maternal trauma during labour and delivery

Question 1

what are the three categories that maternal injuries during labour fall under ?

Answer 1

perineal trauma
genital lacerations
uterine rupture

Question 2

what is the perineum ?

Answer 2

point of connection of all pelvic floor muscles except the ischocavernosus muscle

Question 3

when do perineal muscles contract ?

Answer 3

in cases of increased abdominal pressure, such as defecation , intercourse and labour

Question 4

what are the classifications of perineal tears ?

Answer 4

first degree
second degree
third degree
fourth degree

Question 5

what are hidden perineal tears ?

Answer 5

tear of the levator anii muscles without apparent perineal tear and may be missed and increase the chance of the occurence of prolapse

Question 6

what are the features of a first degree perineal tear ?

Answer 6

involves the perineal skin
posterior fourchette
posterior vaginal wall

Question 7

what are the features of a second degree perineal tear ?

Answer 7

extension to the perineal muscles but not to the external anal sphincter

Question 8

what are the features of a third degree perineal tear ?

Answer 8

involvement of any part of the anus ( both internal and external sphincter )

Question 9

what are the features of a fourth degree perineal tear ?

Answer 9

extension to the mucosa of the anal canal or rectum

Question 10

what are the complications to perineal trauma ?

Answer 10

1. dyspareunia
2. incontinence of stool and flatus in complete perineal tears
3. incomplete tears predispose to genital prolapse
4. postpartum haemorrhage
5. puerperal sepsis
6. recto-vaginal fistula

Question 11

how does a recto-vaginal fistula happen ?

Answer 11

improper repair of a 4th degree perineal tear

Question 12

how can we prevent perineal trauma ?

Answer 12

performance of an episiotomy in proper timing

proper management of the second stage of labour

Question 13

what is an episiotomy ?

Answer 13

surgical enlargement of the posterior diameter of the pelvic outlet

Question 14

when is an episiotomy typically done ?

Answer 14

during the last part of the second stage of labour (at crowning)

Question 15

what is the recommended technique to perform ann episiotomy ?

Answer 15

medio-laterally and between n45 to 60 degrees

Question 16

what is the time period in which a perineal tear should be repaired in ?

Answer 16

24 hours

Question 17

how are first degree perineal tears repaired ?

Answer 17

by continuous locked or interrupted sutures

Question 18

how are second degree perineal tears repaired ?

Answer 18

1. perineal muscles are approximated using Vicryl sutures
2. vagina is sutured as with 1st degree tears
3. superficial perineal muscles are sutured with Vicryl sutures
4. skin sutured as with 1st degree perineal tears

Question 19

what is the post-operative care required for repaired perineal tears ?

Answer 19

they must be kept clean, dry and sterile , sop antiseptic solution must be used after each defecation or micturition

Question 20

how are complete perineal tears managed post-operativley ?

Answer 20

IV fluids for 12 hours 
Clear fluids for the next 12 hours 
soft diet for an additional 48 hours 
low residue diet for 5 days 
laxatives cant be used but stool softeners can 
along with prophylactic antibiotics

Question 21

what is the aetiology of old complete perineal tears ?

Answer 21

tears that were hidden or missed

improper repair of perineal tears

Question 22

what are the signns of old complete perineal tears ?

Answer 22

muscular defect can be felt on PR examination n

Question 23

how are old complete perineal tears fixed ?

Answer 23

posterior colpo-perineorrhaphy

Question 24

what do genital tract traumas include ?

Answer 24

1. vaginal and cervical lacerations
2. puerperal hematomas
3. obstreitics hematoma

Question 25

what is the aetiology of cervical lacerations ?

Answer 25

1. manual dilatation of the cervix 2. forceps, ventouse or breech extraction before full cervical dilatation 3. improper use of oxytocin 4. precipitate labour

Question 26

what are the predisposing factors to cervical lacerations ?

Answer 26

cervical dystocia scarring of the cervix oedema of the cervix in prolonged labour placenta praevia due to increased vascularity

Question 27

what are the types of cervical lacerations ?

Answer 27

unilateral bilateral stellate annular detachement

Question 28

how can we make a diagnosis of cervical laceration ?

Answer 28

minor cervical lacerations may pass unnoticed extensive lacerations present in the picture of traumatic post partum haemorrhage , along with signs of hypovolemic shock then perform both vaginal and speculum examination

Question 29

what are the complications of cervical lacerations ?

Answer 29

1. upward extension causing rupture uterus or broad ligament hematoma 2. postpartum haemorrhage 3. infection 4. cervical incompetence 5. ureteric injury

Question 30

how are cervical lacerations managed ?

Answer 30

immediate repair through suturing starting from above the apex

Question 31

if there is extension to the lower uterine segment as a complication of cervical laceration what is the best treatment?

Answer 31

laparotomy and is managed as a ruptured uterus

Question 32

what are primary vaginal lacerations caused by ?

Answer 32

forceps application | vacuum extraction

Question 33

what are the causes of secondary vaginal lacerations?

Answer 33

more common and are due to extension from perineal or cervical tears

Question 34

what is the management of vaginal lacerations ?

Answer 34

immediate repair tight pack in small tears repair is usually not indicated

Question 35

what are the different types of puerperal hematomas ?

Answer 35

``` vulval hematoma (infra-levator) vaginal hematoma ( supra-levator) broad ligament hematoma ```

Question 36

what are the causes of vulval hematoma ?

Answer 36

traumatic : incomplete hemostasis | direct trauma

Question 37

what is the clinical picture of vulval hematoma ?

Answer 37

hematoma usually appears in 12-48 hours after delivery

Question 38

what is the cause of vaginal hematoma ?

Answer 38

vaginal laceration

Question 39

what is the clinical picture of vaginal hematomas?

Answer 39

may not be visible externally | may not be painful until it reaches a large size

Question 40

what is the cause of broad ligament hematoma ?

Answer 40

extension of upper vaginal, cervical or uterine tears which usually involves the uterine and vaginal artery

Question 41

what is the clinical picture of broad ligament hematoma ?

Answer 41

1. hypovolemia , anemia and shock 2. the uterus is felt left and deviated to the opposite side 3. fever unilateral leg oedema

Question 42

what is the management of small hematoma ?

Answer 42

managed conservatively | prophylactic antibiotic

Question 43

what is the management of a large hematoma that is progressively enlarging ?

Answer 43

hematoma is incised longitudinally evacuation bleeding point is ligated gap is closed in layers

Question 44

what is the management for a broad ligament hematoma ?

Answer 44

laparotomy ( through incision of the anterior leaflet of the broad ligament)

Question 45

what are the types of obstetric fistulae ?

Answer 45

vesico-vaginal fistula urethro-vaginal fistula recto-vaginal fistula uretero-vaginal fistula

Question 46

what is the main aetiology of fistulae?

Answer 46

prolonged obstructed labour

Question 47

what is the main cause of fistulae in developed nations ?

Answer 47

gynecological surgery especially hysterectomy

Question 48

how are recto-vaginal fistulae diagnosed ?

Answer 48

ano-rectal and transvaginal ultrasounds dye test CT , MRI

Question 49

what are the main causes of rupture uterus ?

Answer 49

``` VBAC obstructed labour rupture of a uterine scar abruptio placenta perforation external trauma grand multipara internal podalic version manual seperation of the placenta ```

Question 50

what are the types of uterine rupture ?

Answer 50

complete : involving the whole uterus and peritoneum | incomplete: not involving the peritoneal coat

Question 51

what are the differential diagnosis of rupture uterus ?

Answer 51

abruptio placentae extrauterine ectopic pregnancy other causes of acute abdomen

Question 52

what is the management of uterine rupture ?

Answer 52

anti-shock measures immediate laparotomy delivery of the foetus and placenta abdominal hysterectomy if the damage is beyond repair

Question 53

what happens to the fetus during uterine rupture ?

Answer 53

death due to asphyxia from detachment of the placenta