COMPLICATIONS OF THE THIRD STAGE OF LABOR :INJURIES_TO_THE_BIRTH_CANAL.pptx

COMPLICATION OF THIRD STAGE OF LABOR :INTRODUCTION :Maternal birth canal injuries during child birth process are quite common and significant to maternal morbidity and even to death .Second most frequent cause of PPH .Prevention, earldetection, prompt and effective management are essential to minimize the morbidity and gynecological problems in later life .CLASSIFICATION OF INJURY
Depending on anatomical structure involved,Injury to bony parts –symphysis pubis , sacro-coccygeal joint , sacro-iliac joint,Injury to soft tissues-vulva ,perineal tear ,laceration to vagina or cervix , rupture of uterusCAUSES OFINJURY�:Incomplete dilatationcervix,InstrumentationPrecipitate labor,Protracted labor due to boderline CPD ,obstructed labor iaotrogenic
INJURIES TO SOFT TISSUES:� VULVA :Lacerations: laceration of the vulval skin posteriorly
Paraurethral tear on the inner aspect of the labia minora PERINEAL TEAR:1% of all the vaginal deliveries.Causes :overstretching and /or Rapid stretching of the perineum especially when the perineum is inelastic ( elderly primigravida , perineal scar)PREVENTION :Proper conduct in the second stage of labor.Taking due care of the perineumMANAGEMENT
RECENT TEAR :-repair immediately following the delivery of the placenta
-reduces the chances of infection and minimize the blood loss.DELAY BEYOND 24 HOURS- Repear should be withheld- Antibiotics to be started .The complete tear should be repair after 3 months if delayed beyond 24 hours’
REPAIR OF COMPLETE PERINEAL TEAR :Patient is put in lithotomy position . Antiseptic cleaning . Repair can be done with local infiltration of 1% lignocaine hydrochloride / regional or general anaesthesia-The rectal and anal mucosa is first suture fromabovEdownward(interrupted stitches with knots inside the lumen. -the rectal muscles including the pararectal fascia
-the torn ends of sphincter ani externus (overlapping or end to end approximation method for repair.Repair of perineal muscle done by interrupted sutures.4.The vaginal wall and the perineal skin are opposed by interrupted sutures.Repair of perineal muscle done byinterrupted sutures.4.The vaginal wall and the perineal skin are opposed by interrupted suturesVAGINAL TEAR :Isolated vaginal tears or lacerations without involvement ofperineum or cervix areuncommon.Usually seen following instrumental or manipulative delivery .In such cases ,the tears are extensive and often associated with brisk hemorrhage.CERVICAL TEAR :Minor degree of cervical tear is invariable during first delivery and requires no treatment .Extensive tear is rare. It is the commonest cause of traumatic post partum hemorrhage .RUPTURE OF THE UTERUS :DEFINITION : Disruption in the continuity of the all uterine layers any time beyond 28th weeks of pregnancy is called rupture of the uterus.INCIDENCE :1 in 2000 to 1 in 200deliveries.ETIOLOGY1.Spontaneous2.Scar rupture3.Iatrogenic MANAGEMENT RESUSCITATION,LAPAROTOMY.Hysterectomy,Repair ,sterilization

1. COMPLICATIONS OF THIRD STAGE : INJURIES TO BIRTH CANAL URIKKHINBAM SONIA MSC (N) OBG

2. INJURIES TO THE BIRTH CANAL INTRODUCTION Maternal birth canal injuries during child birth process are quite common and significant to maternal morbidity and even to death . Second most frequent cause of PPH . Prevention, early detection, prompt and effective management are essential to minimize the morbidity and gynecological problems in later life

3. DEFINITION OF BIRTH CANAL The passage through which the fetus is expelled during parturition , leading from the uterus through the cervix , vagina and vulva. Structure of birth canal : bones-pelvis, soft tissues-vulva ,vagina , cervix and perineum. Vagina ,vulva and perineum are often injured during the expulsion of labour .

4. CLASSIFICATION OF INJURY Depending on anatomical structure involved Injury to bony parts – symphysis pubis , sacro -coccygeal joint , sacro -iliac joint Injury to soft tissues -vulva ,perineal tear ,laceration to vagina or cervix , rupture of uterus

5. CAUSES OF INJURY Incomplete dilatation of cervix Instrumentation Precipitate labor Protracted labor due to boderline CPD obstructed labor iotrogenic

6. INJURIES TO SOFT TISSUES : VULVA Lacerations: laceration of the vulval skin posteriorly Paraurethral tear on the inner aspect of the labia minora PERINEAL TEAR 1% of all the vaginal deliveries Causes overstretching and /or Rapid stretching of the perineum especially when the perineum is inelastic ( elderly primigravida , perineal scar)

7. CLASSIFICATION OF OBSTETRIC ANAL SPHINCTER INJURY TYPE DESCRIPTION FIRST DEGREE Injury to perineal skin only SECOND DEGREE Injury to perineal involving perineal muscles but not involving the anal sphincter THIRD DEGREE Injury to perineum , involving the anal sphincter complex FOURTH DEGREE Injury to perineum , involving the anal sphincter complex and anal epithelium

8. PREVENTION Proper conduct in the second stage of labor Taking due care of the perineum MANAGEMENT RECENT TEAR : - repair immediately following the delivery of the placenta -reduces the chances of infection and minimize the blood loss. DELAY BEYOND 24 HOURS - Repear should be withheld - Antibiotics to be started . The complete tear should be repair after 3 months if delayed beyond 24 hours’

9. REPAIR OF COMPLETE PERINEAL TEAR Patient is put in lithotomy position . Antiseptic cleaning . Repair can be done with local infiltration of 1% lignocaine hydrochloride / regional or general anaesthesia -The rectal and anal mucosa is first suture from above downward(interrupted stitches with knots inside the lumen. -the rectal muscles including the pararectal fascia -the torn ends of sphincter ani externus (overlapping or end to end approximation method for repair.

10. Contd. 3.Repair of perineal muscle done by interrupted sutures. 4.The vaginal wall and the perineal skin are opposed by interrupted sutures

11. AFTER CARE Similar to episiotomy care Special care include: - low residual diet consisting of milk ,bread ,egg ,fish ,etc are given from the third day onward . -lactulose 8ml twice daily beginning on the second day then 15ml on the third day to soften the stool. Broad spectrum antibiotic : cefuroxime 1.5 gm ,iv is used during intra and post operative period . Metronidazole 400 mg ,TID for 5-7 days. pelvic floor exercise and physiotherapy is advised. Follow up 6-12 week postpartum.

12. VAGINAL TEAR Isolated vaginal tears or lacerations without involvement of perineum or cervix are uncommon. Usually seen following instrumental or manipulative delivery .In such cases ,the tears are extensive and often associated with brisk hemorrhage .

13. CAUSES Can be traumatic or spontaneous Occur Forceps delivery , fetal malpresentation , large fetal head and insufficient distensibility of vaginal wall .

14. TREATMENT Tears associated with brisk hemorrhage -Exploration under general anaesthesia -Repair by interrupted or continuous sutures using chromic catgut No.``0”. Extensive laceration -addition to suture , hemostasis may be achieved by intravaginal plugging by roller gauze ,soaked with glycerin and acriflavine .The plug should be removed after 24 hours. -selective arterial embolization may also be done if bleeding persists .

15. COLPORRHEXIS Rupture of the vault of the vagina May be -Primary (vault only) -Secondary associated with cervical tear ( common), or -Complete ( peritoneum is opened up)

16. CERVICAL TEAR Minor degree of cervical tear is invariable during first delivery and requires no treatment Extensive tear is rare. It is the commonest cause of traumatic post partum hemorrhage .

17. CAUSES Iatrogenic - attempted forceps delivery or breech extraction through incompletely dilated cervix Rigid cervix- congenital or scar Strong uterine contractions-precipitate labor Detachment of cervix

18. DIAGNOSIS Excessive vaginal bleeding immediately following delivery in presence of hard and contracted uterus . DANGERS Early –deep cervical tear –severe post partum hemorrhage , broad ligament hematoma, pelvic cellulitis, thrombophlebitis late - ectropion, cervical incompetence

19. TREATMENT Repair should be done immediately after delivery under general anaesthesia

20. PELVIC HEMATOMA DEFINITION : Collection of blood anywhere in the area between the pelvic peritoneum and the perineal skin is called pelvic hematoma . ANATOMICAL TYPES Infralevator hematoma : commonest one is vulval hematoma. Supralevator hematoma : rare

21. INFRALEVATOR HEMATOMA Below the levator ani muscle usually around vulva ,perineum and lower vagina AETIOLOGY Improper hemostasis during repair of vaginal or perineal tear or episiotomy wound rupture of the paravaginal venous

22. SIGNS Variable degree of shock may be evident Local examination reveals a tense swelling at the vulva SYMPTOMS Persistent ,severe pain on the perineal region There may be rectal tenesmus or bearing down efforts when extension occurs to the ischiorectal fossa ,even retention of urine

23. TREATMENT Small hematoma may be treated conservatively with cold compression Larger hematoma -exploration under general anaesthesia simultaneously resuscitation measures are to be taken -blood clots are scooped out and the bleeding points are to be secured The dead space is to be obliterated by deep mattress sutures and a closed suction drain may be kept in that place for 24 hours Prophylactic antibiotic is to be administered.

24. SUPRALEVATOR HEMATOMA Spread upwards and outwards beneath the broad ligament downward to bulge into the wall of the upper vagina or backward into the retroperitoneal space. CAUSES Extension of cervical laceration or primary colporrhexis Lower uterine segment rupture Spontaneous rupture of paravaginal venous plexus adjacent to the vault

25. MANAGEMENT Shock management Laparotomy –blood clot is scooped out . The bleeding points ,if visible ,are to be secured and ligated .

26. RUPTURE OF THE UTERUS DEFINITION : Disruption in the continuity of the all uterine layers any time beyond 28 th weeks of pregnancy is called rupture of the uterus. INCIDENCE 1 in 2000 to 1 in 200 deliveries.

27. ETIOLOGY The cause of rupture of the uterus is broadly divided into : 1. Spontaneous 2. Scar rupture 3. Iatrogenic

28. SPONTANEOUS DURING PREGNANCY Previous damage to the walls following D & C or manual removal of placenta Rarely –thin uterine wall in grand multipara or congenital malformation of the uterus Spontaneous rupture during pregnancy is usually complete , involves the upper segment and usually occur in the later stage of pregnancy.

29. Contd. DURING LABOR - obstructed labor : the rupture involve lower segment. -grand multiparae : usually involve fundus and complete.

30. SCAR RUPTURE AETIOLOGY -History of previous caesarean section , hysterectomy ,myomectomy , etc During pregnancy , lower segment scar are rarely ruptures but during labor , lower segment scar predominately rupture.

31. IATROGENIC OR TRAUMATIC During pregnancy -injudicious administration of oxytocin -use of prostaglandins for induction of labor -forcible external version Fall or blow on the abdomen During labor Internal podalic version Manual removal of placenta Forceps or breech extraction Destructive operation Injudicious administration of oxytocin .

32. Classification Of Uterine Rupture Based on the etiology Scarred uterus rupture Unscarred uterus rupture . Based on pathogenesis Spontaneous Voluntary Based on the layers of the uterus involved Complete incomplete

33. DIAGNOSIS OF RUPTURE UTERUS scar rupture classical or hysterotomy -dull abdominal pain over the scar area with slight vaginal bleeding -varying degree of tenderness on uterine palpation. -FHS may be irregular or absent . - Sooner or Later ,the rupture become complete . There is a sense of something giving away accompanied by acute abdominal pain and collapse.

34. Cntd . Spontaneous rupture in unscarred uterus -In acute type , acute pain of abdomen with fainting attacks and may collapse -feature of shock , acute tenderness on abdominal examination , palpation of superficial fetal parts ,if complete rupture and absence of fetal heart rate .

35. Rupture following fall , blow ,or external version or use of oxytocin History of such accident followed by acute abdominal pain and slight vaginal bleeding Rapid pulse Tender uterus Confirmation is done by laparotomy .

36. rupture following manipulative or instrumental delivery Sudden deterioration of the general condition of the patient with varying degree of vaginal bleeding diagnosis is not revealed until after varying intervals following development of Shock or broad ligament hematoma or peritonitis

37. MANAGEMENT - RESUSCITATION - LAPAROTOMY Depending upon the state of the clinical condition, either resuscitation is to be done followed by laparotomy Or in acute conditions , resuscitation and laparotomy are to be done simultaneously.

38. Contd. LAPAROTOMY : Any of the three procedures may be adopted following laparotomy Hysterectomy - For rupture uterus unless there is sufficient reason to preserve it . Repair – Applicable to a scar rupture where the margins are clean Repair and sterilization – For clean cut scar rupture having desired number of number of children .