INJURIES TO BIRTH CANAL INJURIES TO BIRTH CANAL

INJURIES TO BIRTH CANAL

INJURIES TO BIRTH CANAL NOT SO UNCOMMON – SPONTANEOUS or ASSISTED DELIVERIES DEPEND UPON THE CARE PROVIDED BY THE OBSTETRICIAN AVOIDANCE, EARLY DETECTION & PROMPT MANAGEMENT – KEY TO REDUCE SIGNIFICANT MORBIDITY

INJURIES TO BIRTH CANAL 1. 2. CLASSIFIED: INJURIES TO BONY PARTS i) Injury to Symphysis Pubis ii) Injury to Sacro-coccygeal Joint iii)Injury to Sacro-iliac Joint INJURIES TO SOFT TISSUE i) Injury to Vulva ii) Perineal Tears iii)Laceration of Vagina & Cervix iv)Rupture of Uterus

INJURIES TO BONY PARTS INJURY TO SYMPHYSIS PUBIS: • DURING FORCIBLE EXTRACTION OF THE HEAD BY FORCEPS OR IN BREECH DELIVERY • NOT SO SERIOUS • URETHRA & BLADDER MAY BE INVOLVED – COMPLICATE THE CASE

INJURIES TO BONY PARTS INJURY TO SYMPHYSIS PUBIS: • DIAGNOSIS: PAIN AT PUBIC REGION or MOVEMENT GAP MAY BE FELT TENDER PUBIC SYMPHYSIS • TREATMENT: BED REST FOR 2 -3 WEEK ANALGESICS FIRM BINDER AROUND THE PELVIS BLADDER CARE

INJURIES TO BONY PARTS # & DISLOCATION OF COCCYX: • DURING EXTRACTION WHERE SUB-PUBIC ANGLE IS NARROW • PAIN AT THE REGION OF COCCYX WHILE SITTING • MOBILE OR DISPLACED COCCYX • EXCISE THE COCYX

INJURIES TO BONY PARTS INJURY TO SACRO-ILIAC JOINT: • Result after injury to Symphysis Pubis, Symphysiotomy or Pubiotomy • Ligaments are torn & Flaring out of the iliac bones • Do not support pelvis- can’t use limbs • Bed Rest; Straping of pelvis for 2 -3 weeks

INJURIES TO SOFT TISSUE INJUR TO VULVA: • MINOR TEAR OF LABIA MINORA, FOURCHETTE COMMON NO TREATMENT • VULVAL HEMATOMA: BLEEDING FROM PARAVAGINAL VEINS TENSE, BLUISH & TENDER LARGE: INCISION & CLOTS REMOVED

INJURIES TO SOFT TISSUE • • 1. 2. 3. PERINEAL TEARS: GROSS INJURY IS DUE TO MISMANAGED 2 ND STAGE OF LABOUR ETIOLOGY: OVER STRETCHING OF PERINIUM RAPID STRETCHING OF PERINIUM INELASTIC PERINIUM

INJURIES TO SOFT TISSUE PERINEAL TEARS: DEGREES: First-degree: involve the perineal skin, and vaginal mucosa Second-degree: 1 st degree and the fascia and muscles of the perineal body Third-degree: 2 nd degree and involve the anal sphincter. A fourth-degree: extends through the rectal mucosa to expose the lumen of the rectum.

THIRD DEGREE PERINEAL TEAR FOURTH-DEGREE PERINEAL TEAR

INJURIES TO SOFT TISSUE • 1. 2. 3. PERINEAL TEARS: PREVENTION: LIBERAL USE OF EPISIOTOMY PROPER CONDUCT OF LABOUR DURING 2 ND STAGE PERINEAL SUPPORT DURING 2 ND STAGE

INJURIES TO SOFT TISSUE • ü ü PERINEAL TEARS: TREATMENT: SHOULD REPAIR IMMEDIATELY FOLLOWNG PLACENTAL DELIVERY DELAYED BY 24 HRS DELAYED CLOSURE DIAGNOSE THE DEGREE OF TEAR GOOD LIGHT, EXPOSURE & ASSISTANCE

INJURIES TO SOFT TISSUE • 1. 2. 3. PERINEAL TEARS: TREATMENT: LITHOTOMY POSITION INCOMPLETE TEAR: CONTINUOUS VAGINAL MUCOSA SUTURE INTERRUPTED TO MUSCLE MATTRESS TO SKIN COMPLETE TEAR: TAKE FIRST THE RECTAL MUCOSA AND CONVERT TO INCOMPLETE TEAR

INJURIES TO SOFT TISSUE 4. AFTER CARE: LOW RESIDUE DIET STOOL SOFTNER SEITZ BATH BD ORAL ANTIBIOTICS: ANAEROBIC ANALGESICS

INJURIES TO SOFT TISSUE • • • VAGINAL LACERATION: FORCEPS DELIVERIES OR BREECH EXTRACTIONS OBSTRUCTED LABOUR TREATMENT: MINOR TEAR: NO SUTURING MAJOR LACERATION: REPAIR USING ABSORABL SUTURE

INJURIES TO SOFT TISSUE CERVICAL LACERATION: MINOR INJURY OCCUR IN ALL CASES • DEEP TEARS ARE ALWAYS PREVENTABLE • IDENTIFY AFTER DELIVERY AS PPH • CAUSES: 1. RAPID DELIVERY OF FETUS 2. ASSISTED DELIVERIES 3. RIGID CERVIX •

INJURIES TO SOFT TISSUE • 1. 2. 3. 4. 5. 6. CERVICAL LACERATION: SEQUELAE: INFECTION, PERSISTENT CERVISITIS EXTENSIVE SCARRING STERILITY REPEATED ABORTION PREMATURE LABOUR DYSTOCIA

INJURIES TO SOFT TISSUE • CERVICAL LACERATION: TREATMENT: MINOR TEAR: NO TREATMENT MAJOR TEAR: INSPECT THE WHOLE CERVIX HOLD THE TORN END WITH SPONGE HOLDING FORCEPS INTURRUPTED CATGUT SUTURES – VERTICAL MATTRESS SUTURE

INJURIES TO SOFT TISSUE • • • 1. 2. RUPTURE OF UTERUS: DISRUPTION IN THE CONTINUITY OF UTERINE WALL INCIDENCE: 0. 05% (1 IN 2000) CAUSES: SPONTANEOUS: CONGENITAL MALFORMMATION, OBSTRUCTED LABOUR, GRAND MULTIPARITY SCAR RUPTURE: PREVIOUS CS (1 -2%), MYOMECTOMY

INJURIES TO SOFT TISSUE • 3. • 1. 2. RUPTURE OF UTERUS: CAUSES: IATROGENIC: INJUDICIOUS USE OF OXYTOCIN, FORCIBLE ECV/ IPV, FALL OR BLOW OVER THE ABDOMEN, , FORCEPS or BREECH EXTRACTION TYPES: INCOMPLETE RUPTURE: PERITONIUM REMAINS INTACT COMPLETE RUPTURE: SCAR IN UPPER SEGMENT - INVOLVES PERITONIUM

INJURIES TO SOFT TISSUE • ü RUPTURE OF UTERUS: DIAGNOSIS: DURING PREGNANCY: PAIN OVER LOWER ABDOMEN TENDERNESS SUDDEN ABDOMINAL DISTENSION FEATURES OF SHOCK FHS – IRREGULAR OR ABSENT

INJURIES TO SOFT TISSUE • ü RUPTURE OF UTERUS: DIAGNOSIS: DURING LABOUR: BACKGROUND OF PROLONG OBSTRUCTED LABOUR SHOCK, COLLAPSED STATE WEAK & RAPID PULSE, LOW BP FETAL PART EASILY FELT

INJURIES TO SOFT TISSUE • ü RUPTURE OF UTERUS: TREATMENT: RESUSCITATION: 2 WIDE BORE IV CANULA / VENOUS CUT DOWN / CVP IV FLUIDS: RL / HAEMACCEL BLOOD CROSS MATCH & TRANSFUSE MONITOR VITALS, CVP & UO

INJURIES TO SOFT TISSUE • ü RUPTURE OF UTERUS: TREATMENT: LAPAROTOMY: REPAIR: IN CASES OF SCAR RUPTURE WITH CLEAN MARGIN REPAIR & STERILISATION: HYSTERECTOMY: LOW GENERAL CONDITION, GRAND MULTIPARA, MORBID DISTORTION OF ANATOMY, INFECTED CASE

Episiotomy: Episiotomy is a surgically planned incision on the perineum and the posterior vaginal wall during the second stage of labor. It is also known as Perineotomy.

Muscles of perineal body

Episiotomy A surgical incision into the perineum between the vagina and anus. Prior to instrumental delivery (forceps, vacuum) to widen the vagina

Objective of Episotomy: To enlarge the vaginal introitus so as to facilitate easy and safe delivery of fetus. To minimize overstretching and rupture of the perineal muscle and fascia. To reduce the stress and strain on the fetal head(more for premature baby).

Indications: In rigid/inelastic perineum- primigravida, old perineal scar of episiotomy 2. Anticipated perineal tear- Primi, big baby, face to pubis or face delivery, narrow pubic arch, breech delivery 3. Operative procedure- forcep or vaccum delivery 1.

4. To shorten the second stage. Heart diseases, severe pre-eclampsia or preeclampsia, post C/S cases, postmaturity 5. Foetal Interest- foetal distress, premature baby, breech delivery

Timing of episiotomy: Bulging thinned perineum during contraction just prior to crowning is the ideal time

Advantages: A. Maternal – 1. Easy to repair 2. Prevent prolapse 3. Prevent lacerations extending to rectum. 4. Shortening of 2 nd stage of labour B. Foetal 1. Minimise intracranial injuries in premature baby 2. Reduces foetal asphyxia and acidosis

Types: Mediolateral Median Lateral J- shaped

Following structures are cut from inside – outwards. a) The posterior vaginal wall b) The deep and the superficial transverse perineal muscle, the bulbospongiosus and part of the levator ani muscle. c) The fascia covering the muscle d) Transverse perineal branches of the pudendal vessels and nerves. e) The subcutaneous tissue and the skin.

Procedure: Cleaning and draping Anesthesia Incision - Site and timing - Technique Repair: - Timing and Methods

Post operative care: Clean wound with clean water after each urination and defaecation. Keep area dry Apply clean pads Analgesics if needed Peri-care and peri-light Suture removal on 7 th -10 th post op day if silk is applied. F/U after 6 wks if no complication

Complications: Immediate: - Extension of incision to involve the anal sphincter - Hemorrhage - Vulval haematoma : the apex of the incision is not included in the stich. The dead space in not obliterated properly. The sprouting vessels if not ligated. - Wound infection - Wound dehiscence - Retention of urine Remote: - Dyspareunia - Rectvaginal fistula, - scar endometriosis

3. Bartolin cyst- if the duct of the bartholins gland is included in the episiotomy wound. 4. Scar endometriosis. 5. Deficient perineum

Prevention of perineal tear: Well support of the perineum at the time of delivery of head Delivery by early extension is to be avoided Spontaneously forcible delivery is to be avoided To deliver the head in between contraction To perform timely epsiotomy To take care during delivery of shoulder

Controversy of Routine Episiotomy

The final rule is that there is no substitute for surgical judgment and common sense.