maternal trauma during labour and delivery Flashcards
what are the three categories that maternal injuries during labour fall under ?
perineal trauma
genital lacerations
uterine rupture
what is the perineum ?
point of connection of all pelvic floor muscles except the ischocavernosus muscle
when do perineal muscles contract ?
in cases of increased abdominal pressure, such as defecation , intercourse and labour
what are the classifications of perineal tears ?
first degree
second degree
third degree
fourth degree
what are hidden perineal tears ?
tear of the levator anii muscles without apparent perineal tear and may be missed and increase the chance of the occurence of prolapse
what are the features of a first degree perineal tear ?
involves the perineal skin
posterior fourchette
posterior vaginal wall
what are the features of a second degree perineal tear ?
extension to the perineal muscles but not to the external anal sphincter
what are the features of a third degree perineal tear ?
involvement of any part of the anus ( both internal and external sphincter )
what are the features of a fourth degree perineal tear ?
extension to the mucosa of the anal canal or rectum
what are the complications to perineal trauma ?
- dyspareunia
- incontinence of stool and flatus in complete perineal tears
- incomplete tears predispose to genital prolapse
- postpartum haemorrhage
- puerperal sepsis
- recto-vaginal fistula
how does a recto-vaginal fistula happen ?
improper repair of a 4th degree perineal tear
how can we prevent perineal trauma ?
performance of an episiotomy in proper timing
proper management of the second stage of labour
what is an episiotomy ?
surgical enlargement of the posterior diameter of the pelvic outlet
when is an episiotomy typically done ?
during the last part of the second stage of labour (at crowning)
what is the recommended technique to perform ann episiotomy ?
medio-laterally and between n45 to 60 degrees
what is the time period in which a perineal tear should be repaired in ?
24 hours
how are first degree perineal tears repaired ?
by continuous locked or interrupted sutures
how are second degree perineal tears repaired ?
- perineal muscles are approximated using Vicryl sutures
- vagina is sutured as with 1st degree tears
- superficial perineal muscles are sutured with Vicryl sutures
- skin sutured as with 1st degree perineal tears
what is the post-operative care required for repaired perineal tears ?
they must be kept clean, dry and sterile , sop antiseptic solution must be used after each defecation or micturition
how are complete perineal tears managed post-operativley ?
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
what is the aetiology of old complete perineal tears ?
tears that were hidden or missed
improper repair of perineal tears
what are the signns of old complete perineal tears ?
muscular defect can be felt on PR examination n
how are old complete perineal tears fixed ?
posterior colpo-perineorrhaphy
what do genital tract traumas include ?
- vaginal and cervical lacerations
- puerperal hematomas
- obstreitics hematoma
what is the aetiology of cervical lacerations ?
- manual dilatation of the cervix
- forceps, ventouse or breech extraction before full cervical dilatation
- improper use of oxytocin
- precipitate labour
what are the predisposing factors to cervical lacerations ?
cervical dystocia
scarring of the cervix
oedema of the cervix in prolonged labour
placenta praevia due to increased vascularity
what are the types of cervical lacerations ?
unilateral
bilateral
stellate
annular detachement
how can we make a diagnosis of cervical laceration ?
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
what are the complications of cervical lacerations ?
- upward extension causing rupture uterus or broad ligament hematoma
- postpartum haemorrhage
- infection
- cervical incompetence
- ureteric injury
how are cervical lacerations managed ?
immediate repair through suturing starting from above the apex
if there is extension to the lower uterine segment as a complication of cervical laceration what is the best treatment?
laparotomy and is managed as a ruptured uterus
what are primary vaginal lacerations caused by ?
forceps application
vacuum extraction
what are the causes of secondary vaginal lacerations?
more common and are due to extension from perineal or cervical tears
what is the management of vaginal lacerations ?
immediate repair
tight pack
in small tears repair is usually not indicated
what are the different types of puerperal hematomas ?
vulval hematoma (infra-levator) vaginal hematoma ( supra-levator) broad ligament hematoma
what are the causes of vulval hematoma ?
traumatic : incomplete hemostasis
direct trauma
what is the clinical picture of vulval hematoma ?
hematoma usually appears in 12-48 hours after delivery
what is the cause of vaginal hematoma ?
vaginal laceration
what is the clinical picture of vaginal hematomas?
may not be visible externally
may not be painful until it reaches a large size
what is the cause of broad ligament hematoma ?
extension of upper vaginal, cervical or uterine tears which usually involves the uterine and vaginal artery
what is the clinical picture of broad ligament hematoma ?
- hypovolemia , anemia and shock
- the uterus is felt left and deviated to the opposite side
- fever unilateral leg oedema
what is the management of small hematoma ?
managed conservatively
prophylactic antibiotic
what is the management of a large hematoma that is progressively enlarging ?
hematoma is incised longitudinally
evacuation
bleeding point is ligated
gap is closed in layers
what is the management for a broad ligament hematoma ?
laparotomy ( through incision of the anterior leaflet of the broad ligament)
what are the types of obstetric fistulae ?
vesico-vaginal fistula
urethro-vaginal fistula
recto-vaginal fistula
uretero-vaginal fistula
what is the main aetiology of fistulae?
prolonged obstructed labour
what is the main cause of fistulae in developed nations ?
gynecological surgery especially hysterectomy
how are recto-vaginal fistulae diagnosed ?
ano-rectal and transvaginal ultrasounds
dye test
CT , MRI
what are the main causes of rupture uterus ?
VBAC obstructed labour rupture of a uterine scar abruptio placenta perforation external trauma grand multipara internal podalic version manual seperation of the placenta
what are the types of uterine rupture ?
complete : involving the whole uterus and peritoneum
incomplete: not involving the peritoneal coat
what are the differential diagnosis of rupture uterus ?
abruptio placentae
extrauterine ectopic pregnancy
other causes of acute abdomen
what is the management of uterine rupture ?
anti-shock measures
immediate laparotomy
delivery of the foetus and placenta
abdominal hysterectomy if the damage is beyond repair
what happens to the fetus during uterine rupture ?
death due to asphyxia from detachment of the placenta
