33/ 34 Uterine rupture and other birth traumas of the mother. Flashcards
what is uterine rupture ?
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
what is the etiology of uterine rupture ?
1) During pregnancy
SPONTANEOUS - later months
a) intact uterus = multipara , congenital malformation of the uterus , placental abruption
b) scared uterus
through c section , hysterectomy , dilation and curettage
IATROGENIC
a) traumatic - external cephalic version
b) oxytocins
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2) during labour
SPONTANEOUS
a) intact uterus
obstructive labour - involves the lower segment and usually extends through one lateral side of the uterus to the upper segment
non obstructive - grand multipare
b) scarred tissue -
IATROGENIC
a) traumatic - internal version , manual removal of placenta
b) oxytocins
which type of scarring rarely ruptures during pregnancy ?
lower segment
Uterine scar, following operation on the nonpregnant uterus such as myomectomy or metroplasty hardly rupture as the wound heals well
what are the two main types of uterine rupture ?
complete - all layers and torn
incomplete
when the uterine muscle is separated but the visceral peritoneum is intact also called uterine dehiscence
what are the symptoms of uterine rupture ?
when it is about to happen
= severe abdominal pain
increased contraction - hyperactive labour
bandl ring forms above the belly button due to powerful contraction of the upper segment
in uterine rupture
*severe abdominal pain
sudden pause in contractions
fetal distress - bradycardia
- vaginal bleeding
- regression of presenting fetal part - loss of station
- palpable fetal part through rupture
how can we diagnose uterine rupture ?
US
diagnostic triad - painful bleeding , loss of station , loss of fetal heart rate absent or irregular
also a sense of something giving away
uterine rupture is confirmed by laparotomy
management of uterine rupture ?
resuscitation (blood transfusion) and laparotomy
laparotomy :
1) hysterectomy (quick subtotal hysterectomy)
2) repair - most applicable with scar rupture when the margins are clear
if during labour - c section and laparotomy
what are common sites of tear ?
posterior laceration of vulva (opening of vagina, major and minor labia , clitorius)
parauretheral tear
what is the pelvic floor (inner most ) ?
it is the pelvic diaphragm
formed of levitator ani (puborectalis , pubococcygeus , ischiococcygeus) and coccygeus muscles covered by parietal fascia
gaps in the pelvic wall - urogenital hiatus - where the urethera and vagina pass
rectal hiatus - anal canal pass
describe the anatomy from deep to superficial after the pelvic floor ?
urogenital diaphragm - external to pelvic diaphragm within the deep pelvic pouch - disc shape around the urethera
= deep transverse perineal , sphincter urethera and internal and external fascia covering
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then it is the perineal membrane does NOT EXIST OVER THE ANAL TRIANGLE
superior to the perineal membrane is the deep perineal pouch
inferior perineal membrane - superficial perineal pouch
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in the superficial pouch
- anterior urogenital triangle (anal triangle posteriorly)
ischiocavernous
bulbospongiosus - surrounding the vagina - aids in secretion of bartholin gland
superficial transverse perineal
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fascia
what is the perineum ?
diamond shaped space
superior;y - pelvic floor
ant- pubic symphysis and pubic bones
laterally - ischiopubic rami/ nferioir pubic rami, and ischial tuberosity , scarotuberous lig
posteriorly - coccyx
inferiority - skin and fascia
perineal injury is more common in whom?
primigravida
what causes perineal tear?
minor injury quite common which is second and first
third and fourth degree is due to mismanaged second stage of labour : big baby ?3kg pelvic outlet contraction and narrow pubic arch should dystocia scar- epstiotimy midline epstiotomy malpresentation - breech and face forceps or vacuum
what are the degree in perineal tear ?
first - limited to vaginal mucosa and skin of introits
second degree - extension to fascia and muscles of perineal body (muscles)
third degree - anal sphincter
a- less than 50 percent of EAS
b - more
c - both external and internal AS
fourth degree - rectal lumen and extends through rectal mucosa
what are the clinical manifestations of perineal tear ?
acute :
>post partum hemorrhage
> perineal pain
> urinary retention and incontinence
rectal incontience
what is the prevention of perineal tear ?
tile epstiotomy given in all primigravida
proper support of perineum at time of crowing and expulsion of head
what is the management of perineal tear ?
lacerations repeaired within 24 hrs of delivery
if after 24hrs - antibiotics given FIRST an repaired within 3 months
best suture material catgut and fine mono filament for skin
first degree - no suturing required or interrupted
second degree vaginal tear is repaired first should include deeper tissue to limit the dead space with interrupted sutures with chromic catgut
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after care = similar to epstiotomy low residual diet - milk etc lactulose broad spectrum antibiotics in intraoperative and postoperative physiotherapy and pelvic floor exercises
what are the complications of perineal care if left untreated ?
infection - perineal abcess
hemorrhagic shock
3rd to 4th tear if left untreated - urinary and fecal incontinence
uterovaginal prolapse
what is the classification of inversion of uterus ?
1 - incomplete minimal fundus descension but has not crossed though the cervix
2 - complete
the fundus has passed through the cervix but not outside vagna
3 - outside vagina
4 - uterus , cervix and vagina completed turned inside out
causes of inverted uterus ?
Spontaneous (40%): localized atony on the placental site over the fundus associated with sharp rise of intraabdominal pressure as in coughing, sneezing or bearing down effort.
excessive cord traction when placenta unseparated
or
when the uterus is atonic especially when combined with fundal pressure
excessive fundal pressure when relaxed uterus
placenta accreta
signs and symptoms of inversion of uterus ?
and diagnosis ?
v dangerous
hemorrhage
shock - initially disproprtinte with the amount of blood loss
hypovolemic shock
severe abdominal pain
hypotension with
bradycardia
uterine fundus no longer palpable
masss in vagina or in vaginal examination
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Cupping or dimpling of the fundal surface
Bimanual examination
us
what is the treatment for inversion of uterus
emergency -intravenous crystalloids (normal saline or lactated Ringer’s solution)
blood transfusion
general anaesthesia
Discontinue uterotonic drugs since uterine relaxation is needed for replacement of the uterine fundus.
if placenta partially attached - peeled out before replacement of uterus
if placenta attached only removed leave it on - only removal after replacement and uterus starts contracting
attempt to replace the fundus
- using gloved hand placing a hand inside the vagina and pushing the fundus along the long axis of the vagina toward the umbilicus (Johnson’s Maneuver)
the part of the uterus which came down last should be replaced first
once replaced oxytocin infusion started before removing uterine hand.
antiobotcs also administered
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if the uterus is still relaxed - bimanual compression - finsting hand to anterior fornix of vagina and grabbing the back of the fundus of the uterus through abdominal
or
Sullivan hydrostatic method (can be used for 2nd degree) - Warm sterile fluid (up to 5 liters) is gradually instilled into the vagina through a iv tube in posterior fornix .
The vaginal orifice around the wrist of the assistant and by labial .
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Haultain operation if the above fails
vertical incision – through the posterior portion of the cervix to incise the constructing cervical ring allowing the fundus to be manually replaced into the through the vagina
During delivery, which of the following muscles is most likely to be torn?
superficial transverse perineal muscle
vaginal tears are caused by ?
forceps or vacuum delivery
in such cases the tears are extensive and BRISK hemorrhage
colporrhexis - rupture of vaginal vault (or upper 1/3 of vagina) caused secondary to primary cervical tear
Primary colporrhexis is defined as a tear limited to the vaginal vault without cervical or uterine extension
it is said to be complete when the peritoneum is opened up
what is the treatmnet of vaginal tears ?
exploration under general anesthesia for brisk hemorrhage -
chromic catgut sutures
if extensive
intravaginal plugging also added by roller gauze soaked with glycerine and acriflavine
this plug is removed after 24 hrs
if persists - arterial embolisation or ligation
what is the most common traumatic post partum hemorrhage ?
cervical tear
what are the causes for cervical tear ?
iatrogenic - forceps or vacuum , breech extraction through incompletely dilated cervix
rigid cervix - from scars (conization) or congenital
or extremely vascular cervix - placenta previa
what is the diagnosis of cervical tears ?
exploration of uterovaginal canal under good light
first - not over 2cm
second - more than 2 cm but does not involve the vaginal fornices
third - extends to vaginal fornices - v dangerous
what is the treatmnet of cervical tear ?
up to 2cm is inevitable - first degree
they heal rapidly
only deep cervical tear associated with bleeding should be repaired soon after delivery of the placenta - under general anaesthesia in lithotomy position need good light and suturing with catgut vicryl and sponge forceps
what are the anatomical types of pelvic hematoma ?
depend on whether it is above or below the levitator ani
infralevator - common
MOST COMMON - VULVA HEMATOMA
supralevator - uncommon
what is the causes for cause of vulva hematoma ?
improper hemostasis during repair vaginal , perineal tears or epstiotomy wound
- which is failure to take precaution in suturing the apex of tear or obliterate the dead space while suturing the vaginal walls
what are the signs and symptoms of INFRALEVATOR pelvic hematoma ?
persistent and severe pain of the perineal region
maybe rectal tenesmus
urinary retention
Variable degrees of shock
Tense swelling at the vulva which becomes dusky and purple in color and tender to touch
what is the treatmnet of infralevator pelvic hematoma ?
less than5 cm - conservatively with cold compress and watchful waiting and analgesia.
larger - IV saline
under general anesthesia
evacuation of any clots present,
surgically drained. To do this,
dead space should be obliterated with deep mattress sutures
You might also be given an antibiotic to prevent an infection.
closed suction drain may be kept in that place for 24 hrs
selective arterial embolisation
what are the causes for supralevator hematoma ?
extension of cervical lacerations
primary coloprrhexis
lower uterine segment rupture
rupture of paravaginal venous plexus adjacent to the vaginal vault
what is the diagnosis of supralevator hematoma
made late - due to no pain
shock which is unexplained
abdominal examination - swelling above inguinal lig pushing uterus to contralateral aside
vaginal examination - occlusion vaginal canal by bulge or swelling felt through fornix
rectal examination confirms a boogy mass
US
what is the treatmnet of supralevator hematoma ?
laparotomy
bleeding points sutured and ligated
