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NOT SO UNCOMMON – SPONTANEOUS or
ASSISTED DELIVERIES
DEPEND UPON THE CARE PROVIDED BY THE
OBSTETRICIAN
AVOIDANCE, EARLY DETECTION & PROMPT
MANAGEMENT – KEY TO REDUCE SIGNIFICANT
MORBIDITY
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2.
CLASSIFIED:
INJURIES TO BONY PARTS
i) Injury to Symphysis Pubis
ii) Injury to Sacro-coccygeal Joint
iii)Injury to Sacro-iliac Joint
INJURIES TO SOFT TISSUE
i) Injury to Vulva
ii) Perineal Tears
iii)Laceration of Vagina & Cervix
iv)Rupture of Uterus
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INJURY TO SYMPHYSIS PUBIS:
DURING FORCIBLE EXTRACTION OF THE HEAD BY
FORCEPS OR IN BREECH DELIVERY
• NOT SO SERIOUS
• URETHRA & BLADDER MAY BE INVOLVED –
COMPLICATE THE CASE
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INJURY TO SYMPHYSIS PUBIS:
• DIAGNOSIS: PAIN AT PUBIC REGION or
MOVEMENT
GAP MAY BE FELT
TENDER PUBIC SYMPHYSIS
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TREATMENT: BED REST FOR 2-3 WEEK
ANALGESICS
FIRM BINDER AROUND THE PELVIS
BLADDER CARE
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# & DISLOCATION OF COCCYX:
DURING EXTRACTION WHERE SUB-PUBIC ANGLE
IS NARROW
• PAIN AT THE REGION OF COCCYX WHILE SITTING
• MOBILE OR DISPLACED COCCYX
• EXCISE THE COCYX
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INJURY TO SACRO-ILIAC JOINT:
Result after injury to Symphysis Pubis,
Symphysiotomy or Pubiotomy
• Ligaments are torn & Flaring out of the iliac
bones
• Do not support pelvis- can’t use limbs
• Bed Rest; Straping of pelvis for 2-3 weeks
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INJUR TO VULVA:
MINOR TEAR OF LABIA MINORA, FOURCHETTE
COMMON  NO TREATMENT
• VULVAL HEMATOMA:
BLEEDING FROM PARAVAGINAL VEINS
TENSE, BLUISH & TENDER
LARGE: INCISION & CLOTS REMOVED
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PERINEAL TEARS:
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GROSS INJURY IS DUE TO MISMANAGED 2ND
STAGE OF LABOUR
•
ETIOLOGY:
OVER STRETCHING OF PERINIUM
RAPID STRETCHING OF PERINIUM
INELASTIC PERINIUM
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PERINEAL TEARS:
DEGREES:
First-degree: involve the perineal skin, and
vaginal mucosa
Second-degree: 1st degree and the fascia and
muscles of the perineal body
Third-degree: 2nd degree and involve the anal
sphincter.
A fourth-degree: extends through the rectal
mucosa to expose the lumen of the rectum.
FOURTH-DEGREE
PERINEAL TEAR
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PERINEAL TEARS:
PREVENTION:
LIBERAL USE OF EPISIOTOMY
PROPER CONDUCT OF LABOUR DURING 2ND
STAGE
PERINEAL SUPPORT DURING 2ND STAGE
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PERINEAL TEARS:
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TREATMENT:
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SHOULD REPAIR IMMEDIATELY
FOLLOWNG PLACENTAL DELIVERY
DELAYED BY 24 HRS DELAYED
CLOSURE
DIAGNOSE THE DEGREE OF TEAR
GOOD LIGHT, EXPOSURE & ASSISTANCE
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2.
3.
PERINEAL TEARS:
TREATMENT:
LITHOTOMY POSITION
INCOMPLETE TEAR: CONTINUOUS
VAGINAL MUCOSA SUTURE
INTERRUPTED TO MUSCLE
MATTRESS TO SKIN
COMPLETE TEAR: TAKE FIRST THE
RECTAL MUCOSA AND CONVERT TO
INCOMPLETE TEAR
4.
AFTER CARE:
LOW RESIDUE DIET
STOOL SOFTNER
SEITZ BATH BD
ORAL ANTIBIOTICS: ANAEROBIC
ANALGESICS
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VAGINAL LACERATION:
FORCEPS DELIVERIES OR BREECH
EXTRACTIONS
OBSTRUCTED LABOUR
TREATMENT:
MINOR TEAR: NO SUTURING
MAJOR LACERATION: REPAIR USING
ABSORABL SUTURE
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CERVICAL LACERATION:
MINOR INJURY OCCUR IN ALL CASES
• DEEP TEARS ARE ALWAYS PREVENTABLE
• IDENTIFY AFTER DELIVERY AS PPH
• CAUSES:
1. RAPID DELIVERY OF FETUS
2. ASSISTED DELIVERIES
3. RIGID CERVIX
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CERVICAL LACERATION:
SEQUELAE:
INFECTION, PERSISTENT CERVISITIS
EXTENSIVE SCARRING
STERILITY
REPEATED ABORTION
PREMATURE LABOUR
DYSTOCIA
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CERVICAL LACERATION:
TREATMENT:
MINOR TEAR: NO TREATMENT
MAJOR TEAR:
INSPECT THE WHOLE CERVIX
HOLD THE TORN END WITH SPONGE
HOLDING FORCEPS
INTURRUPTED CATGUT SUTURES –
VERTICAL MATTRESS SUTURE
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RUPTURE OF UTERUS:
DISRUPTION IN THE CONTINUITY OF
UTERINE WALL
INCIDENCE: 0.05% (1 IN 2000)
CAUSES:
SPONTANEOUS: CONGENITAL
MALFORMMATION, OBSTRUCTED
LABOUR, GRAND MULTIPARITY
SCAR RUPTURE: PREVIOUS CS (1-2%),
MYOMECTOMY
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RUPTURE OF UTERUS:
CAUSES:
IATROGENIC: INJUDICIOUS USE OF OXYTOCIN,
FORCIBLE ECV/ IPV, FALL OR BLOW OVER THE
ABDOMEN, , FORCEPS or BREECH EXTRACTION
TYPES:
INCOMPLETE RUPTURE: PERITONIUM REMAINS
INTACT
COMPLETE RUPTURE: SCAR IN UPPER
SEGMENT- INVOLVES PERITONIUM
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RUPTURE OF UTERUS:
DIAGNOSIS:
DURING PREGNANCY:
PAIN OVER LOWER ABDOMEN
TENDERNESS
SUDDEN ABDOMINAL DISTENSION
FEATURES OF SHOCK
FHS – IRREGULAR OR ABSENT
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RUPTURE OF UTERUS:
DIAGNOSIS:
DURING LABOUR:
BACKGROUND OF PROLONG OBSTRUCTED
LABOUR
SHOCK, COLLAPSED STATE
WEAK & RAPID PULSE, LOW BP
FETAL PART EASILY FELT
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RUPTURE OF UTERUS:
TREATMENT:
RESUSCITATION:
2 WIDE BORE IV CANULA / VENOUS CUT DOWN
/ CVP
IV FLUIDS: RL / HAEMACCEL
BLOOD CROSS MATCH & TRANSFUSE
MONITOR VITALS, CVP & UO
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RUPTURE OF UTERUS:
TREATMENT:
LAPAROTOMY:
REPAIR: IN CASES OF SCAR RUPTURE WITH
CLEAN MARGIN
REPAIR & STERILISATION:
HYSTERECTOMY: LOW GENERAL CONDITION,
GRAND MULTIPARA, MORBID DISTORTION OF
ANATOMY, INFECTED CASE
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Episiotomy is a surgically planned incision
on the perineum and the posterior vaginal
wall during the second stage of labor.
It is also known as Perineotomy.
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A surgical incision into the
perineum between the
vagina and anus.
Prior to instrumental
delivery (forceps, vacuum)
to widen the vagina
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To enlarge the vaginal introitus so as to
facilitate easy and safe delivery of fetus.
To minimize overstretching and rupture of
the perineal muscle and fascia.
To reduce the stress and strain on the fetal
head(more for premature baby).
In rigid/inelastic perineum- primigravida,
old perineal scar of episiotomy
2. Anticipated perineal tear- Primi, big baby,
face to pubis or face delivery, narrow pubic
arch, breech delivery
3. Operative procedure- forcep or vaccum
delivery
1.
4.To shorten the second stageHeart diseases, severe pre-eclampsia or
pre-eclampsia, post C/S cases, postmaturity
5. Foetal Interest- foetal distress, premature
baby, breech delivery
Bulging thinned perineum during contraction
just prior to crowning is the ideal time
A. Maternal – 1.Easy to repair
2.Prevent prolapse
3.Prevent lacerations extending
to rectum.
4.Shortening of 2nd stage of
labour
B. Foetal1.Minimise intracranial injuries
in premature baby
2. Reduces foetal asphyxia and
acidosis
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Mediolateral
Median
Lateral
J- shaped
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a) The posterior vaginal wall
b) The deep and the superficial transverse
perineal muscle,the bulbospongiosus and
part of the levator ani muscle.
c) The fascia covering the muscle
d) Transverse perineal branches of the
pudendal vessels and nerves.
e) The subcutaneous tissue and the skin.
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Cleaning and draping
Anesthesia
Incision
- Site and timing
- Technique
Repair:
- Timing and Methods
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Clean wound with clean water after each
urination and defaecation.
Keep area dry
Apply clean pads
Analgesics if needed
Peri-care and peri-light
Suture removal on 7th -10th post op day if silk
is applied.
F/U after 6 wks if no complication
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Immediate:
- Extension of incision to involve the anal sphincter
- Hemorrhage
- Vulval haematoma : the apex of the incision is not included
in the stich.
The dead space in not obliterated properly.
The sprouting vessels if not ligated.
- Wound infection
- Wound dehiscence
- Retention of urine
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Remote:
- Dyspareunia
- Rectvaginal fistula, - scar endometriosis
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3. Bartolin cyst- if the duct of the bartholins
gland is included in the episiotomy wound.
4. Scar endometriosis.
5. Deficient perineum
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Well support of the perineum at the time of
delivery of head
Delivery by early extension is to be avoided
Spontaneously forcible delivery is to be
avoided
To deliver the head in between contraction
To perform timely epsiotomy
To take care during delivery of shoulder
Controversy of Routine Episiotomy
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The final rule is that there is no substitute for
surgical judgment and common sense.