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MULLANA AMBALA
Genital tract injury: The maternal genital tract may get variety of injuries during child birth
process. These injuries are quite common and contribute significantly to maternal morbidity and
even to death
These include:
Vaginal tears.
Hematoma of the vulva.
Perineal tears
Cervical tears
Rupture of the uterus
Etiology
Lack of perineal elasticity:
o Elderly primigravida.
o Excessive scarring from a previous operation as posterior colpoperineorrhaphy.
o Friability due to perineal oedema.
Marked perineal stretch:
Allowing head extension before crowning.
o Macrosomic baby.
o Face to pubis delivery.
o Forceps delivery.
o Narrow subpubic angle pushing the head backward.
Rapid perineal stretch:
o Precipitate labour.
Rapid delivery of the after-coming head in breech presentation
Trauma to the perineum during vaginal childbirth. Delivery may lead to overstretching of the
vagina, causing tears in the perineal tissue between the vagina and rectum. Lacerations are
classified into four categories:
First degree tear: laceration is limited to the fourchette and superficial perineal skin or vaginal
mucosa
Second degree tear: laceration extends beyond fourchette, perineal skin and vaginal mucosa
to perineal muscles and fascia, but not the anal sphincter
Third degree tear: fourchette, perineal skin, vaginal mucosa, muscles, and anal sphincter are
torn.
Fourth degree tear: fourchette, perineal skin, vaginal mucosa, muscles, anal sphincter, and
rectal mucosa are torn.
Superficial layer
External anal sphincter muscle:-encircles the anus and is attached behind by a few fibres to the
coccyx.
• composed of three pairs of muscles, which together are known as the lavetor ani muscles
.Each lavetor ani muscle consist of following:-
.
Vaginal Lacerations
Causes:
Management
Immediate repair: Continuous locked cut gut sutures are taken starting from above the apex
to control bleeding from the retracted blood vessels.
Tight pack: may be needed to control bleeding from a raw surface area.
Foley's catheter should be inserted before packing and both are removed after 12-24 hours.
Observe & document color and amount of urine.
Vulval Haematoma
Causes:
Traumatic due to:
o Incomplete hemostasis during repair of episiotomy or tear.
o Direct trauma as kick or falling down.
Spontaneous: due to rupture of a varicose vein.
Symptoms
The hematoma usually appears 12-48 hours after delivery.
The collection of blood is limited by the levator ani above but laterally it may extend to fill
the ischiorectal fossa reaching a volume of 500 ml or more.
There is a progressive enlarged, painful, tender, tense, bluish swelling at the vulva.
Management:
Vaginal Hematoma
Management:
Small hematoma is managed conservatively
Large increasing hematoma more than 5cm in diameter needs to be evacuated
Any bleeding point needs to be caught and ligated
If cavity is large after evacuation then vaginal packing is done for 12 hours
Close monitoring and recording of vitals
Replace the blood if needed with proper documentation
Narcotic analgesics is given for pain
Prophylactically antibiotics are given
Cervical Lacerations
Etiology
Forceps, ventouse or breech extraction before full cervical dilatation.
Manual dilatation of the cervix.
Improper use of oxytocins.
Precipitate labour.
Predisposing Factors
Cervical rigidity.
Scarring of the cervix.
Oedema as in prolonged labour.
Placenta Previa due to increased vascularity. .
Diagnosis
Postpartum hemorrhage, in spite of well contracted uterus.
Vaginal examination: The tear can be felt.
Speculum examination: using a posterior wall self retaining speculum or vaginal retractors
and 2 ring forceps to grasp the anterior and posterior lips of the cervix so the tear can be
visualized.
Complications
Postpartum hemorrhage.
Rupture uterus due to upward extension.
Infection: cervicitis and parametritis.
Cervical incompetence leading to future recurrent abortion or preterm labour.
Ureteric injury: from the extension of the tear or during its repair.
Management:
Immediate repair: is carried out under general anesthesia with good light exposure. .
o The vaginal walls are held apart with retractors.
o Interrupted cut gut or vicryl sutures are taken starting from above the apex of the
tear to control bleeding from the retracted blood vessels.
If the apex is not easily seen a traction on a stitch taken as high as possible in the tear will show
the apex
Retroperitoneal Hematoma
Causes:
Upper vaginal, cervical or uterine tears which usually involve the vaginal or uterine artery.
Clinical features:
Hypovolemia, anemia or shock: is usually present due to large amount of internal
hemorrhage.
Swelling on one side of the uterus which increasing over a period of hours or days and may
reach up to the lower pole of the kidney or even the diaphragm.
The uterus is felt separate and deviated to the opposite side.
Management:
Small not-increasing hematoma: is managed conservatively as vulval hematoma.
Large increasing hematoma: needs
o Laparotomy.
o Incision in the anterior leaflet of the broad ligament.
o Evacuation of the blood clots.
o Securing hemostasis, bilateral internal artery ligation or hysterectomy may be
indicated. .
Complications
Postpartum hemorrhage.
Puerperal infection.
Incontinence of stool and flatus in unrepaired or imperfectly repaired 3rd or 4th degree
tear.
Residual recto-vaginal fistula in imperfectly repaired 4th degree tear.
Future genital prolapse.
Dyspareunia due to tender vaginal scar.
Prevention
First degree tear: The vaginal wall is repaired with continuous locked or interrupted
Sutures and the skin with interrupted sutures.
Incidence
About 1:4000, 95% of cases occur in multipara particularly grand multipara.
Causes:
During pregnancy
o Spontaneous:
Rupture of a uterine scar: e.g. previous C.S. especially upper segment, myomectomy,
hysterotomy, uteroplasty or perforation.
Abruptio placenta with severe concealed hemorrhage.
Anterior sacculation in case of incarcerated retroverted gravid uterus or posterior
sacculation due to previous ventrofixation of the uterus.
Rupture of a rudimentary horn at the 4th- 5th month.
Perforating vesicular mole.
o Traumatic
Perforation during vaginal evacuation.
External trauma.
During labour:
o Spontaneous:
Obstructed labour.
Rupture of a uterine scar.
Grand multipara: due to degeneration and over thinning of the uterine muscles.
o Traumatic:
Internal version: particularly after drainage of liquor.
Manual separation of the placenta.
Destructive operations.
Extending cervical tear due to e.g. forceps or ventouse applications before full cervical
dilatation.
o Improper use of oxytocins.
Weak uterine scar may be a result to:
Types
Complete: involving the whole uterine wall including the peritoneum.
Incomplete: not involving the peritoneal coat.
Clinical features
Before actual rupture the following manifestations may be detected:
Lower abdominal pain.
Tender uterine scar.
Vaginal spotting (minimal bleeding).
o Sudden severe abdominal pain: It is differentiated from labour pain being continuous.
o If the patient was in labour there is cessation of uterine contractions.
o Shoulder pain on lying down due to irritation of the phrenic nerve by accumulating blood
under the diaphragm.
o Silent rupture: minimal symptoms may occur in rupture lower segment scar due to
presence of fibrosis and minimal internal hemorrhage.
Variable degrees of collapse are present according to amount of blood loss. This may
appear postpartum in case of traumatic rupture uterus.
o Abdominal examination:
Scar of the previous operation.
Foetal parts are prominent and felt easy.
The presenting part recedes upwards.
Abnormal foetal attitude and lie.
FHS usually not heard.
The uterus is felt separated from the foetus .
In incomplete rupture, the foetus still inside the uterus with suprapubic painful tender
swelling which is an accumulated blood in the vesico-uterine pouch.
o Vaginal examination:
The presenting part recedes upwards.
Vaginal bleeding may be present.
Contracted pelvis may be detected.
A cervical tear may be found extending to the lower uterine segment and a broad
ligament hematoma may be present.
Management: Prophylactic:
Curative:
Blood transfusion and antishock measures.
Immediate laparotomy.
Deliver the foetus and placenta.
Explore the rupture site:
o If it is amenable for repair and the patient did not complete her family ® repair is
done.
o If it is not amenable for repair® hysterectomy. Subtotal hysterectomy is less time
consuming so it is done if there is no cervical tear.
Exploration of the other viscera mainly the bladder.
Internal iliac artery ligation may be needed in case of broad ligament hematoma as the
uterine artery is usually retracted and difficult to be identified.
Vaginal repair: may be amenable if there is slight extension of a cervical tear with
accessible apex.
Complications (Maternal)
Shock.
Hemorrhage.
Paralytic ileus.
Bladder, ureter or visceral injuries.
Infection.
Foetal:
Death due to asphyxia from detachment of the placenta.
Nursing diagnosis
Nursing management:
2. Parulekar V . Shashank Text Book for midwives VORA medical publications: P 509- 538
3. Dutta’s D.C Text Book of Obstetrics New Central Book Agency (P) Ltd: P- 4222-431
From net :
1. http://www.emedicinehealth.com/pregnancy_bleeding/page5_em.htm
2. http://www.gfmer.ch/Obstetrics_simplified/maternal_obstetric_injuries.htm