InjuriesToBirthCanal_OBG_125-127_2024_Final.pptx

Injuries to birth canal

1. GENITAL TRACT INJURIES Presented by 125 – Vedant sethi 126 – vivek hesarur 127 – Yamini rai

2. Specific Learning Objectives OG 19.3 Discuss various injuries to the birth canal and its management.

3. Vulval Injury 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. Perineum Injuries Causes Perineal injury (mainly the third and fourth degree) results from ( i ) over stretching and (ii) rapid stretching of the perineum especially when the perineum is inelastic (elderly primigravida, perineal scar). Prevention Delivery by early extension is to be avoided Spontaneous forcible delivery of the head is to be avoided by assuring the patient not to bear down during contractions. To deliver the head in between contractions . To perform timely episiotomy (when indicated). To take care during delivery of the shoulders as the wider bisacromial diameter (12 cm) emerges out of the introitus.

5. Delivery of the shoulders: Not to be hasty in delivery of the shoulders . T he bisacromial diameter is placed in the anteroposterior diameter of the pelvis. During the next contraction, the anterior shoulder is born behind the symphysis. If there is delay, the head is grasped by both hands and is gently drawn posteriorly until the anterior shoulder is released from under the pubis. By drawing the head in upward direction, the posterior shoulder is delivered out of the perineum. Traction on the head should be gentle. Delivery of the trunk: the fore finger of each hand are inserted under the axillae and the trunk is delivered gently by lateral flexion .

6. Management of Perineal Tear Recent tear should be repaired immediately following the delivery of the placenta In cases of delay beyond 24 hours , the repair is to be withheld. Antibiotics should be started to prevent infection. The complete tear should be repaired after 3 months if delayed beyond 24 hours .

7. Step I: Patient is put in lithotomy position. Antiseptic cleaning of the local area is done. Step II ; The rectal and anal mucosa is first sutured from above downward. No. “3-0” vicryl or 3-0 PDS, atraumatic needle, interrupted stitches with knots inside the lumen are used. The rectal muscles including the pararectal fascia are then sutured by interrupted sutures using the same suture material - The torn ends of the sphincter ani externus (EAS) are then exposed by Allis’s tissue forceps. For repair of EAS either an overlapping or end-to-end approximation method can be used with similar outcome Step III: Repair of perineal muscle is done by interrupted sutures using No. “0” PDS or dexon or polyglactin ( vicryl ). Step IV: The vaginal wall and the perineal skin are apposed by interrupted sutures.

8. AFTERCARE: L ow residual diet Lactulose 8 mL twice daily IV cefuroxime 1.5 g is used during the intraoperative and the postoperative period. Metronidazole 400 mg thrice daily is to be continued for 5–7 days.

9. Vaginal Injuries Isolated vaginal tears or lacerations without involvement of the perineum or cervix are not uncommon. Treatment ; 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. COLPORRHEXIS: Rupture of the vault of the vagina is called colporrhexis .

10. Cervical Injury It is the commonest cause of traumatic postpartum hemorrhage . Left lateral tear is the commonest. CAUSES: (1) Iatrogenic – attempted forceps delivery or breech extraction through incompletely dilated cervix . (2) Rigid cervix – it is more commonly following scar from previous operations on the cervix like amputation, conization or presence of a lesion like carcinoma cervix (3) Strong uterine contractions as in precipitate labor or extremely vascular cervix as in placenta previa. (4) Detachment - may be annular which involved the entire circumference of the cervix and occurs following prolonged labor in primary cervical dystocia. DIAGNOSIS: Excessive vaginal bleeding immediately following delivery in presence of a hard and contracted uterus—raises the suspicion of a traumatic bleeding

11. Complications - Early — (1) Deep cervical tears (2) Broad ligament hematoma. (3) Pelvic cellulitis. (4) Thrombophlebitis. Late — (1) Ectropion. (2) Cervical incompetence with mid trimester abortion. TREATMENT: Repair should be done under general anesthesia , in lithotomy position with a good light . Procedure : The anterior and posterior margins of the torn cervix are grasped by the sponge holding forceps. 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.

12. The bleeding stops immediately. The rest of the tear is repaired by similar mattress sutures. Mattress suture is preferable as it prevents rolling in of the edges. Sims’ posterior vaginal speculum, vaginal wall retractors, at least two sponge holding forceps

13. Pelvic Hematoma DEFINITION: Collection of blood anywhere in the area between the pelvic peritoneum and the perineal skin is called pelvic hematoma Vulvar hematoma may due to injury to the pudendal artery, inferior rectal artery or perineal arteries. Para vaginal hematoma are due to injury of descending branch of uterine artery. ANATOMICAL TYPES: Infralevator hematoma—common ; Supralevator hematoma—rare

14. Infra- levator Hematoma Etiology: (1) Improper hemostasis during repair of vaginal or perineal tears or episiotomy wound ; (2) Rupture of paravaginal venous plexus either spontaneously or following instrumental delivery. Symptoms: 1. Severe pain on vulvar or perineal region 2. May be rectal tenesmus or retention of urine. Signs: (1) Variable degrees of shock may be evident. (2) Tense swelling at 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.

15. Supra levator Hematoma 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. 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.

16. Treatment : The anterior leaf of the broad ligament peritoneum is incised and the blood clot is scooped out. The bleeding points, if visible, are to be secured and ligated. Random blind sutures should not be placed to prevent ureteric damage . If the oozing continues, one may have to tie the anterior division of the internal iliac artery.

17. 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 .

18. Pathology TYPES: Pathologically , it is customary to distinguish between complete and incomplete rupture depending on whether the peritoneal coat is involved or not . Incomplete rupture 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 usually occurs following disruption of the scar in upper segment. It may also be due to spontaneous rupture of both obstructive and nonobstructive type. SITES: 1. Spontaneous nonobstructive rupture usually involves the upper segment and often involves the fundus. 2. I n obstructive type , the rupture involves the anterior lower segment transversely and often extends upward along the lateral uterine wall. The margins are ragged and necrosed

19. 3. Not infrequently, the tear extends downward to involve the cervix and the vaginal wall ( colporrhexis ). The bladder may be involved, at times. Rupture over the previous scar is almost always located at the site of the scar. The margins of the ruptured cesarean scar are usually clean and look fibrosed. The rent over the lower segment scar may extend to one or both the sides to involve the major branches of uterine vessels.

20. 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 (d) varying amount of bleeding from the margins or from its extension. (e) uterine cavity and peritoneal cavity become continuous. 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.

21. Prognosis Lower segment scar rupture gives a comparatively better prognosis. But, rupture following obstructed labor either spontaneous or due to instrumentation gives a maternal death rate of about 20% or more. The major causes of death are hemorrhage, shock and sepsis.

22. Diagnosis During Pregnancy: Scar Rupture Spontaneous Iatrogenic During Labor: Scar Rupture Spontaneous Obstructive Spontaneous Nonobstructive Iatrogenic

23. During Pregnancy Scar rupture: Classical or hysterotomy —The patient complains of a dull abdominal pain over the scar area with slight vaginal bleeding. There is tenderness on uterine palpation. FHS may be irregular or absent. CTG tracings reveal variable or late deceleration – most consistent finding. Spontaneous rupture in uninjured uterus —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 shock, acute tenderness on abdominal examination, palpation of superficial fetal parts, if the rupture is complete and absence of fetal heart rate.

24. Cont. However , with insidious onset , the diagnosis is often confused with concealed accidental hemorrhage or rectus sheath hematoma . Rupture following fall, blow or external version or use of oxytocics . The confirmation is done by laparotomy. This is too often confused with accidental hemorrhage .

25. During Labor Scar rupture - Classical or hysterotomy scar rupture ; The onset is usually acute. Lower segment scar rupture The onset is insidious. There is no classical feature of lower segment scar rupture and is confirmed by laparotomy. The features of scar rupture are not as dramatic as those following obstructed labor (vide infra) and hence called “silent rupture”. Spontaneous obstructive rupture: Phase of rupture : (1) There is a sense of something 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.

26. Spontaneous nonobstructive rupture: R are 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 —presence of shock, evidences of internal hemorrhage, tenderness over the uterus and varying amount of vaginal bleeding. Rupture following manipulative or instrumental delivery: Sudden deterioration of the general condition of the patient with varying amount of vaginal bleeding. Shortening of the cord immediately following a difficult vaginal delivery is pathognomonic of uterine rupture

27. Management Prophylaxis – The at-risk mothers, likely to rupture, should have mandatory hospital delivery. These are— (a) Contracted pelvis. (b) Previous history of cesarean section, hysterotomy or myomectomy. (c) Uncorrected transverse lie. (d) Grand multiparity. (e) Known case of hydrocephalus. General anesthesia should not be used to give undue force in external version.

28. Treatment TREATMENT: 1. Resuscitation 2. Laparotomy LAPAROTOMY: Any of the three procedures may be adopted following laparotomy Hysterectomy: Hysterectomy is the surgery for rupture uterus unless there is sufficient reason to preserve it . It is especially indicated in spontaneous obstructive rupture. Considering the low general condition and disturbed morbid anatomical near the cervicovaginal region, it is preferable to perform a quick subtotal hysterectomy , rather than total hysterectomy. Repair: It is mostly applicable to a scar rupture where the margins are clean . Repair is done by excision of the fibrous tissue at the margins Repair and sterilization: It is mostly done in patients with a clean cut scar rupture having desired number of children.

29. Visceral Injuries BLADDER: Causes 1. Traumatic – Instrumental vaginal delivery , Abdominal operation such as hysterectomy. 2. Sloughing fistula It results from prolonged compression effect on the bladder between the head and symphysis pubis in obstructed labor. Diagnosis Traumatic — (1) Urine dribbles out soon following the operative delivery. Blood stained urine following cesarean section or hysterectomy is suggestive of bladder injury. (B) Sloughing fistula — (1) History of prolonged labor. (2) Dribbling of urine occurs after varying interval following delivery (5–7 days). (3) Margins devitalized and necrosed .

30. Management Management: Traumatic fistula : Immediate local repair is preferable , if the local tissues are healthy. In unfavorable condition , a self-retaining catheter is introduced and to be kept for 10–14 days. If it fails , repair is to be done after 3 months . Sloughing fistula: Repair is to be done after 3 months . RECTUM ; Rectal injury is rare. This is because , the middle-third of the rectum is protected by the curved sacral hollow and the upper thirdis protected by the peritoneal lining. The repair in such cases should be postponed for at least 3 months. URETHRA: Urethral injury may be traumatic resulting from instrumental delivery or during pubiotomy; may be ischemic sloughing.

31. References DC Dutta’s Textbook of Obstetrics 10 th edition

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