perineal tears & birth injuries Flashcards
What is the common presentation of perineal injuries?
Bleeding intrapartum or postpartum
What are the characteristics of first degree perineal lacerations?
- affects only vaginal epithelium & perineal skin
- they heal quickly & don’t cause long-term damage
- can be managed by suturing or not
What are the characteristics of a second degree laceration?
- injury to perineum that spares the anal sphincter complex but involves the perineal muscles (bulbospongiosus & superficial perineal muscles)
- like episiotomy
How should 1st & 2nd degree perineal tears be taken care of?
1- encourage good hydration, drinking 2 liters at least of fluid per day
2- eat balanced diet to avoid constipation
3- good hygiene
4- wash area with water only
5- cold ice pack for pain
6- change sanitary pads regularly
What are the types of third degree perineal lacerations?
3A: <50% tear in external anal sphincter
3B: 50% or more tear in external anal sphincter
3C: external & internal sphincter are completely
What are the characteristics of a 4th degree perineal laceration?
The perineal body, entire anal sphincter complex, & anorectal mucosa are lacerated
- buttonhole injury between mucosa & vagina only (missed if rectal exam is not done)
What are the risk factors for OASIS?
3rd & 4th degree perineal tears due to
1- nulliparity
2- midline episiotomy
3- persistent OP
4- macrosomia
5- operative vaginal delivery forceps > vacuum
6- prolonged second stage of labour
How are obstetric anal sphincter injuries (OASIS) managed?
1- regional or pudendal block for better evaluation
2- single dose of prophylactic IV antibiotics
3- separate the labia for better visualization & do rectal exam
4- repair rectal mucosa first followed by external & internal anal sphincter (end to end or overlap technique)
What are the complications of OASIS repair?
1- hematoma
2- disruption or dehesience risk
3- infection risk
4- dyspareunia
5- anal incontinence
How should OASIS be cared for after repair of injury?
1- oral antibiotics for 5-7 years
2- laxative such as lactulose
3- analgesics
4- follow up after 6-12 weeks
5- risk of recurrence is 6-8%
6- avoid straining
What are the types of uterine rupture?
Primary -> in previously normal uterus
- occurs in thinned lower segment & can extend up or down or into the broad ligament
Secondary -> in previously scarred uterus or uterus with congenital anomaly
- ranges from dehiscence to rupture in myometrium or to complete rupture
What are the risk factors for uterine rupture?
PRIMARY
1- prostaglandin induction/oxytocin hyper stimulation
2- prolonged labour/difficult forceps delivery
3- external trauma/ECV
4- polyhydramnios/multiple gestation
5- fetal anomaly
SECONDARY
1- previous CS
2- myomectomies/GTD
3- operative hysteroscopy
4- previous rupture in previous pregnancy
5- pregnancy in rudimentary horn/connective tissue diseases
How does rupture of the uterus present?
- vaginal bleeding
- abdominal pain
- cessation of contraction
- maternal tachycardia & hypotension
- easily palpable fetal parts abdominally
- loss of FHS
- loss of station
What are the complications of uterine rupture?
Maternal
- hemorrhage
- bladder injury
- ureter injury
- hysterectomy
Fetal
- NICU admission
- low apgar score
- hypoxic ischemic encephalopathy
- fetal death
How is uterine rupture managed?
1- Resuscitation
2- Laparotomy to evaluate rupture
3- hysterectomy for difficult repair with massive bleeding
4- repair of injured nearby structures
