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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 1. 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 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 • INJURY TO SYMPHYSIS PUBIS: • DIAGNOSIS: PAIN AT PUBIC REGION or MOVEMENT GAP MAY BE FELT TENDER PUBIC SYMPHYSIS • TREATMENT: BED REST FOR 2-3 WEEK ANALGESICS FIRM BINDER AROUND THE PELVIS BLADDER CARE # & 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 • 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 • 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 • PERINEAL TEARS: • GROSS INJURY IS DUE TO MISMANAGED 2ND STAGE OF LABOUR • ETIOLOGY: OVER STRETCHING OF PERINIUM RAPID STRETCHING OF PERINIUM INELASTIC PERINIUM 1. 2. 3. 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 • 1. 2. 3. PERINEAL TEARS: PREVENTION: LIBERAL USE OF EPISIOTOMY PROPER CONDUCT OF LABOUR DURING 2ND STAGE PERINEAL SUPPORT DURING 2ND STAGE PERINEAL TEARS: • TREATMENT: SHOULD REPAIR IMMEDIATELY FOLLOWNG PLACENTAL DELIVERY DELAYED BY 24 HRS DELAYED CLOSURE DIAGNOSE THE DEGREE OF TEAR GOOD LIGHT, EXPOSURE & ASSISTANCE • 1. 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 • • • VAGINAL LACERATION: FORCEPS DELIVERIES OR BREECH EXTRACTIONS OBSTRUCTED LABOUR TREATMENT: MINOR TEAR: NO SUTURING MAJOR LACERATION: REPAIR USING ABSORABL SUTURE 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 • • 1. 2. 3. 4. 5. 6. CERVICAL LACERATION: SEQUELAE: INFECTION, PERSISTENT CERVISITIS EXTENSIVE SCARRING STERILITY REPEATED ABORTION PREMATURE LABOUR DYSTOCIA • 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 • • • 1. 2. 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 • 3. • 1. 2. 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 • RUPTURE OF UTERUS: DIAGNOSIS: DURING PREGNANCY: PAIN OVER LOWER ABDOMEN TENDERNESS SUDDEN ABDOMINAL DISTENSION FEATURES OF SHOCK FHS – IRREGULAR OR ABSENT • RUPTURE OF UTERUS: DIAGNOSIS: DURING LABOUR: BACKGROUND OF PROLONG OBSTRUCTED LABOUR SHOCK, COLLAPSED STATE WEAK & RAPID PULSE, LOW BP FETAL PART EASILY FELT • 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 • 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 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. A surgical incision into the perineum between the vagina and anus. Prior to instrumental delivery (forceps, vacuum) to widen the vagina 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 Mediolateral Median Lateral J- shaped 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. Cleaning and draping Anesthesia Incision - Site and timing - Technique Repair: - Timing and Methods 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 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 Remote: - Dyspareunia - Rectvaginal fistula, - scar endometriosis 3. Bartolin cyst- if the duct of the bartholins gland is included in the episiotomy wound. 4. Scar endometriosis. 5. Deficient perineum 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 The final rule is that there is no substitute for surgical judgment and common sense.