Special Operations Forces Medical Handbook

3-104

Third and Fourth Degree Repair: (see figure 3-15)

1. Reapproximate the rectal mucosa with interrupted, fine 4-0 sutures (usually two layers), taking care not to
   puncture the mucosa and to leave the ends of the suture in the tissue, not the rectal lumen.


2. Repair the torn ends of the doughnut-shaped anal sphincter with four well-spaced interrupted sutures that
   traverse through the capsule of the muscle.


3. Then repair the wound as in a second-degree laceration or an episiotomy (above).

Management after Episiotomy

1. Apply ice to the affected area tid to control swelling.


2. Relieve pain with Tylenol #3 1-2 tabs po every 3-4 hours.


3. Pain may be an indication of a large hematoma or perineal cellulitis. Examine these areas carefully if pain
   is severe or persistent.


4. Give stool softeners for approximately 7-14 days and direct increased intake of fiber and water.


5. Do not give enemas.

What Not To Do:
Do not fail to restore anatomical features.
Do not use too many sutures.
Do not fail to achieve hemostasis.

Symptom: OB Problems: Preeclampsia/Eclampsia

MAJ Marvin Williams, MC, USA

Introduction: Preeclampsia is maternal hypertension accompanied by proteinuria or edema, seen from the
20th week of gestation through delivery. If these symptoms are complicated by seizures or coma, the mother
has eclampsia. Hypertensive disorders are the most common medical complications of pregnancy, effecting
approximately 5-14 percent of pregnancies, and are more common in first-time mothers. The etiology
of preeclampsia is unknown and it can be defined as mild or severe. Approximately 1% of patients with
preeclampsia develop eclampsia.

Subjective: Symptoms
Visual disturbances (usually irregular luminous patches in the visual fields after physical or mental labor),
headaches, nausea, vomiting, epigastric pain and generalized edema, seizures or coma.

Objective: Signs
Mild Preeclampsia (1 of the following):

1. Blood pressure changes (measure on two occasions at least 6 hours apart):
   a. Systolic blood pressure (SBP) of 140 mm Hg or greater OR
   b. Diastolic BP (DBP) of 90 mm Hg or greater (< 110) OR
   c. Mean arterial BP (MAP) (calculated as 1/3 the difference between SBP and DBP, plus the DBP) of 105 mm
   Hg and/or an increase of 20 mm Hg over baseline


2. Proteinuria 2+ or > on a urine dipstick


3. Pathologic edema: generalized or involving the hands or face (Note: Moderate edema is a feature of
   approx. 70-80% of normal pregnancies). Weight gain greater than 4 pounds/week in the third trimester
   may be one of the first signs of preeclampsia.

Severe Preeclampsia (1 of the following):

1. Blood pressure changes (measure on two occasions at least 6 hours apart):
   a. SBP of 160 mm Hg or greater OR
   b. DBP of 110 mm Hg or greater


2. Proteinuria 3+ OR 4+ on dipstick


3. Severe edema, including pulmonary edema