Complications of labor

complications of labor, post-partum hemorrhage, episiotomy

1. Complications of labor…

2. Preterm labor…

3. is defined as one where the labor starts before the 37th completed week, counting from the first day of LMP. Cause unknown. Often multifactorial Clinical features similar to that in normal labor

4. Risk factor History: previous history, assisted reproductive techniques, asymptomatic/recurrent UTI, smoking, maternal stress Complications: Maternal: Pre- eclampsia , APH, PROM, polyhydraminos Cervical incompetence, uterine malformation Acute fever, pyelonephritis, diarrhea, appendicitis, infections Hypertension, diabetes, heart disease, severe anemia Fetal: multi-fetal gestation, congenital malformation, IUD Placental: infarction, thrombosis, previa /abruption Iatrogenic: elected – if any medical/obstetrics complication Idiopathic

5. Management To prevent preterm onset of labor Primary care: reduce risk factors Secondary care: early detection and prohylactic treatment ( tocolytics ) Tertiary care: reduce mortality(steroids) Arrest preterm labor Bed rest Adequate hydration and prophylactic antibiotics Prophylactic cervical cerclage Tocolytics ( nifedipine , atosiban , progesterone) MgSO4 dosing and monitoring – prophylaxis of pre- eclampsia Appropriate management Effective neonatal care

6. Management in labor First stage: Adequate bed rest: to prevent ROM Adequate oxygenation and anesthesia Maternal and fetal monitoring NICU to be prepared before-hand Second stage: Slow and gentle birth Episiotomy Cord clamped immediately (to prevent hypervolemia and hyper- bilirubinemia )

7. Spontaneous rupture of the membranes any time beyond 28th week of pregnancy but before the onset of labor is called pre-labor rupture of the membranes (PROM ) If after 37wks but before onset of labor: PROM If before 37 th wk : preterm PROM (PPROM)

8. Pre-labor rupture of membranes…

9. Causes Increases friability of membranes Decreased tensile strength of membranes Polyhydraminos Cervical incompetence Multi-fetal gestation Infections – UTI, chorio-amnionitis , lower genital tract infection Previous history Low BMI

10. Clinical features Watery discharge PV – gush of fluid or slow leak Careful Speculum examination: liquor escaping through the cervix USG Avoid digital PV examination Investigations CBC, CRP, Urine analysis, Vaginal swab for culture Estimation of phosphatidylglycerol and L:S ratio USG and cardio- tocography /non-stress test

11. Complications… Preterm labor and prematurity Ascending infections: chorio-amnionitis and fetal infections, endometritis Cord prolapse Dry labor Placental abruption, retained placenta, maternal sepsis Fetal pulmonary hypoplasia Neonatal sepsis, RDS, IVH, NEC, cerebral palsy, fetal death

12. Management… Preliminaries – Aseptic examination, avoid digital PV examination, bed rest Monitor maternal pulse, FHR & start prophylactic broad spectrum antibiotics & corticosteroids Assess for amnionitis , placental abruption, fetal distress/death if present then expeditious delivery, broad spectrum antibiotics and NICU care

13. Pregnancy <34 weeks Bed rest, antenatal corticosteroids, broad spectrum antibiotics Steroids not given in presence of frank infection Dose: Betamethasone: 12mg – 2 doses – 24hours apart OR dexamethsone 6mg – 4doses – 6hours apart Pregnancy 34 th -37 th weeks Pregnancy >37 th weeks Wait for spontaneous onset of labor for 24-48 hours If fails then Induction of labor or LSCS

14. Prolonged and post term pregnancy…

15. a pregnancy continuing beyond 2 weeks of the expected date of delivery (> 294 days) is called postmaturity or post-term pregnancy. Unknown causes Factors related; Wrong dates Hereditary Primipara , previous history, sedentary, elderly multiparae Congenital anomalies: anaencephaly Placental factors

16. Complications… Placental ageing  placental calcification and infarction  insufficiency Fetal hypoxia and distress due to placental insufficiency, meconium stained liquor and oligohydraminos Labor Fetal hypoxia and acidosis Labor dysfunction, meconium aspiration Cord compression Shoulder dystocia Birth trauma – non-molding (hardening of skull bones) Operative delivery Delivery Meconium aspiration – Chemical pneumonitis, atelectasis/collapse, pulmonary hypertension Hypoxia and respiratory failure Hypoglycemia and polycythemia NICU admission

17. Diagnosis… Menstrual history: regular/irregular cycles, contraceptive history, LMP Clinical findings: Weight records: stationary/decreasing Girth of abdomen: amniotic fluid content False labor pains Obstetrics palpation: height of uterus, size of fetus and hardness of skull bones Internal examination Cervical ripeness Color of amniotic fluid: greenish-yellow/saffron

18. Management… Be sure of fetal maturity and fetal surveillance Uncomplicated cases can be induced If cervix unripe  6hrly PGE2 given PV then ripe If cervix ripe  artificial rupture of membrane done  oxytocin drip given  delivery Complicated cases  LSCS

19. Intra-uterine Fetal Death

20. Ante-partum death beyond the period of viability is termed as IUD Delivery of macerated fetus

21. Causes… Maternal (5-10%) HTM, DM, fever, infections, thrombophilia, auto-immune, prolonged/obstructed labor, ruptured uterus, post-term pregnancy Fetal Chromosomal anomalies, infections, Rh-incompatibility Placental APH, cord( prolpse , knot, around neck), twins Iatrogenic – drugs, Idiopathic

22. Clinical features… Absence of fetal movements Signs: Per abdomen Gradual regression of fundal geight Uterine tone diminised and flaccid feels No fetal movements felt Absent FHR NST: flat trace Egg shell cracking feel of fetal head Complications: Psychological upset, infections, blood coagulation disorder (silent DIC), uterine inertia, retained placenta and PPH

23. Investigations… USG Lack of cardia and fetal motions Oligohydraminos Collapsed/overlapping skull bones X-rays abdomen (rarely done) Spalding sign: irregular overlapping of skull bones (7 th day) Hyperflexion of spine and hyperextension of neck. Crowding of rib shadows Robert’s signs: appearance of gas shadows in chambers of heart and great vessels (12hrs) Blood

24. Management… Prevention: Preconceptional counselling and care, screening and early diagnosis Breaking bad news Expectant attitude: spontaneous expulsion within 2 weeks Methods of delivery Oral mifepristoe (200mg) and PV 25mcg misoprostol 4 hourly intravaginally 25-50mcg misoprostol 4 hourly 5-10 U of oxytocin in 500ml of RL Cesarean – previous 2 or more LSCS, placenta previa , transverse lie Post-partum suppression of lactation Bereavement management - counselling

25. Prolonged labor…

26. The labor is said to be prolonged when the combined duration of the first and second stage is more than the arbitrary time limit of 18 hours. Due to Protracted cervical dilatation Inadequate descent

27. Prolonged latent phase >20hrs in primi and >14hrs in multiparous women Causes Unripe cervix Malposition and malpresentation Cephalo -pelvic disproportion PROM Induction of labor Early onset of regional anesthetic Management: Rest and analgesia Augmentation (oxytocin or Prostaglandins) Not an indication for cesarean delivery

28. Causes… First stage (failure to dilate cervix) Fault in power: abnormal contraction(inertia), in-coordinated contraction Fault in passage: contracted pelvis, pelvic tumor or full bladder Fault in passenger: malposition and malpresentation , congenital anomalies(hydrocephalus) Injudicious use of sedatives and analgesics Second stage(non-descent) Fault in power: uterine inertia, exhaustion, analgesia, constriction ring Fault in passage: CPD, spasm or old scaring, tumor Fault in passenger: malposition and malpresentation , big baby, congenital malformation

29. Treatment… Prevention Antenatal detection Use of partograph Selective and judicious augmentation Change of posture, emotional support, avoid dehydration

30. Actual treatment First stage delay Verify fetal position and station Amniotomy and oxytocin infusion Pain relief LSCS if unsafe vaginal delivery Second stage delay Assisted delivery Forceps and vacuum delivery LSCS

31. Obstructed labor…

32. Obstructed labor is one where in spite of good uterine contractions, the progressive descent of the presenting part is arrested due to mechanical obstruction. Causes: Fault in passage Bony: CPD, contracted pelvis Soft tissue obstruction: cervical dystocia due to prolapse or previous operative scarring , cervical or broad ligament fibroid , impacted ovarian tumor or the non-gravid horn of a bicornuate uterus below the presenting part. Fault in passenger Transverse lie, brow presentation, hydrocephalus, fetal ascites, big baby, locked twins

33. Effect on mother Immediate: exhaustion, dehydration, genital sepsis, injury of genital tract, ruptured uterus, Remote: fistula, vaginal atresia Effect on fetus Asphyxia Intra-cranial haeorrhage Infection Fetal hypoxia and maternal acidosis

34. Treatment… Principles: Relieve obstruction Combat dehydration and ketoacidosis Control sepsis Obstetrics management Rule out rupture of uterus Vaginal delivery Cesarean section

35. Shoulder dystocia…

36. Shoulder dystocia occurs when either the anterior or the posterior (rare) fetal shoulder impacts on the maternal symphysis or on the sacral promontory respectively

37. Risk factors: Previous shoulder dystocia, Macrosomia (>4.5 kg), Diabetes , Obesity (BMI >30 kg/m2), Induced labor, Prolonged first stage or second stage of labor, Secondary arrest of labor, Postmaturity , Multiparity , Anencephaly , Mid-pelvic instrumental delivery (more following ventouse than forceps), Fetal ascites.

38. Complications: Fetal: asphyxia, brachial plexus injury, humerus fracture, clavicle or sternomastoid hematoma during delivery. Maternal: PPH (11%), cervical laceration, vaginal tear, perineal tear (3rd and 4th degree), rupture of uterus, bladder, sacroiliac joint dislocation and morbidity

39. Diagnosis: (1) Definite recoil of the head back against the perineum, (2) Inadequate spontaneous restitution , (3) Fetal face becomes plethoric, (4) Failure of shoulder to descend. Management principles: Extra help is to be called (a ) To clear infant’s mouth and nose (b ) Not to give traction over baby’s head (c ) Never to apply fundal pressure as it causes further impaction of the shoulder (d ) To perform wide mediolateral episiotomy as it provides space posteriorly ( e) To involve the anesthetist ( as analgesia is ideal) and the pediatrician (for infant’s resuscitation).

40. Treatment… Suprapubic pressure McRoberts maneuvre : Abbduct matermal thigh and hyperflex them onto abdomen. Apply suprapubic pressure Woods maneuvre : posterior shoulder is rotated to anterior position, Apply suprapubic pressure All fours position

41. Hydrocephalus… Excessive accumulation of cerebrospinal fluid (0.5–1.5 L) in the ventricles with consequent thinning of the brain tissue and enlargement of the cranium. Usually associated with congenital anomalies. Diagnosis: Larger, globular and softer head Head high-up in pelvis and impossible to push down FHS is high up above the umbilicus USG: Globular cranial shadow Wide fontanels and sutures with Thinner vault bones Dilated ventricles with thinning of cerebral cortex Internal examination Gaping sutures and fontanels Cracking sensation on pressing the head In breech presentation, however, the diagnosis is not made until the after coming head is arrested at the brim. Presence of open spina bifida points strongly toward hydrocephalus.

42. Management… Principle is to decompress the hydrocephalic head in labor either in vertex or in breech presentation . This is also done during cesarean delivery before incising the uterus. Bladder is evacuated before hand. Once the labor is established and the cervix is 3–4 cm dilated, decompression of the head is done by a sharp pointed scissors or with a wide bore (17 gauge) long needle.

43. Precipitate Labor…

44. A labor is called precipitate when the combined duration of the first and second stage is less than 3 hours . It is common in multiparae . Rapid expulsion is due to the combined effect of hyperactive uterine contractions associated with diminished soft tissue resistance. Maternal risks include: Extensive laceration of the cervix, vagina and perineum PPH due to uterine hypotonia that develops subsequent to unusual vigorous contractions , Inversion , Uterine rupture, Infection , Amniotic fluid embolism . The fetal risks include — intracranial stress and hemorrhage, bleeding from the torn cord and direct hit on the skull, brachial plexus injury are real hazards.

45. Treatment… The patient having previous history of precipitate labor should be hospitalized prior to labor. During labor, the uterine contraction may be suppressed by administering ether or magnesium sulfate during contractions. Delivery of the head should be controlled . Episiotomy should be done liberally . Elective induction of labor by low rupture of membranes and conduction of controlled delivery is helpful. Oxytocin augmentation should be avoided.

46. Rupture of Uterus…

47. Disruption in the continuity of the all uterine layers (endometrium, myometrium and serosa ) any time beyond 28 weeks of pregnancy is called rupture of the uterus. Causes: Spontaneous Pregnancy: dilatation and curettage, grand multipare congenital malformation of uterus, placenta percreta Labor: obstructed labor, grand multiparae Scar rupture Classical cesarean/ hysterotomy scar Iatrogenic Oxytocins , prostaglandins, fall or blow to abdomen, forceps, manual removal of placenta

48. Scar dehiscence — disruption of part of scar and not the entire length. fetal membranes remain intact . bleeding is almost nil or minimal. Scar rupture — disruption of the entire length of the scar. complete separation of all the uterine layers including serosa. rupture of the membranes with . varying amount of bleeding from the margins or from its extension. uterine cavity and peritoneal cavity become continuous. Fetus and placenta: may or may not escape out of the uterus

49. Diagnosis… Scar rupture: dull abdominal pain, slight PV bleeding, tender uterus, FHS irregular or absent, sense of give away with acute abdominal pain and collapse Labor: Distended tender lower segment with fetal distress or absent FHS Sense of give away, constant pain  dull aching pain, superficial fetal parts, absence of uterine contour, two distinct swelling PV – recession of presenting part, bleeding Shock, internal hemorrhage,

50. Management… Preventive: At risk patient – mandatory hospital delivery Judicious use of oxytocin Careful monitoring Avoid undue prolongation, vaginal birth, forceps delivery Treatment: Lapartomy : hysterectomy, repair or repair and sterilisation Resuscitation

51. Malposition, Mal-presentation Cord Prolapse

52. Malposition… Occiput-Posterior Position Malposition refers to any position of the vertex other than flexed occipito -anterior one. That is occiput lies over sacrum or sacro -iliac joint Causes: Shape of pelvis – anthropoid or android Anterior Low lying placenta Abnormal uterine contractions Abnormal fetal skull

53. Diagnosis… Abdomen: flat below umbilicus Palpation: Fetal limbs near midline and back in the flanks Head not engaged Auscultation: FHS heard on the flank or or the midline

54. Management… 90% cases: internal rotation of head by 3/8 th of a circle remaining as usual. 10% cases: no rotation or minimal rotation Assisted vaginal delivery Liberal episiotomy Cesarean section

55. Breech presentation…

56. Longitudinal lie with buttocks at the pelvic brim Complete: flexed breech Incomplete: varying degrees of extension Frank breech: with extended legs Footling presentation Knee presentation

57. Factors responsible… Unknown Prematurity Factors preventing spontaneous version: Frank breech, twins, oligohydraminous , short cord, IUD, congenital anomalies of uterus Hydrocephalus, placenta previa , contracted pelvis Trisomies , anencephaly

58. Complications… Maternal: Trauma to genital tract Operative delivery sepsis Fetal: Intra-partum fetal death Injuries to brain and skull: hemorrhage, fractures Birth asphyxia – d/t cord compression, prolapse, prolonged labor, respiration while still inside womb Birth injuries – hematoma, fractures, visceral injuries, nerve damage Congenital dislocation of hip

59. Diagnosis… Clinical USG: Confirms clinical diagnosis Type of breech

60. Management… Antenatal: Screening and identification External cephalic version Assisted vaginal breech delivery Elective cesarean delivery Criteria for vaginal breech delivery Avg fetal weight(1.5 – 3.5kgs) Flexed fetal head Adequate pelvis No any medical or obstetric complication Availabilty of OT and its components Indications of Cesarean Section (CS ): Cases seen for the first time in labor with presence of complications; Arrest in the progress of labor; Nonreassuring FHR pattern (Fetal distress ); Cord presentation or prolapse.

61. Vaginal breech delivery… Spontaneous: very little assistance Assisted breech: assistance from beginning to end Principle: Never to rush Never pull from below but push from above Always keep the fetus with the back anteriorly

62. Positioning and toileting Episiotomy Patient is asked to bear down, NO TOUCH TO THE FETUS policy is adopted till the buttocks are delivered (with legs in flexed breech) up to the trunk with the umbilicus. In frank breech: after buttocks are delivered – the extended legs is delivered by pressure on popliteal fossa in manner of abduction and flexion of the thighs. Umbilical cord is pulled and mobilised to one side If back is posterior – rotated to make back anterior Arms are delivered by hooking down each elbow with finger. Delivery of the head is the most crucial step

63. Delivery of the head should be within 5-10mins of delivery of umbilicus. Techniques: Burns-Marshall method Forcep delivery Malar flexion and shoulder traction Resuscitation of the baby Other methods in arrest of descent: Pinard’s method Loveset maneuvre

64. Transverse lie…

65. When the long axis of the fetus lies perpendicularly to the maternal spine or centralized uterine axis , it is called transverse lie. If obliquely placed – Oblique Lie Causes: Multiparity Prematurity Twins Hydraminos Contracted pelvis Placenta previa Pelvic tumors Congenital malformation of uterus IUD

66. Diagnosis… Inspection broader and often asymmetrical uterus Palpation Fundal height is less than period of amenorrhoea Fundal grip: empty Lateral grip: buttocks and head on either side of midline with back felt anteriorly Pelvic grip: empty Auscultation: FHS heard usually higher area PV: prolapse of hand/leg or a loop of cord

67. Management… Antenatal: admitted at 37 th wks – elective LSCS In ROM Early Labor: External cephalic version Cesarean section Late Labor: Baby alive – LSCS Baby dead – LSCS In macerated or premature baby (without ROM) Spontaneous rectification or version Spontaneous evolution Spontaneous expulsion

68. Cord prolapse…

69. Abnormal descent of the umbilical cord by the side of the presenting part Types Occult prolapse – cord is placed by the side of presenting part and not felt during PV Cord presentation – cord slips down below the presenting part and lies in the bag of membrane Cord prolapse – cord lies inside the vagina or outside the vulva following rupture of membrane

70. Causes Mal-presentation – transverse lie, breech with flexed legs or footling and compound presentation Contracted pelvis Prematurity Twins Hydraminos Placenta previa with marginal insertion of cord Iatrogenic – low ROM

71. Management… Cord presentation – DO NOT REPLACE CORD BACK If vaginal delivery contra-indicated – LSCS done Cord Prolapse Baby living Definitive t/t – LSCS If head engaged – forcep delivery If breech – breech extraction Bladder filling with 400-750ml NS done via catheter and clamped – lifts the presenting part of the compressed cord Baby dead Labor allowed to proceed – spontaneous delivery

72. Retained Placenta…

73. The placenta is said to be retained when it is not expelled out even 30 minutes after the birth of the baby (WHO 15 minutes). 3 steps – Separation, descent and finally expulsion Causes: Separated but retained – poor efforts to push Adherent placenta – atonic uterus, prolonged labor, uterine malformation Morbid adherent placenta Placenta incarcerated due to constriction ring

74. Dangers… Hemorrhage Shock Blood loss Retained for more than 1 hour Puerperal sepsis Recurrence in next pregnancy

75. Management… Period of watchful expectancy Empty bladder Controlled cord traction Manual removal of placenta Hysterectomy with or without partial cystectomy

76. Injuries to Birth Canal…

77. Perineum… While minor injury is quite common especially during first birth, gross injury (third and fourth degree) is invariably a result of mismanaged second stage of labor. Causes: Over-stretching – Outlet contraction Rapid stretching – Shoulder dystocia Elderly primigravida – Forceps delivery Big baby – Scar in perineum Nulliparity – Precipitate labor Mid-line episiotomy

78. Classification… First degree: Injury to perineal skin only Second degree: Injury to perineum involving perineal body (muscles) but not involving the anal sphincter Third degree: Injury to perineum, involving the anal sphincter complex (both external and internal) Fourth degree: Injury to perineum involving the anal sphincter complex (EAS and IAS) and anal epithelium

79. Management… Recent tear repaired immediately following delivery of placenta. Antibiotics given Positioning, toileting, local/general anesthesia Rectal and anal mucosa first sutured from above downwards (interrupted sutures) Then Rectal muscles  then torn ends of sphinchter (figure of 8 stitch) Repair of perineal muscles Vaginal wall and perineal skin

80. After care… High fiber diet from 3 rd diet from day 3 onwards Lactulose BD Antibiotics Physiotherapy and pelvic muscle exercise Sitz bath

81. Cephalo -Pelvic Disproportion

82. The disparity in the relation between the head and the pelvis is called cephalopelvic disproportion . Disproportion may be either due to an average size baby with a small pelvis or due to a big baby (hydrocephalus) with normal size pelvis or due to a combination of both the factors.

83. Diagnosis… Clinical: Previous history of spontaneous delivery of average size baby rules out CPD But in primigravida , non-engagement of head suggest CPD Abdominal method: head is pushed down and seen whether there is overlapping of symphysis pubis with parietal bones. Abdomino -vaginal methods: bimanual examination, to see if head can be pushed down towards ischial spine. Imaging: Lateral X-ray, USG measurement of bi-parietal diameter, MRI

84. Management… Inlet contraction: Spontaneous delivery Elective cesarean section Trial of labor Midpelvic and outlet disproportion: Elective cesarean section Assisted vaginal delivery Symphysiotomy Craniotomy if baby is dead

85. Injuries to Birth Canal…

86. Perineum… While minor injury is quite common especially during first birth, gross injury (third and fourth degree) is invariably a result of mismanaged second stage of labor. Causes: Over-stretching – Outlet contraction Rapid stretching – Shoulder dystocia Elderly primigravida – Forceps delivery Big baby – Scar in perineum Nulliparity – Precipitate labor Mid-line episiotomy

87. Classification… First degree: Injury to perineal skin only Second degree: Injury to perineum involving perineal body (muscles) but not involving the anal sphincter Third degree: Injury to perineum, involving the anal sphincter complex (both external and internal) Fourth degree: Injury to perineum involving the anal sphincter complex (EAS and IAS) and anal epithelium

88. Management… Recent tear repaired immediately following delivery of placenta. Antibiotics given Positioning, toileting, local/general anesthesia Rectal and anal mucosa first sutured from above downwards (interrupted sutures) Then Rectal muscles  then torn ends of sphinchter (figure of 8 stitch) Repair of perineal muscles Vaginal wall and perineal skin

89. After care… High fiber diet from 3 rd diet from day 3 onwards Lactulose BD Antibiotics Physiotherapy and pelvic muscle exercise Sitz bath

90. Post partum hemorrhage…

91. The amount of blood loss in excess of 500 mL following birth of the baby (WHO). “any amount of bleeding from or into the genital tract following birth of the baby up to the end of the puerperium , which adversely affects the general condition of the patient evidenced by rise in pulse rate and falling blood pressure is called postpartum hemorrhage.

92. Minor (<1L) Major (>1L) Severe(>2L) Types Primary: within 24hrs of birth of baby Secondary: beyond 24hrs

93. Causes… Atonic uterus Traumatic Retained tissues Blood coagulopathy

94. Prevention ANC Improve health status High-risk patient screened Blood grouping and arrangement of blood Placental localisation Intra-natal Active management of 3 rd stage Oxytocin infusion for 1 hour Observation Examination of placenta

95. Management… Call for help Two wide bore iv cannulas for iv fluids Send for cross-matching and ask for 2pints of blood Oxytocin 10U IM Catheterize bladder Antibiotics Manual removal of placenta(not done) Monitor vitals

96. Atonic uterus… Step 1: Massage uterus to make it hard, methergine 0.2mg iv, oxytocin infusion 10-20U in 500ml NS, iv tranexamic acid 1gm in 100ml NS @1ml/min Examine expelled placenta Step 2: Exploration under general anesthesia, blood transfusion, continue oxytocin drip Misoprotol 800mcg per rectum Step 3: Uterine massage and bimanual compression Step 4: Uterine tamponade (tight packing/ ballooon tamponade )

97. Step 5: Surgical control B-lynch compression sutyre Ligation of uterine arteries Ligation of ovarian and uterine artery anastomosis Step7: hysterectomy

98. Episiotomy…

99. A surgically planned incision on the perineum and the posterior vaginal wall during the second stage of labor is called episiotomy ( perineotomy ). It is in fact an inflicted second-degree perineal injury. It is the most common obstetric operation performed. Objective: Enlarge vaginal introitus Minimize tear or rupture of perineal muscle

100. Indication… Rigid perineum Anticipating tear: big baby, breech delivery, shoulder dystocia Operative delivery: vacuum, forcep Previous perineal surgery TIMING Bulging thin perineum during contraction just prior to crowning (3-4cm of head visible)

101. Structures cut Posterior vaginal wall Superficial and deep perineal muscles, levator ani Fascia covering these muscles, Transverse perineal branches of pudendal vessels and nerves Subcutaneous skin and fat Steps Antisepsis, local anesthesia Incision and then delivery of fetus Repair Vaginal mucosa and sub-mucosal tissues Perineal muscles Skin and Subcutaneous tissues

102. Complications… Immediate: (1) Extension of the incision to involve the rectum. (2) vulval hematoma (3) infection: the clinical features are—(a) throbbing pain on the perineum (b) rise in temperature (c) the wound area looks moist, red and swollen and (d) offensive discharge comes out through the wound margins. (IV). (4) Wound dehiscence is often due to infection, hematoma formation or faulty repair. (5) Injury to anal sphincter causing incontinence of flatus or feces. (6) Rectovaginal fistula and rarely. (7) Necrotizing fasciitis (rare) in a woman who is diabetic or immunocompromised . Remote : ( 1) Dyspareunia ( 2) chance of perineal lacerations (3 ) scar endometriosis (rare ) .

103. Post op care… Dressing each time following urination and defecation Relieve pain: MgSO4 compression, ice packs and analgesic Ambulance after 24 hours Sitz bath