Topic №4: Birth trauma

Injury of the perineum and the vaginal walls:

 

Causes:

• perineal tissue stiffness, the most pronounced in nulliparous age, scarring of the vaginal wall, high crotch;previa head and the eruption of its large size;
• flexion of the presenting part
• operative delivery (forceps, vacuum extraction);
• large fetus;
• anatomically narrow pelvis;
• fast childbirth;
• premature extension and the eruption of the head,

 

Diagnostics:

• Perineal symptoms precede threat crotch rupture:
• bulging of the perineum,
• cyanosis,
• edema,
• blanching,
• perineal skin becomes shiny,
• cracks,

 

then there is a perineal rupture!

 

The degree of perineal rupture:

1st degree - compromised the integrity of the posterior commissure;

2nd degree - laceration of the perineum, the vaginal wall and the pelvic floor muscles, except for the external sphincter of the rectum;

3rd degree - the rupture external sphincter of the rectum and sometimes the anterior wall of the rectum.

Bleeding with deep vaginal ruptures stopped when suturing. Hematoma vagina sewn (with or without an opening) and tightly backfill for 24 hours. The growth of the hematoma is accompanied by a feeling of tension, pain, urge to act of defecation, increase of anemia. In this case it is necessary to identify the bleeding vessel, flash, assign activities to prevent infection.

Perineal ruptures are not usually accompanied by significant bleeding detected during inspection and sutured to the nature and extent of the damage.

 

Prevention:

careful management of childbirth, vaginal sanitation, prevention of the birth of the largest fetus.

 

Cervical Ruptures

 

Causes:

• scar neck strain;
• cervicitis;
• rigid neck at age primapara;
• large fetus;
• extensor previa;
• quick, rapid, prolonged labor;
• operational benefits delivery (forceps, vacuum extraction, extraction of the stem, destroying the fetus operations, manual removal of placenta and isolation, and others.);
• unsustainable second stage of labor.

 

 

Diagnostics

The main symptom of cervical fracture is bleeding after the birth of the fetus, and the uterus is well reduced. Bleeding can be from mild to heavy, the amount of bleeding depends on the caliber of the damaged vessel.

Usually after the baby is born and the placenta begins bleeding from the birth canal bright scarlet stream (blood), leading to the rapid hemodynamic disturbances. Inspection of the cervix in the mirror confirms that cervical rupture. With ruptures 3rd degree necessary to avoid damage to the lower uterine segment.

After delivery, childbirth necessarily  produce all  inspection of the cervix in the mirrors. For this cervix fenestrated foceps grip the front lip, and intercepting them sequentially for the cervix distance every 2 cm, inspect gradually entire cervix clockwise.

 

Degrees of cervical fracture:

1st degree - the value of the rupture is not more than 2 cm;

2nd degree - the rupture is greater than 2 cm, but does not reach the

vaginal vault;

3rd degree - the rupture reaches the vaginal vault.

 

Treatment

  The basic principle of treatment consists in suturing the cervix break immediately after his diagnosis. Closure of the rupture immediately after birth produced through all layers of the cervix from the vagina catgut single-row suture. Suturing produce rupture from the upper edge toward the outer fauces, first provisionally applied ligature above fracture edges 0.5-1 cm. The distance between the individual sutures 0.7-1 cm.

 

uterine rupture

uterine rupture is one of the most severe obstetric pathologies. Mortality in uterine rupture reaches 12,8-18,6%.

 

Causes:

• hyperextension of the lower segment due
• narrow pelvis,
• hydrocephalus fetus
• large fetus,
• incorrect position of the fetus
• incorrect insertion of the fetal head;
• tumors of the uterus and birth canal;
• anomalies of labor activity;
• scars on the uterus after prior surgery (perforation of the uterus, a cesarean section, conservative myomectomy).

 

Classification of uterine rupture

  The clinical course:

1. Threatened uterine rupture.

2. The beginning of uterine rupture.

3. Take a uterine rupture.

 

By the nature of damage:

1. Incomplete rupture of the uterus (not penetrating into the abdominal cavity).

2. Complete uterine rupture (penetrating into the abdominal cavity).

Clinic

 

Threatened uterine rupture:

• Painful contractions,
• The appearance of a woman's desire to push with high standing fetal presenting part (Vastens positive symptom)
• Excessive stretching of the lower uterine segment,
• Stress and pain of the lower uterine segment,
• High standing of the contraction of the ring,
• Cervical edema
• Difficulty in urination,
• Signs of fetal suffering.

 

Uterine rupture, which began:

• bout sharply painful and take a convulsive character,
• from the birth canal appear spotting
• swelling of the vagina increases,
• blood in urine is detected,
• broken heart activity of the fetus,
• appear active fetal movement,
• passage of meconium (with cephalic presentation)
• may occur sudden death of the fetus.

 

Take a uterine rupture:

• at break new mothers often feel a strong cutting pain,
• contractions cease,
• objectively - there:
  • apathy,
  • appears pale skin,
  • tachycardia,
  • there is a cold sweat,
  • nausea,
  • vomiting,
  • hiccups.
  • palpation and percussion are determined -
  • abdominal pain, especially its lower half,
  • positive symptom Shchetkina-Blumberg,
  • blunting in the side sections - free liquid.
  • quickly appears and grows as a result of bloating intestinal atony,
  • It observed bleeding from the vagina, which increases when moving away up the presenting part,
  • the fetus dies,
  • when stepping into the abdominal cavity of the fetus stomach becomes irregular in shape, and through the anterior abdominal wall is easily palpated small part of the fruit.

 

Obstetric Management of uterine rupture

threatening uterine rupture

• you must immediately stop generic activities and complete birth surgically.
• when the dead fetus and the fetal head, located in the pelvic cavity - destroying the fetus operations.

started and accomplished uterine rupture

always shown laparotomy, the purpose of which is to eliminate the source of bleeding, restoring the anatomy of the pelvic organs, preventing the spread of infection.

 

The volume of transactions - suturing rupture supravaginal hysterectomy, hysterectomy, and drainage of the abdominal cavity and retroperitoneal fat.

 

Obstetric fistula

For severe birth injury include urinary and intestinal-vaginal fistulas. Their presence leads to disability, infringement sexual, menstrual, generative and other functions usually occur emotional disorders.

 

Fistulas are the following:

• vesico-intestinal,
• cervicovaginal / between the bladder and cervical channel /
• uretrovaginal,
• ureterovaginal,
• entero-vaginal,
• vesico-vaginal (the most occurring fistulas).

 

Causes

Long standing head in one plane of the pelvis:

• with a narrow pelvis,
• anomalies of insertion and praevia,
• large / giant / fetus

Slipping tools when presenting part of  destroying the fetus operations

 

Clinic

• Incontinence and passage of it through the vagina with the urogenital fistulas,
• Stepping through the vagina gases and feces in intestinal-vaginal fistulas.

Diagnostics

- Inspection in the mirror

- cystoscopy

- Sigmoidoscopy.

 

Treatment - surgical.

 

Stretching and rupture of the joints of the pelvis

Etiology and pathogenesis. Excessive softening of the joints of the pelvic bones, especially the pubic symphysis ( "simphysiophaty") predisposes them to rupture and excessive stretching during childbirth by mechanical abuse or surgical interventions.

Breaks symphysis pubis often observed in the operational delivery, as well as the presence of a narrow pelvis and a vibrant labor. In 85% of cases at the symphysis pubis rupture occurred intervention to delivery. At the same time 55% of the cases used forceps and 8% - for the extraction of fetal pelvic end.

In areas stretching or tearing are formed hemorrhage, in which the infection postpartum inflammation appear appropriate pelvic joints. In rare cases, the symphysis pubis rupture accompanied by damage to the urethra, bladder, and the clitoris.

 

Clinic

• complaints of pain in the pelvic area of the associated joints, most often appear 2-3 days after birth,
• increased pain when moving down.
• Puerperas bedridden, some hip rotated outwards and at the same time deployed with slightly bent knees (to "frog") - a symptom NM Volkovich.
• "Duck" gait.

 

First degree - a discrepancy in the pubic rami 5-9 mm

second degree - 10-20 mm

third degree - more than 20 mm.

 

Treatment

• bed rest,
• antibiotic therapy,
• vitamin.
• tight bandaging of the circular basin
• trauma counseling