Birth Canal Injuries Prof S P Jaiswar Professor

Birth Canal Injuries Prof. S. P. Jaiswar Professor Dept. Of Obstetrics & Gynaecology

Injuries of the maternal birth canal One should suspect traumatic bleeding in women having excessive bleeding after expulsion of placenta and uterus is well contracted. In such cases the perineum and lower genital tract should be explore under good light. Common birth canal injuries are – I. Perineal tear II. vaginal and cervical tear

Lacerations Periurethral lacerations Periclitoral lacerations Vaginal lacerations Cervical lacerations/ cervical tear

Priurethral / Periclitoral lacerations • • Occurs due to pressure from delivering head to the anterior perineum by the intact posterior perineum. If light bleeding- pressure with a pad for 1 -2 minutes arrest the bleeding If significant bleeding- repair to be done using fine continuous sutures. If stitches are taken urethral catheter be placed.

Perineal tear Gross perineal tear is usually due to mismanaged 2 nd stage of labour. Degree of perineal tear – 1 st degree perineal tear- it involves the vaginal mucosa and subcutaneus tissue and forchette. 2 nd degree perineal tear- it involves the vaginal mucosa , subcutaneous tissue (connective tissue) varying degree of perineal body tear but it is not reaching up to external anal sphincter.

Perineal tear 1 st & 2 nd perineal tears are termed as incomplete perineal tear. 3 rd degree perineal tear- in this injury to perineum involves –post vaginal wall tear of whole of the perineum as well as complete transection of anal sphincter.

cont…. . 4 th degree perineal tear- involving the vaginal mucosa, perineum, anal sphincter, anal and rectal mucosa 3 rd & 4 th degree perineal tear are complete perineal tear.

Treatment of the perineal tears Prevention- proper conduction of 2 nd stage of labour is preventive i. e, Early extension of head during delivery to be avoided Slow delivery of fetal head in between contraction To perform timely episiotomy when indicated To take care of perineum during delivery of shoulder.

Repair of perineal tears Recent perineal tear should be repaired immediately following delivery of placenta. In case of delay more than 24 hrs immediate repair to be with held. care of in 2 nd degree it should done after antibiotic coverage and when ever wound become clean. In case of complete perineal tear when delay is >24 hrs then repair to be done after 3 rd month of delivery.

Repair of incomplete tear cont…. . It is just like episiotomy repair i. e. stitch the vaginal mucosa, subcutaneous tissue , and skin -suture maternal 1 or 1 -0 1 st stitch the vaginal mucosa by continuous suture Stitching should be started 1 cm beyond the apex of vaginal mucosa. Then stitch the subcutaneous tissue by interrupted suture

Repair of incomplete tear cont…. . Skin by interrupted suture. If tear was deep perform a rectal examination make sure that no stitch in rectum Clean the stitch line and perineum Dressing of stitch line.

Repair of recent complete perineal tear i. e, within 24 hrs Patient is to be put in lithotomy position All aseptic precaution to be taken Local anaesthesia or preferable GA. Suture material used is 1 -0 vicryl or chromic cut gut The rectal mucosa is sutured 1 st from above downward with interrupted suture Then stitch the rectal muscle and para-rectal fascia by interrupted suture

Repair of recent complete perineal tear i. e, within 24 hrs cont…… Now explore the torn end of anal sphincter with the help of allies forceps Torn end of sphincter are sutured in midline by figure of eight stitch It is supported by another layer of interrupted suture Stitch the vaginal mucosa, perineal muscles and skin by interrupted suture.

After care Just like episiotomy cleaning and dressing of wound after each urination and defecation. Special care to be taken in repair of complete perineal tear Liquid diet on 1 st day Low residual diet (such as milk, rice, bread, egg, fish, potato, sweets, fruit juice)for 4 days. Lactose 8 ml twice a day for one week to soften the stool

After care cont…. . Broad spectrum antibiotics along with metronidozol (400 mg) TDS for 5 -7 days Avoid giving enema and examination for two weeks rectal

Cervical tear Minor degree of cervical tear is during 1 st delivery is common. It is commonest cause of traumatic PPH Left lateral cervical tear is more common

Cause of cervical tear I. Iatrogenic- in case of operative vaginal delivery or breech extraction through incomplete dilatation of cervix II. Rigid cervix following previous cervical operation III. Precipitate labour

DIAGNOSIS Cervical tear or vaginal tear should be suspected when PPH is there in-spite of well contracted uterus. Explore the cervix and vagina for tear under good light.

How to explore Exploration of cervix With all aseptic precaution Evacuation of bladder if full Place the patient in lithotomy position Insert speculum and retract the posterior vaginal wall

How to explore cont…. . Ask the assistant to push down the fundus of uterus gently. Hold the anterior lip of cervix with sponge holder and trace whole of the cervix with another sponge holder forceps in clock wise manner and identify the cervical tear Now grasped the both margin of the tear of cervix by the sponge holder.

How to explore Cont…. Stitch the cervical tear by interrupted mattress suture by taking the whole thickness of cervix, suture material is 1 -0 chromic catgut with round body needle. The repair should be started 1 cm above the apex of the tear.

How to explore cont…. . Mattress suture prevents rolling of the edges. If the cervical tear is extending to the lower segment or vault with broad ligament haematoma needs laparotomy.

Vaginal tear After the proper exposure haemostatic suture and vaginal tear suturing to be done if multiple laceration, then pack the vagina for 24 hrs. after removing the packing see for bleeding

Vaginal tear Cont…. Vulva injuries- vulval laceration, perineal laceration and hematoma needs to be drained and proper haemostatic suture should be given Sometime local packing requires.

Haematomas Vulval haematoma Paravaginal Broad haematoma ligament and retroperitoneal haematoma

Vulval haematomas Small vulval haematomas (≤ 5 cm) may be treated conservatively with analgesics, observation and ice packs If pain is not controlled, enlarging or large haematoma need to incise and evacuate. Regional / general anaesthesia needed. Incision is made over the most prominent area and clots evacuated.

Vulval haematomas contd. . . Discreet bleeding points are ligated although frequently none are found Oozing areas may be oversewn with figure-of -eight sutures Vaginal packing be done Foley catheter is placed Broad spectrum antibiotics be given.

Vulval haematomas contd. . . Sub peritoneal and supravaginal haematomas not repaired vaginally Laparotomy is advisable Angiographic embolisation of internal iliac arteries may be done.

Multiple Choice Questions

1) Perineal tears should be repaired: a) 24 hours later b) 48 hours later c) 36 hours later d) Immediately

d) Immediately

2) Most suitable method of treatment of 4 inches size episiotomy haematoma is bya) Evacuation b) Magsulf compression c) Cold compress d) marsupialisation

A ) Evacuation

3) In a patient with third degree perineal tear, presenting after 1 week, repair should be done: a) Immediately b) 2 weeks c) After 6 weeks d) After 12 weeks

d) After 12 weeks

4) A woman delivers a 4 kg baby with a midline episiotomy and suffers a third degree tear. Inspection shows which of the following structures is intact: a) Anal sphincter b) Perineal body c) Perineal muscles d) Rectal mucosa

d) Rectal mucosa

5) IIIrd degree perineal tear is involvement of : a) Vaginal mucosa b) Urethral mucosa c) Levator ani muscles d) Anal sphincter

d) Anal sphincter

6) Which of the following is the best treatment for vulvar hematomas that are extremely painful, bit stable in size: a) analgesics b) Ice compress c) Incision and drainage d) Angiographic embolization

c) Incision and drainage

7) Concerning vaginal lacerations involving the middle or upper third of vagina, which of the following is true: a) These are often the result of forceps delivery b) These result from uterine overdistension c) These are usually associated with injuries to the levator ani muscles d) All of the above

a) These are often the result of forceps delivery

K N A H T U O Y