incision is not necessary to perform for the birth of
a fetus. In addition, not including the posterior perineum in vaginal
outlectomy prevents significant bleeding related to episiotomy during
parturition, postpartum moderate to severe perineal pain, and, later on,
superficial dyspareunia.

The vaginal outlectomy estimated bleeding is minimal, Fig. 5.
Furthermore, closing the surgical defect of vaginal outlectomy
(outlectorrhaphy) requires only two or three sutures. Compared to
episiorrhaphy, Ostrzenski's vaginal outlectomy significantly reduces
clinical training and using suturing materials. After healing, the
fine-scare, almost invisible, provides a very appealing esthetic look,
and the vaginal outlet is not gapping postpartum, Fig. 4. In one case
out of eighteen, vaginal outlectomy extension occurred in this study
group. The extension included the perineal skin, perineal fascia, right
bulbospongiosus muscle (the second degree), Fig. 5 B. However, the
vaginal wall, corrugator muscle, and external anal sphincter were
intact. Thus, the vaginal outlet extension did not progress towards the
anal sphincter. Estimated vaginal outlectomy extension bleeding was
heavier when compared to uncomplicated vaginal outlectomy, Fig. 2 and
Fig. 5. Additionally, the woman who experienced vaginal outlectomy
extension reported moderate postpartum perineal pain that lasted for
five days and required pain medication (NRS was 5 pain perception
intensity). At three months postpartum follow-up, the subjects did not
report superficial dyspareunia. Therefore, this case demonstrates that
vaginal outlectomy extension can occur and obstetrical injury of the
bulbospongiosus muscle causes heavier bleeding than uncomplicated
vaginal outlectomy, Fig. 2 and Fig. 5, and moderate postpartum perineal
pain.

\emph{Strengths and Limitations}

The present study shows that the posterior perineal musculature does not
significantly affect the vaginal outlet resistance force on a fetal head
during birth. Instead, the most substantial contribution to resistance
is the vaginal outlet. Thus, Ostrzenski's vaginal outlectomy eliminates
incision of the posterior perineum, decreases post vaginal outlectomy
bleeding, reduces using surgical suturing materials, re-establishes the
natural esthetic look of vaginal orifice without gapping, eliminates
moderate or severe postpartum perineal pain perception, abolishes
post-birth superficial dyspareunia, and significantly reduces the length
of traditional episiotomy scar. Additionally, the learning curve is
short and does not require as intense training as the traditional
episiotomy. Esthetically, vaginal outlectomy provides impressive
results, creates an almost invisible scar, and eliminates postpartum
vaginal gapping. Furthermore, vaginal outlectomy reduces the time of
repairing the excision site and cuts on using surgical suture materials
(2-3 stitches are needed).

The current study's limitation is the small number of subjects to draw
general conclusions or determine the safety and effectiveness of vaginal
outlectomy. Still, this number was sufficient to decide on the clinical
implementation of a vaginal outlectomy. Also, the weakness of this
clinical investigation is the absence of standardization when a vaginal
outlectomy should be performed, and the indication for performing
vaginal outlectomy was adopted from the existing practice mode for
selective episiotomy and not established for Ostrzenski's vaginal
outlectomy, Tabl. 1 Furthermore, this obstetrical procedure was not used
at the time of operative vaginal delivery, and whether a vaginal
outlectomy will reduce the development of obstetrical anal sphincter
injuries - OASIS, particularly in forceps or vacuum delivery, abnormal
fetal presentations, or primiparity.

\emph{Interpretation}The vaginal outlectomy eases the passage of a fetal
head during vaginal delivery by reducing the vaginal outlet tissue
resistance force created by a belt-like structure embracing the fetal
skull---the belt-like consists of the transitional vulvar skin, hymeneal
ring, and hymeneal plate. V-shaped excision in the most distended belt
area is enough for successful fetal head and body delivery.

Histology of the excised vaginal outlet showed no perineal muscle
skeletal muscle present in the excised specimens and verified anatomical
findings of three distinctive layers: the hymeneal membrane, ring, and
plate, Fig. 1C. The absence of the perineal muscle within the excised
V-shape tissue helps understand the mechanism of posterior postpartum
pain and, later on, superficial dyspareunia. Therefore, the present
study shows that the posterior perineal musculature is unnecessary to
cut for widening the vaginal outlet to deliver a fetal head.

The surgical concept of Ostrzenski's vaginal outlectomy is how to
minimize the ``belt-like'' tissue resistance force on a fetal head being
entrapped by the vaginal outlet and not by the posterior perineum. This
procedure is easy to learn and execute with only negligible blood loss
and minimal postpartum perineal discomfort and does not produce
superficial dyspareunia.

A traditional mediolateral episiotomy incorporates into the incision
several anatomical structures: the posterior-distal vaginal, perineal
body, hymeneal membrane, hymeneal ring, vaginal plate, inferior labium
minus, perineal skin, posterior perineal fascia, superficial transverse
perineal muscle, bulbospongiosus muscle, dorsal perineal membrane,
urethrovaginal sphincter muscle, the pubovaginalis muscle (the fragment
of the levator ani muscle), and superficial external sphincter muscle. A
midline episiotomy includes anatomical structures: the posterior-distal
vaginal wall, perineal body, vaginal outlet, fossa navicularis,
fourchette, posterior perineal skin, perineal fascia, the central point
of the posterior perineum, superficial external sphincter muscle, and
distal rectovaginal septum.\textsuperscript{12} These episiotomy
techniques were developed to prevent posterior perineum damages,
including anal sphincters, pelvic floor dysfunction, and the fetus from
either intracranial hemorrhage or intrauterine asphyxia. None of these
suppositions were validated by clinical-scientific studies, and
traditional episiotomies are responsible for severe
complications.\textsuperscript{13} Unfortunately, episiotomy does not
prevent damages but does create damages of the posterior perineum in
women,

Estimated blood loss associated with traditional episiotomy exceeds the
amount observed at cesarean section.\textsuperscript{14} The immediate
postpartum severe posterior perineal pain followed traditional
episiotomy often lasts for several
weeks.\textsuperscript{15,16}Episiotomy extension to the external and
internal anal sphincter causes more pain for several weeks after birth
and requires strong pain medication.\textsuperscript{17} Additionally,
an episiotomy or other obstetrical perineal trauma can cause transient
or prolonged, or permanent superficial dyspareunia, which plays a
significant role in female sexual dysfunction.\textsuperscript{18} Also,
episiotomy, particularly midline episiotomy, can lead to debilitating
urinary or fecal incontinence, or both due to injuries of the perineal
body.\textsuperscript{19-23} Furthermore, an obstetrician's or midwife's
skill to perform episiorrhaphy is very often inappropriately done. The
method of repair techniques increases short- and long-term women
morbidity and negatively influences the quality of life, Fig.
4D.\textsuperscript{18, 21, 24}

\emph{Future Research}

The present study's findings showed that vaginal outlectomy has the
potential for obstetrical use in everyday practice. However, there is a
need for additional clinical-scientific research to assess vaginal
outlectomy further since the current study design could not answer the
safety and effectiveness of vaginal outlectomy or whether vaginal
outlectomy can be applied in the form of a restrictive or routine use.
If the restrictive use would be preferable, what are the indications for
vaginal outlectomy? In addition, how vaginal outlectomy will assist
during vaginal instrumental delivery should also be studied.

\textbf{Conclusions} The vaginal outlet is responsible for resistance
force on a fetal head passing through it and not the posterior perineum
that only supports the vaginal outlet. Ostrzenski's vaginal outlectomy
widens the vaginal outlet sufficiently for a fetal vaginal birth and
eliminates postpartum perineal pain and dyspareunia.

\textbf{Declaration of Competing Interest}

The author declares that he has not known competing for financial
interest or personal relationships that could have influenced the work
reported in this paper.

\textbf{Acknowledgment}

I am grateful to Prof. Dr. Pawel Krajewski, chairman of the Department
of Forensic Medicine, Warsaw Medical University, for selecting fresh
human adult female cadavers for anatomy study and practicing vaginal
outlectomy. The author also wishes to express gratitude to Dr. Zbigniew
Antosz, from Diagnostics Consilatione, Cracow, Poland, for assisting in
histologic preparation and interpretations of the microscopic features.
Additionally, I like to thank you Dr. Mark N. Scheinberg, for taking
photograms.

Ethical statement

Two independent University Bioethics Committees approved both study's
anatomical and clinical protocol before the investigations were
commenced.

Funding

This work did not receive any funding

\emph{Author contributions~}

The author develops the concept of Ostrzenski's vaginal outlectomy,
designs the studys' protocols, collects data, analyses and interprets
data, and drafts the manuscript.

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\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image4/image4}

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  10.1002/14651858.CD002866.pub2{]}\textbf{Figures legends}
  \textbf{Figure 1.} Discovery of the vaginal outlet anatomy and
  histology\textbf{A.} The yellow arrow represents the hymeneal membrane
  and its tags. Upon dissecting the hymen membrane, the hymeneal ring is
  white and indicated by the orange arrow. The low segment of the
  hymeneal ring fuses with the hymeneal plate, creating the crease and
  protuberance (the blue arrow).\textbf{B.} The excised fragment of the
  vaginal outlet without posterior perineal muscles. The yellow arrow
  refers to the hymeneal membrane; the orange denotes the hymeneal ring;
  the blue arrow points out the hymeneal plate.\textbf{C.} The histology
  (Hematoxylin \& Eosin stained, and 40x magnification) of the vaginal
  outlet structure consists of the three histological layers:
  superficial (the green arrow), middle (the orange arrow deep layer
  (the blue arrow) of the excised strip of the vaginal outlet obtained
  during parturition. The vaginal outlet consists of the three
  histological layers: superficial (the green arrow), middle (the orange
  arrow, and deep layer (the blue arrow). The first histological layer
  (the hymeneal membrane) is the superficial layer (the green arrow),
  consisting of multilayer flat squamous cells of the epithelium, loose
  fibrous connective tissue, collagen fibers, numerous network of
  capillary blood vessels, and multiple nerve endings. The second or the
  middle layer (the hymeneal ring) is well-organized, compressed fibers
  of the collagen fibers, a network of blood vessels of a larger caliber
  than in the superficial layer, heavily distributed nerve endings more
  than in the superficial layer (the orange arrow). Finally, the third
  layer (the hymeneal plate) is less organized and compact collagen
  fibers than the hymeneal ring (the blue arrow). In this layer, the
  smooth vaginal muscles fuse with the hymeneal plate, and it is the
  only connection of the vaginal wall with the vaginal outlet. A
  significantly smaller number of nerve endings is present in this
  stratum when compared to the hymeneal ring---none of the microscopic
  specimens from the V-shape excision shows perineal skeletal muscle.
\end{enumerate}

\textbf{Figure 2.} The implementation of Ostrzenski's vaginal outlectomy
at the time of fetal head crowning.\textbf{A.} The side of local
anesthetic injection before the vaginal outlet excision,\textbf{B.} The
fragment V-shape excision that includes tissue of the transitional
vulvar skin, hymeneal membrane, hymeneal ring, and hymeneal
plate,\textbf{C.} The minimal amount of bleeding is associated with a
vaginal outlectomy.

\textbf{Figure 3.} Crowning of the fetal head through the vaginal outlet
(``belt-like'') is depicted. The vaginal outlet anatomy consists of a
hymeneal membrane (stretched to the point that is almost invisible); the
next layer is the hymeneal ring, and under it is the upper crease that
separates the next layer of the hymeneal plate, seen as the protuberant
configuration. The lower part of the hymeneal plate and the inner
surface of the labium minus create a well-visible lower crease.

\textbf{Figure 4.} Post outlectorrhaphy, the suture line (the black
arrow) is almost invisible, and the vagina orifice is not gapping.

\textbf{Figure. 5.} Comparison of vaginal outlectomy bleeding with
vaginal outlectomy extension and midline episiotomy bleeding\textbf{A.}
Amount of bleeding associated with vaginal outlectomy,\textbf{B.}
Vaginal outlectomy extension to the posterior perineum\textbf{,}
bleeding is heavier than from an uncomplicated vaginal
outlectomy,\textbf{C.} Midline episiotomy (the black arrow) divides the
skin, posterior-distal vaginal wall, the perineal body, posterior
perineal fascia, and five surgically separated muscles (1- the
bulbospongiosus muscle, 2- the urethrovaginal sphincter muscle, 3- the
superficial transverse perineal muscle, 4- superficial external anal
sphincter muscle, 5- the perineal body muscle located under the
posterior-distal vaginal wall. The white on blue numbers represent the
separated posterior perineum musculatures. The white on green no. 5
depicts the perineal body, and no. 6 describes the levator ani defect.

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\verb`OVO Fig. 2. .docx`  available at \url{https://authorea.com/users/472319/articles/563235-new-episiotomy-a-prospective-case-series-study}

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\verb`OVO Fig. 3.docx`  available at \url{https://authorea.com/users/472319/articles/563235-new-episiotomy-a-prospective-case-series-study}

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\verb`OVO fig. 4.docx`  available at \url{https://authorea.com/users/472319/articles/563235-new-episiotomy-a-prospective-case-series-study}

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\verb`OVO Fig.5.docx`  available at \url{https://authorea.com/users/472319/articles/563235-new-episiotomy-a-prospective-case-series-study}

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\verb`OVO Table 1-5.docx`  available at \url{https://authorea.com/users/472319/articles/563235-new-episiotomy-a-prospective-case-series-study}

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