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WH > maternal trauma during labour and delivery > Flashcards

maternal trauma during labour and delivery Flashcards

1
Q

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

A

perineal trauma
genital lacerations
uterine rupture

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2
Q

what is the perineum ?

A

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

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3
Q

when do perineal muscles contract ?

A

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

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4
Q

what are the classifications of perineal tears ?

A

first degree
second degree
third degree
fourth degree

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5
Q

what are hidden perineal tears ?

A

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

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6
Q

what are the features of a first degree perineal tear ?

A

involves the perineal skin
posterior fourchette
posterior vaginal wall

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7
Q

what are the features of a second degree perineal tear ?

A

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

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8
Q

what are the features of a third degree perineal tear ?

A

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

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9
Q

what are the features of a fourth degree perineal tear ?

A

extension to the mucosa of the anal canal or rectum

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10
Q

what are the complications to perineal trauma ?

A
  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
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11
Q

how does a recto-vaginal fistula happen ?

A

improper repair of a 4th degree perineal tear

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12
Q

how can we prevent perineal trauma ?

A

performance of an episiotomy in proper timing

proper management of the second stage of labour

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13
Q

what is an episiotomy ?

A

surgical enlargement of the posterior diameter of the pelvic outlet

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14
Q

when is an episiotomy typically done ?

A

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

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15
Q

what is the recommended technique to perform ann episiotomy ?

A

medio-laterally and between n45 to 60 degrees

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16
Q

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

A

24 hours

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17
Q

how are first degree perineal tears repaired ?

A

by continuous locked or interrupted sutures

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18
Q

how are second degree perineal tears repaired ?

A
  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
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19
Q

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

A

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

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20
Q

how are complete perineal tears managed post-operativley ?

A 
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
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21
Q

what is the aetiology of old complete perineal tears ?

A

tears that were hidden or missed

improper repair of perineal tears

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22
Q

what are the signns of old complete perineal tears ?

A

muscular defect can be felt on PR examination n

23
Q

how are old complete perineal tears fixed ?

A

posterior colpo-perineorrhaphy

24
Q

what do genital tract traumas include ?

A
  1. vaginal and cervical lacerations
  2. puerperal hematomas
  3. obstreitics hematoma
25
Q

what is the aetiology of cervical lacerations ?

A
  1. manual dilatation of the cervix
  2. forceps, ventouse or breech extraction before full cervical dilatation
  3. improper use of oxytocin
  4. precipitate labour
26
Q

what are the predisposing factors to cervical lacerations ?

A

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

27
Q

what are the types of cervical lacerations ?

A

unilateral
bilateral
stellate
annular detachement

28
Q

how can we make a diagnosis of cervical laceration ?

A

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

29
Q

what are the complications of cervical lacerations ?

A
  1. upward extension causing rupture uterus or broad ligament hematoma
  2. postpartum haemorrhage
  3. infection
  4. cervical incompetence
  5. ureteric injury
30
Q

how are cervical lacerations managed ?

A

immediate repair through suturing starting from above the apex

31
Q

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

A

laparotomy and is managed as a ruptured uterus

32
Q

what are primary vaginal lacerations caused by ?

A

forceps application

vacuum extraction

33
Q

what are the causes of secondary vaginal lacerations?

A

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

34
Q

what is the management of vaginal lacerations ?

A

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

35
Q

what are the different types of puerperal hematomas ?

A 
vulval hematoma (infra-levator)
vaginal hematoma ( supra-levator)
broad ligament hematoma
36
Q

what are the causes of vulval hematoma ?

A

traumatic : incomplete hemostasis

direct trauma

37
Q

what is the clinical picture of vulval hematoma ?

A

hematoma usually appears in 12-48 hours after delivery

38
Q

what is the cause of vaginal hematoma ?

A

vaginal laceration

39
Q

what is the clinical picture of vaginal hematomas?

A

may not be visible externally

may not be painful until it reaches a large size

40
Q

what is the cause of broad ligament hematoma ?

A

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

41
Q

what is the clinical picture of broad ligament hematoma ?

A
  1. hypovolemia , anemia and shock
  2. the uterus is felt left and deviated to the opposite side
  3. fever unilateral leg oedema
42
Q

what is the management of small hematoma ?

A

managed conservatively

prophylactic antibiotic

43
Q

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

A

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

44
Q

what is the management for a broad ligament hematoma ?

A

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

45
Q

what are the types of obstetric fistulae ?

A

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

46
Q

what is the main aetiology of fistulae?

A

prolonged obstructed labour

47
Q

what is the main cause of fistulae in developed nations ?

A

gynecological surgery especially hysterectomy

48
Q

how are recto-vaginal fistulae diagnosed ?

A

ano-rectal and transvaginal ultrasounds
dye test
CT , MRI

49
Q

what are the main causes of rupture uterus ?

A 
VBAC 
obstructed labour 
rupture of a uterine scar 
abruptio placenta 
perforation 
external trauma 
grand multipara 
internal podalic version
manual seperation of the placenta
50
Q

what are the types of uterine rupture ?

A

complete : involving the whole uterus and peritoneum

incomplete: not involving the peritoneal coat

51
Q

what are the differential diagnosis of rupture uterus ?

A

abruptio placentae
extrauterine ectopic pregnancy
other causes of acute abdomen

52
Q

what is the management of uterine rupture ?

A

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

53
Q

what happens to the fetus during uterine rupture ?

A

death due to asphyxia from detachment of the placenta

WH (68 decks)

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