GENITAL INJURIES and various degrees of tear.pptx

Maternal injuries following childbirth process are quite common and contribute significantly to maternal morbidity and even to death.
Prevention, early detection and prompt and effective management not only minimize the morbidity but prevent many gynecological problems from developing later in life

1. GENITAL INJURIES

2. Maternal injuries following childbirth process are quite common and contribute significantly to maternal morbidity and even to death. Prevention , early detection and prompt and effective management not only minimize the morbidity but prevent many gynecological problems from developing later in life.

3. VULVAL TEARS Lacerations of the vulval skin posteriorly and the paraurethral tear on the inner aspect of the labia minora are the common sites. Paraurethral tear may be associated with brisk hemorrhage and should be repaired by interrupted catgut sutures, preferably after introduction of a rubber catheter into the bladder to prevent injury of the urethra.

4. PERINEAL TEARS Gross injury (third and fourth degree) is invariably a result of mismanaged second stage of labor . CAUSES: Perineal injury (mainly the third and fourth degree) results from ( i ) over stretching and/ or ( ii) 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 perineum when it is likely to be damaged is essential.    

5. Risk Factors for Third Degree Perineal Tear Bigbaby (weight >3kg) Nulliparity Outlet contraction with narrow pubic arch Shoulder dystocia Forceps delivery Scar in the perineum ( perineorrhaphy,episiotomy ) Face to pubis delivery Midline episiotomy Precipitate labor

6. Classification of Obstetric Anal Sphincter Injury (RCOG–2007 ) 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) 3a:<50 % of EAS thickness torn3b :> 50%of EAS thickness torn3c:Both EAS and IAS torn Fourth degree: Injury to perineum involving the anal sphincter complex (EAS and IAS) and anal epithelium (Fig. 29.1)

7. DEGREES OF PERINEAL TEARS

8. Recent tear should be repaired immediately following the delivery of the placenta . This reduces the chance of infection and minimizes the blood loss. In cases of delay beyond 24hours , the repair is withheld and it should be done after 3 months Antibiotics should be started to prevent infection . Step I : Patient is put in lithotomy position. Antiseptic cleaning of the local area is done. Repair may be done with local infiltration of 1% lignocaine hydrochloride (10–15 mL ) or with pudendal block or preferably under regional or general anesthesia.

9. StepII : (a) The rectal and anal mucosa is first sutured from above downward.No .“ 3-0”vicrylor3-0 PDS, atraumatic needle,interrupted stitches with knots inside the lumen are used. (b) The rectal muscles including the pararectal fascia are then sutured by interrupted sutures using the same suture material. (c) The torn ends of the sphincter ani externus (EAS) are then exposed by Allis’s tissue forceps. The sphincter is then reconstructed with a figure of eight stitch,and it is supported by another layer of interrupted sutures. IAS repair is done by interrupted suture.

10. Step III: Repair of perineal muscle is done by interrupted sutures using No. “0” PDS or dexon or polyglactin ( vicryl ). StepIV: T he vaginal wall and the perineal skin are apposed by interrupted sutures. Suture material: For repair ofEAS , monofilament sutures such as polydioxanone (PDS) or polyglactin ( vicryl ) can be used. Repair of IAS is done with fine suture size such as 3-0 PDS and 2-0 vicryl as they cause less irritation and discomfort.

11. AFTERCARE: ( 1)Allow residual diet consisting of milk , bread, egg, biscuits, fish , sweets, etc. is given from third day onward. ( 2) Lactulose 8 mL twice daily beginning on the second day and increasing the dose to 15mL on the third day is a satisfactory regime to soften the stool. (3)Any one of the broad-spectrum antibiotics (IVcefuroxime1.5g) is used during the intraoperative and the postoperative period. (4) Metronidazole 400mgth rice daily is to be continued for 5–7 days to cover the anaerobic contamination of fecal matter. (5)The woman is advised physiotherapy and pelvic floor exercises and she is reviewed again 6–12 weeks postpartum.

12. PLAN FOR FUTURE DELIVERY: All women need to have institutional delivery following repair of obstetric sphincter injury. Vaginal delivery may be allowed in a selected case with or without episiotomy. Women having symptoms or with abnormal endoanal USG and/or manometry should be delivered by elective cesarean birth.

13. VAGINAL TEARS These are usually seen following instrumental or manipulative delivery and often associated with brisk hemorrhage. TREATMENT : Tears associated with brisk hemorrhage require exploration under general anesthesia with a good light. The tears are repaired by interrupted or continuous sutures using chromic catgut No . “0 ”. In case of extensive lacerations , in addition to sutures,hemostasis may be achieved by intravaginal plugging by roller gauze, soaked with glycerin and acriflavine . The plug should be removed after 24hours . Selective arterial embolization may also be done if bleeding persists.

14. COLPORRHEXIS Rupture of the vault of the vagina is called colporrhexis . It may be primary where only the vault is involved or secondary when associated with cervical tear (common). It is said to be complete when the peritoneum is opened up. Posterior fornix usually ruptures, however, cervical tear is usually associated with tear of the lateral fornix. TREATMENT — If the tear is limited to the vault close to the cervix, the repair is done from below. If, however, the cervical tear extends high up into the lower segment or major branches of uterine vessels are damaged, laparotomy is to be done simultaneously with resuscitative measures. Evacuation of hematoma and arterial ligation may be needed.  

15. CERVICAL TEARS Minor degree of cervical tear is invariable during first delivery and requires no treatment. It is the commonest cause of traumatic postpartum hemorrhage . Left lateral tear is the commonest . CAUSES : Iatrogenic —Attempted forceps delivery or breech extraction through incompletely dilated cervix . Rigid cervix —This may be congenital or more commonly following scar from previous operations on the cervix like amputation, conization or presence of a lesion like carcinoma cervix. Strong uterine contractions as in precipitate labor or extremely vascular cervix as in placenta previa .

16. DIAGNOSIS : Excessive vaginal bleeding immediately following delivery in presence of a hard and contracted uterus—raises the suspicion of a traumatic bleeding . Exploration of the uterovaginal canal under good light not only confirms the diagnosis but also helps to know the extent of the tear. DANGERS: Early — ( 1)Deep cervical tears involving the major vessels lead to severe postpartum hemorrhage . ( 2)Broad ligament hematoma. (3)Pelvic cellulitis . ( 4) Thrombophlebitis . Late — ( 1) Ectropion . (2) Cervical incompetence with mid trimester abortion .

17. TREATMENT : Only deep cervical tear associated with bleeding should be repaired soon after delivery of the placenta under local or general anesthesia. Procedure : The anterior and posterior margins of the torn cervix are grasped by the sponge holding forceps. Instead of giving traction to the forceps, it is better to push down the fundus gently by the assistant.This makes the tear more accessible for effective suturing.

18. Repair of cervical tear with vertical mattress suture

19. The apex is to be identified first and the first vertical mattress suture is placed just above the apex using polyglactin ( vicryl ) or chromic catgut No .“ 0”taking whole thickness of the cervix. The bleeding stops immediately . The rest of the tear is repaired by similar mattress sutures. A helpful guide for proper exposure in such a case is to start suture at the proximal end and using the suture for traction, more distal tear area is exposed until the apex is in view and is repaired .

20. PELVIC HEMATOMA DEFINITION: Collection of blood any where in the area between the pelvic peritoneum and the perineal skin is called pelvic hematoma . ANATOMICAL TYPES: 1) Infralevatorhematoma —common 2) Supralevatorhematoma —rare

21. INFRALEVATOR HEMATOMA Commonest one is v ulval hematoma

22. Etiology : (1)Improper hemostasis during repair of vaginal or perineal tears or episiotomy wound— (a)Failure to take precaution while suturing the apex of the tear (b)Failure to obliterate the deadspace while suturing the vaginal walls. (2) Rupture of paravaginal venous plexus either spontaneously or following instrumental delivery.

23. Symptoms : (1) Persistent, severe pain on the perineal region. (2) There may be rectal tenesmus or bearing down efforts when extension occurs to the ischiorectal fossa . There may be even retention of urine. Signs: (1)Variable degrees of shock may be evident. (2)Local examination reveals a tense swelling at the vulva which becomes dusky and purple in color and tender to touch. Treatment : A small hematoma (<5 cm) may be treated conservatively with cold compress. Larger hematomas should be explored in the operation theater under general anesthesia. Simultaneous resuscitative measures are to be taken. The blood clots are to be scooped out and the bleeding points are to

24. SUPRALEVATOR HEMATOMA

25. Causes — (1)Extension of cervical laceration or primary colporrhexis (vault rupture). (2) Lower uterine segment rupture. (3) Spontaneous rupture of paravaginal venous plexus adjacent to the vault. Diagnosis : Unexplained shock with features of internal hemorrhage following delivery raises the suspicion. Abdominal examination reveals a swelling above the inguinal ligament pushing the uterus to the contralateral side.

26. Vaginal examination reveals ( a) occlusion of the vaginal canal by a bulge or (b) a boggy swelling felt through the fornix. Rectal examination Corroborates the presence of the boggy mass. Ultrasonography may be needed for exact localization of the hematoma. Management : Usual treatment of shock is to be instituted and arrangement is made for laparotomy .

27. RUPTURE OF THE UTERUS DEFINITION : 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.

28. ETIOLOGY 1)Spontaneous 2)Scar Rupture 3)Iatrogenic SPONTANEOUS During pregnancy : The causes are : ( 1) Previous damage to the uterine walls following dilatation and curettage operation or manual removal of placenta. (2)Rarely in grand multiparae due to thin uterine walls. ( 3)Congenital malformation of the uterus ( bicornuate variety) is a rare possibility. ( 4) In Couvelaire uterus Spontaneous rupture during pregnancy is usually complete , involves the upper segment and usually occurs in later months of pregnancy.

29. During labor : Spontaneous rupture which occurs predominantly in another wise intact uterus is due to: Obstructive rupture — This is the end result of an obstructed labor. The rupture involves the lower segment and usually extends through one lateral side of the uterus to the upper segment. Non obstructive rupture —Grand multiparae are usually affected and rupture usually occurs in early labor. The rupture usually involves the fundal area and is complete.

30. SCAR RUPTURE: With the liberal use of primary cesarean section,scar rupture constitutes significantly to the overall incidence of uterine rupture. The incidence of lower segment scar rupture is about 1–2 %, while that following classical one is 5–10 times higher .

31. During pregnancy : Classical cesarean or hysterotomy scar is likely to give way during later months of pregnancy . The weakening of such scar is due to implantation of the placenta over the scar and consequent increased vascularity . Lowersegmentscar rarely ruptures during pregnancy . During labor : The classical or hysterotomy scar or cornual resection for ectopic pregnancy is more vulnerable to rupture during labor. Although rare, lower segment scar predominantly ruptures during labor.

32. IATROGENIC OR TRAUMATIC During pregnancy : (1)In judicious administration of oxytocin . (2)Use of prostaglandins for induction of abortion or labor . ( 3) Forcible external version especially under general anesthesia . ( 4) Fall or blow on the abdomen. During labor : ( 1) Internal podalic version—especially following obstructed labor. ( 2) Destructive operation. ( 3) Manual removal of placenta . ( 4) Application of forceps or breech extraction through incompletely dilated cervix . (5)In judicious administration of oxytocin for augmentation of labor .

33. TYPES: Incomplete rupture : Peritoneal coat not involved usually results from rupture of the lower segment scar or extension of a cervical tear into the lower segment with formation of a broad ligament hematoma. Complete rupture : peritoneal coat involved usually occurs following disruption of the scar in upper segment. It may also be due to spontaneous rupture of both obstructive and non obstructive type.

34. Dehiscence and scar rupture Scar dehiscence — (a)disruption of part of scar and not the entire length . (b) fetal membranes remain intact . (c) bleeding is almost nil or minimal. Scar rupture — ( a) disruption of the entire length of the scar. (b)complete separation of all the uterine layers including serosa . ( c) rupture of the membranes with. ( d) varying amount of bleeding from the margins or from its extension. (e)uterine cavity and peritoneal cavity become continuous.

35. FETUS AND PLACENTA: In incomplete rupture , both the fetus and placenta remain inside the uterine cavity or part of the fetus may occupy in between the layers of broad ligament. In complete rupture , the fetus with or without the placenta usually escapes out of the uterus . The uterus remains contracted .

36. DIAGNOSIS OF RUPTURE UTERUS During Pregnancy: Scar Rupture : Classical or hysterotomy — 1)The patient complains of a dull abdominal pain over the scar area with slight vaginal bleeding. 2) FHS may be irregular or absent. The features may not be always dramatic in nature (silent phase).Sooner or later, the rupture becomes complete. 3)There is a sense of something giving way accompanied by acute abdominal pain and collapse.

37. DURING LABOR Scar rupture : Classical or hysterotomy scar rupture— The features are the same as those occur during pregnancy. The onset is usually acute. Lower segment scar rupture— The onset is insidious. There is no classical feature of lower segment scar rupture. The confirmation is by laparotomy . The features of scar rupture are not as dramatic as those following obstructed labor (vide infra) and hence called “silent rupture”.

38. DURING PREGNANCY Spontaneous The rupture is usually confined to the high parous women. In acute types, the patient has acute pain abdomen with fainting attacks and may collapse. The diagnosis is established by the presence of features of 1)shock, 2)acute tenderness on abdominal examination, 3)palpation of superficial fetal parts,if the rupture is complete and 4)absence of fetal heart rate. However , with insidious onset , the diagnosis is often confused with concealed accidental hemorrhage or rectus sheath hematoma .

39. Rupture following fall, blow or external version or use of oxytocics —There is history of such an accident followed by acute pain abdomen and slight vaginal bleeding. Rapid pulse and tender uterus raise the suspicion of rupture. The confirmation is done by laparotomy . This is too often confused with accidental hemorrhage .

40. DURING LABOR Spontaneous obstructive rupture: Premonitory phase : The patient is usually a multipara who is in labor with features of obstruction. Initially, the pains become severe in an attempt to overcome the obstruction and come at quick intervals. Gradually, the pains become continuous and mainly confined to the suprapubic region. On examination , 1)dehydrated and exhausted. 2)rise in pulse rate and temperature. Abdominal examination reveals 1) distended tender lower segment. 2) B andl’s ring may be visible 3) evidences of fetal distress or FHS may be absent. On vaginal examination, 1)the presenting p art is found jammed in the pelvis, 2) vagina becomes dry and edematous.

41. Phase of rupture: ( 1) There is a sense of some thing giving way at the height of uterine contraction . (2)The constant pain is changed to dull aching pain with cessation of uterine contractions. (3) General examination reveals features of exhaustion and shock. (4) Abdominal examination reveals — ( i )superficial fetal parts, (ii)absence of FHS, (iii)absence of uterine contour and (iv)two separate swellings, one contracted uterus and the other—fetal ovoid. ( 5) Vaginal examination reveals— ( i ) recession of the presenting part and ( ii) varying degrees of bleeding

42. Spontaneous non obstructive rupture : This is rare and solely confined to high parous women. The patient at the height of uterine contraction is suddenly seized with an agonizing bursting pain followed by a relief , with cessation of contractions. The diagnostic features of the catastrophe are —1)presence of shock, 2)evidences of internal hemorrhage, 3)tenderness over the uterus and 4) varying amount of vaginal bleeding.

43. Rupture following manipulative or instrumental delivery: Sudden deterioration of the general condition of the patient with varying amount of vaginal bleeding following manipulative or instrumental delivery raises the suspicion. Exploration of uterus to feel the rent confirms the diagnosis . Shortening of the cord immediately following a difficult vaginal delivery is pathognomonic of uterine rupture , the placenta being extruded out into the abdominal cavity, through the rent in the uterus.

44. MANAGEMENT OF RUPTURE UTERUS TREATMENT: 1)Resuscitation 2) 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. LAPAROTOMY: Hysterectomy : Hysterectomy is the surgery for rupture uterus unless there is sufficient reason to preserve it. Quick subtotal hysterectomy , rather than total hysterectomy .

45. Repair and sterilization : This is mostly done in patients with a clean cut scar rupture having desired number of children. To tackle a broad ligament hematoma.

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