MATERNAL INJURIES DURING VAGINAL DELIVERY AND ITS MANAGEMENT

Presented by Dr J. SEETOHUL

CONTENTS
RISK FACTORS PERINEAL TEARS VAGINAL TEARS COLPORRHEXIS CERVICAL TEARS HAEMATOMAS RECTO-VAGINAL FISTULA EPISIOTOMIES RUPTURE OF UTERUS INVERSION OF THE UTERUS

RISK FACTORS
Risk factors include: Instrumented deliveries. Primiparity. Pre-eclampsia. Multiple gestation. Vulvovaginal varicosities. Prolonged second stage. Clotting abnormalities

PERINEAL TEARS
The perineum is the region between the vaginal opening and the anus. CAUSES : Over stretching of perineum - due to large baby,
face-to-pubis or face delivery, outlet contraction with narrow pubic arch, shoulder delivery and forceps delivery

Rapid stretching of perineum - due to rapid delivery of the head

during uterine contraction, precipitate labour and delivery of the after-coming head in breech.

Inelastic perineum as in rigid perineum in elderly primigravidae,

scar in the perineum following previous operations such as episiotomy or perineorrhaphy and vulval oedema

DEGREES OF PERINEAL TEAR:

First degree: laceration of the vaginal epithelium or perineal skin only. Second degree: involvement of the perineal muscles but not the anal sphincter. Third degree: disruption of the anal sphincter muscles which should be further subdivided into: 3a: <50% thickness of external sphincter torn. 3b: >50% thickness of external sphincter torn. 3c: internal sphincter also torn. Fourth degree: a third degree tear with disruption of the anal epithelium as well.

First degree tears

Repair of superficial perineal layers. The vaginal mucosa and perineal skin are re-approximated with a continuous stitch of 3-0 delayed absorbable suture.

Second degree tears

Repair of a second degree laceration: A first-degree laceration involves the fourchette, the perineal skin, and the vaginal mucous membrane. A second-degree laceration also includes the muscles of the perineal body. The rectal sphincter remains intact.

Third degree tears

Repair of the sphincter after a thirddegree laceration: A third degree laceration extends not only through the skin, mucous membrane, and perineal body, but includes the anal sphincter. Interrupted figure-of-eight sutures should be placed in the capsule of the sphincter muscle.

Fourth degree tears

Layered primary closure of a fourthdegree obstetric laceration
(A) The anal mucosa is first closed with a running or interrupted layer of a 4-0 delayed absorbable suture. (B) The retracted ends of the internal anal sphincter are reunited with a running layer of a 3-0 delayed absorbable suture. (C) An end-to-end anastomosis of the external anal sphincter (EAS) is accomplished using four or five interrupted 2-0 delayed absorbable sutures placed through the capsule of the EAS. (D) The rectovaginal fascia and puborectalis fibers are approximated with a running 2-0 delayed absorbable suture

Fourth degree obstetric laceration

Repair of rectal mucosa
Internal anal sphincter and external anal sphincter

An intact anal sphincter

A partial tear along the length of the external anal sphincter

An intact anal sphincter during a digital rectal examination

A buttonhole tear of the rectal mucosa with an intact external anal sphincter demonstrated during a digital rectal examination

Repair of episiotomy or first- or second-degree tear

1. Infiltrate with 1% lidocaine (lignocaine) (unless an epidural is in situ or the perineum has been infiltrated prior to delivery). 2. Find the apex of the vaginal incision or tear and place the first suture above this level (but note that the rectum is just posterior to the vaginal wall). 3. Use a continuous locking suture to appose the vaginal wall, continuing until the hymenal edges are apposed. The suture can then be tied, or more simply locked, and the needle threaded between the apposed vaginal edges a few centimetres back ready to close the perineal body. 4. The perineal body sutures should be interrupted, and then a continuous finer suture used for the skin.It is possible that not closing the skin (i.e. leaving the skin edges approximately 5 mm apart) reduces postnatal pain. Check instruments and swabs (a retained swab is a common cause of litigation in obstetrics).

Repair of third- or fourth-degree tears

This should ideally be by an experienced clinician in a theatre with good analgesia and light. The edges of the sphincter should be approximated or overlapped, with the knots tied in the lumen of the bowel rather than buried in the perineal tissues. Antibiotics, laxatives and fibres are important to allow healing. If secondary breakdown occurs, it may be necessary to perform a defunctioning colostomy before re-repairing.

VAGINAL TEARS
Vaginal Tears can occur at any part of the vaginal wall, but are seen mostly at the junction between the lateral and posterior walls. These tears may be superficial with only minor lacerations of the vaginal mucosa. But, sometimes the tears may be deep enough to expose the inner muscles. Vaginal tears can also occur at the region around the urethra - the opening through which urine comes out. These are then called ' Paraurethral tears'. The problem with these type of tears is that there may be profuse bleeding from even a small tear since the region has a large blood supply.

Treatment / Management of vaginal Tears

The vagina should always be examined under proper light immediately after the delivery of the baby for any such tears. All tears should be repaired immediately.

COLPORRHEXIS
RUPTURE OF THE VAULT OF THE VAGINA It may be primary where only the vault is involved or secondary when associated with cervical tear. It is said to be complete when the peritoneum is opened up. Posterior fournix usually ruptures, however, cervical tear is usually associated with tear of the lateral fournix.

TREATMENT OF COLPORRHEXIS
It is generally agreed that abdominal operation is the treatment of choice. Immediate treatment of shock and loss of blood is imperative, followed by repair of the vaginal laceration, with or without hysterectomy in order to facilitate satisfactory exposure and repair.

CERVICAL TEARS
Minor tears of the cervix are very common during delivery, especially in a woman who is delivering her first child. But sometimes, major lacerations which can cause severe bleeding may also occur . In fact, cervical tears are the commonest form of traumatic post partum hemorrhage. Cervical tears are commonest at the lateral angle, between the anterior and posterior lips of the cervix. Causes of Cervical tear: Delivery through an undilated cervix whether spontaneously, or by forceps. Precipitate labour. Rigid cervix due to previous operations like the LEEP (loop electrosurgical excision procedure), conisation, or cervical amputation. Very vascular cervix as can occur in low level placenta previa.

Treatment / Management of Cervical Tears

The aim of treatment is to control bleeding as early as possible by repairing the tear. Minor lacerations without active bleeding does not require to be repaired - they heal spontaneously with no ill effects. Major cervical lacerations or tears need to be repaired in the Operating theater under anesthesia, good light and proper exposure of the tear.

HAEMATOMAS
VULVAL HAEMATOMAS Collection of blood anywhere in the vulval region is called vulval hematoma. Although vulval haematomas can also occur after an injury due to any cause, it is commonly seen after the vaginal delivery of a baby. A Vulval hematoma can occur either spontaneously or after improper repair of an episiotomy wound. Blood from a rupture of the deep veins of this region collects in a closed space with no opening for it to drain out.

VULVAL HAEMATOMA

Symptoms of Vulval Hematoma

A steadily increasing swelling to one side of the vagina. The swelling is tense and tender to the touch. The woman complains of severe pain, more so on sitting down. There may be difficulty in passing urine if the swelling presses on the urethra. The bleeding can be severe enough to cause the patient to go into shock.

Assessment
Abnormal severe pain; pressure in perineal area, including rectal pressure Sensitive tumor / cyst in perineal area with discolored skin Inability to void Palpable tumor Reddish or blue discoloration of the skin Decreased hemoglobin and haematocrit (H&H) Signs of shock such as pallor, tachycardia, and hypotension if significant blood loss has occurred

Implementation Monitor vital signs Monitor client for abnormal pain especially when forceps delivery has occurred Place ice to the hematoma site followed by warm sitz baths later (general rule: Ice X 12-24 hours, then heat) Administer analgesics as prescribed Monitor I&O Encourage fluids Encourage voiding

Treatment / Management of Vulval Haematoma

The aim of treatment is to ligate the bleeding blood vessels as early as possible and support the patient with IV drips and medicines so that she does not go into shock. An incision is made at the most distended point of the hematoma. The incision is then deepened and the blood clots scooped out. The bleeding vessels are identified and tied up. The incision is closed by applying different layers of stitches. A drain may be put in the wound for 24 hours to allow any oozing blood to flow out. Proper antibiotics are prescribed and the patient kept under close observation. Blood transfusion is given if necessary.

PARAVAGINAL HAEMATOMAS
These are not visible externally

CLINICAL MANIFESTATIONS:
Mass or swelling Pelvic pain Suggillation Shock Fever, septic Urinary retention

TREATMENT
Surgical evacuation of the haematoma Tying off any bleeders present Oversewing bleeding areas and obliterating the cavity Catheterizing the bladder and tightly packing the vagina for 12 to 24 hours Infuse with fluids and administer with antibiotics Keep blood in readiness for any future need

PELVIC HAEMATOMAS

RECTO-VAGINAL FISTULA
Abnormal communication between the rectum and the vagina

Symptoms
Large recto-vaginal fistulae produce very distressing symptoms. The patient loses voluntary control over passage of faeces and flatus, and she suffers from a persistent leucorrhoea, due to the associated secondary vaginitis. If the fistula is small, the patients only complaint may be involuntary escape of flatus, which she feels as coming from the vagina

Treatment
In non-malignant cases, the fistula should be closed by plastic operation. Preparation of the patient for operation as well as postoperative care are as important as meticulous operative technique.

A. Fistulas in the lower third of the vagina Lawson Taits (1845-1899) operation:
consists of cutting the remaining bridge of tissue below the fistula, thus converting the fistula into a complete perineal tear. The tear is now sutured in layers, in the same manner and order described under repair of complete tears.

B. Fistulas in the middle third of the vagina

These may be closed in the same manner as has already been described for dealing with vesico-vaginal fistulae. An alternative procedure is to start the operation as in perineorrhaphy for rectocele and to extend the dissection of the recto-vaginal septum upwards above the fistula. The hole in the rectum is then closed, and the operation continued as a perineorrhaphy.

C.Fistulas in the upper third of the vagina:

High recto-vaginal fistulas are usually surrounded by dense fibrosis, and are difficult to close vaginally. They are usually best dealt with by an abdominal (trans-peritoneal) operation.

EPISIOTOMIES
Definition: It is an incision of the pudenda or perineum. It is also called perineotomy. Types: Median (Midline) Episiotomy: Midline incision of the perineum. Mediolateral Episiotomy: Begins in the midline but is directed laterally away from the rectum.

Types of episiotomy
l- Median Episiotomy Easy to repair Rare faulty healing Less pain in the perineum Dyspareunia is rare Less blood loss Extension to the anal sphincter and rectum is more common

II - Mediolateral Episiotomy More difficult to repair Faulty healing is more common More pain in the perineum Dyspareunia is more common More blood loss Extension to the anal sphincter and rectum is less common

Timing of Episiotomy:
Best time to perform episiotomy is when the head is visible during a contraction to a diameter of 3 to 4 cm. Before the application of forceps or vacuum extractor. Too early episiotomy causes bleeding from the gaping to be considerable. Too late episiotomy causes the muscles of the perineal floor to undergo excessive stretching and lacerations will not be prevented.

Advantages of episiotomy :
Clean cut incision which is easy to repair compared to irregular vaginal lacerations Shorter second stage of labour Increase in the diameters of Vulval outlet Reduce fetal complications e.g. intracranial haemorrhage in preterm fetus. Reduce maternal complications e.g. damage to pelvic floor predisposing to vaginal prolapse, and stress incontinence.

Indications of Episiotomy:
A) MATERNAL Short rigid perineum Previous perineal or pelvic floor repair Contracted pelvic outlet B) FETAL Face to pubis delivery Vaginal breech delivery Shoulder dystocia Oversized fetus Forceps or ventouse delivery

Complications of Episiotomy
Increased blood loss. Extension to anal sphincter or ischio-rectal fossa

Haematoma formation.
Infection.

Perineal pain and dyspareunia

Technique:
A vertical incision is made in the perineal body avoiding the fetal presenting part. The incision should be approximately half the length of the perineal body. Mediolateral incisions should be made at a 45 degree angle to the midline of the perineum. The incision should extend into the vagina approximately 2 to 3 cm.

Repair of Episiotomy:
There are many ways to close an Episiotomy but the most common procedure is: Vaginal mucosa and submucosa are closed by chromic catgut up to and approximating the cut ends of the hymeneal ring. Interrupted chromic catgut sutures are used to approximate the muscles and fascia. Closure of the superficial fascia by continuous suture. Closure of the skin by mattress sutures or alternatively by subcuticular continuous stitches.

RUPTURE OF THE UTERUS DURING LABOUR

CAUSES:
-Overstretching of the lower uterine segment in obstructed labour -Uterine defects such as weakening of the uterine wall by caesarean section or myomectomy scars, developmental anomalies or resistance to dilatation following a plastic repair operation involving the cervix -Multiparity -Injudicious use of oxytocic drugs during labour

PATHOLOGY :
Complete: when all coats including the peritoneum are torn. Occurs following disruption of the scar in upper segment. Incomplete: peritoneum remains intact. results from rupture of the lower segment scar or extension of a cervical tear into the lower segment with formation of a broad ligament haematoma.

UTERINE RUPTURE BEFORE DELIVERY

Vaginal bleeding. Abdominal tenderness. Maternal tachycardia. Abnormal fetal heart rate tracing. Cessation of uterine contractions.

UTERINE RUPTURE AFTER DELIVERY

May be found on routine exam. Hypotension more than expected with apparent blood loss. Increased abdominal girth.

MANAGEMENT
Resuscitation and laparatomy are done simultaneously. Subtotal hysterectomy is commonly done. Repair may be done in cases where margins are clean. Repair and sterilization is done when woman has completed her family.

INVERSION OF THE UTERUS

Inversion of the uterus is a turning inside out of the uterus.

Types
1st degree: the fundus is depressed so as to bulge into the uterine cavity, but not through the cervix. 2nd degree: the fundus protrudes through the external os so as to enter the vaginal canal. 3rd degree: the fundus protrudes through the vaginal introitus, the inversion being complete. Puerperal inversion has also been classified on the basis of its duration. Acute inversion occurs immediately after delivery and before the cervix constricts. Once the cervix constricts, the inversion is termed subacute. Chronic inversion is noted more than 4 weeks after delivery.

Diagnosis of uterine inversion

The diagnosis of uterine inversion usually is obvious. Shock and hemorrhage are prominent, as is considerable pain. A dark redblue bleeding mass is palpable and often visible at the cervix, in the vagina, or outside the vagina. A depression in the uterine fundus or even an absent fundus is noted on abdominal examination. Partial inversion in which the fundus stays within the vagina can escape immediate notice if the attendant is not aware of this complication.

Treatment of uterine inversion

Successful management of patients with uterine inversion depends on prompt recognition and treatment. If initial measures fail to relieve the condition, it may progress to the point at which operative treatment or even hysterectomy is necessary. Shock associated with uterine inversion typically is profound. Hemorrhage can be massive, and hypovolemia should be vigorously treated with fluid and blood replacement.