BIRTH CANAL TRAUMA. UTERUS RUPTURE

BY :

MUHAMMAD KHADHARI BIN KAMARUDDIN

GROUP 94

Definition of birth canal: - The passageway through which the fetus is expelled during parturition, leading from the uterus through cervix, vagina and vulva. - Vagina, vulva and perineum are often injured during expulsion stage of labor

WHAT IS BIRTH CANAL?

Bones -pelvic minor

STRUCTURES OF BIRTH CANAL

Soft tissue - Uterus, vagina and external reproductive organs

The types of trauma in birth canal is classified based on localisation : - Cervix - Vagina - Perineum

BIRTH CANAL TRAUMA

CERVICAL LACERATIONS

- Cervical tears are most presented in the lateral cervical sides - Rupture of the cervix is characterized by persistent

bleeding from a contracted firm uterus

There are 3 degrees of cervical lacerations: 1. First degree lacerations - Length of cervical rupture not over 2cm 2. Second degree lacerations - Length of rupture >2cm but does not extend to vaginal fornices 3. Third degree lacerations - Ruptured area extends to the vaginal fornices - If extends to vaginal fornices : very dangerous

- Rigidity of cervix - Abnormal structure due to scarring from

previous surgery - Rapid delivery of head in breech presentation

CAUSES OF CERVICAL LACERATIONS

TREATMENT OF CERVICAL LACERATIONS

• Deep cervical tears should be repaired immediately

• Treatment varies with the extent of the lesion.

When the laceration is limited to the cervix – or even when it

extends somewhat into vaginal fornix

• We can view the cervical tears at the vulva by applies firm downward pressure on the uterus while the operator exerts traction on the lips of the cervix with fenestrated ovum or sponge forceps

VAGINAL LACERATIONS - Usually longitudinal - Lacerations frequently extend deep into the underlying tissues and may give rise to significant hemorrhage - Causes of vaginal lacerations can be traumatic or spontaneous: - The repair of vaginal tears is in placing of interrupted

catgut suture in the edges of the wound

TRAUMATIC SPONTANEOUS

Injuries during forceps delivery

Fetal malpresentation (Esp fetal head extension)

Insufficient distensibility of vaginal wall

Large fetal head

- Classification of perineal lacerations: - 1. First degree - 2. Second degree - 3. Third degree - 4. Fourth degree

PERINEUM LACERATIONS Delivery may lead to overstretching of the vagina, causing tears

in the perineum, between the vagina and rectum.

- The least severe - Superficial tear that involve perineal

skin ,underlying tissue and superficial muscle ( musculus constrictor ani)

FIRST DEGREE LACERATION

SECOND DEGREE LACERATION - Extends to more deep muscle layer of pelvic diaphragm , muscle levator ani

THIRD DEGREE LACERATION - Lacerations extend farther to involve perineal body and circular muscle sphincter ani

- The most severe type - The laceration extends through the rectum’s

mucosa to expose anorectal lumen

FOURTH DEGREE LACERATION

Factors predisposing to Laceration of Perineum

Factors which increase risk of third- and fourth-degree lacerations: 1. Nulliparity 2. Prolong second-stage of labor 3. Persistent occiput posterior position 4. Mid or low forceps 5. Asian race (height) 6. Giant baby / macrosomia 7. Rigidity of perineal muscle 8. Epidural/peridural anesthesia

EPISIOTOMY

- Also known as perineotomy - Incision of perineum and posterior vaginal wall during second stage of labor - Purposes of episiotomy : - Easier to repair the laceration - postoperative pain is less and healing improved with an episiotomy compared with a tear - prevent pelvic floor complications (vaginal wall support defects and incontinence)

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Indications of Episiotomy

- When see threatening signs of perineal laceration - The baby is very large ( need to deliver quickly to avoid any resistance) - When the perineal muscles are excessively rigid

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Types of Episiotomy Median or Midline episiotomy Mediolateral episiotomy

Incision is made at midline, from center of the fourchette and extends on posterior side along midline for 2.5 cm

begin in the midline but be directed laterally and downward away from the rectum, either to left or right about 2.5cm from the anus (midpoint between anus and ischial tuberosity)

Better because it wouldn’t extend until anus

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Midline episiotomy being made. Two fingers are insinuated between the perineum and fetal head, and the episiotomy is then cut vertically downward

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Episiotomy Repair The repair of perineal tears is same as episiotomy incisions

1. Repair of first-degree lacerations - start from the upper angle of the wound - The vaginal mucosa is closed by interrupted catgut suture. And then the perineal skin are sutured - The sutured wound should be treated with an iodine tincture 2. Repair of second-degree lacerations - The upper angle of the wound is first sutured - Then the lacerated perineal muscles are repaired by several buried catgut sutures - After that, the same technique as in the first-degree lacerations

Episiotomy Repair

3. Repair of Third-degree lacerations - rectal mucosa has been repaired with interrupted, fine chronic catgut sutures - The torn ends of the sphincter ani are next approximated with two or three interrupted chromic catgut sutures - The wound is then repaired, as in a second degree laceration

Uterus Rupture

- One of the most dangerous labor complication - A spontaneous or traumatic rupture of the uterus

with extrusion of the fetus or fetal parts into the peritoneal cavity

- By definition, it is associated with the following: - Clinically significant uterine bleeding - Fetal distress - Protrusion or expulsion of the fetus and/or placenta into the abdominal cavity - Need for prompt cesarean delivery - Uterine repair or hysterectomy

Classification of Uterus Rupture 1. Classification by Pathogenesis

Spontaneous - Histochemical etiology of uterine rupture - occurs without any function of uterus - Example: (i) Anatomy anomaly (ii) Dystrophy diseases (connective tissue autoimmune disease, Inflammatory disease of uterus)

Voluntary - result of hyperfunction of uterus - Example: (i) Disproportion between sizes of presenting part and maternal pelvis (malpresentation) (ii) Extra doses of uterotonic drugs

Classification of Uterus Rupture

2. Classification by Layers of Uterus involved in Rupture

Complete rupture Incomplete rupture

3. Classification by Location of Rupture

Lower segment rupture Rupture of corpus/fundus of uterus

Signs of Threatened Uterine Uterus Rupture

- Signs that occur just during the labor - Excessive uterine activity. Uterine

contractions are very fast and painful - Lower uterine segment is overdistended,

thinned and painful at palpation - The margins of the cervical os becomes

edematous due to compression. The edematous extends to the vagina and the perineum

- Urination becomes difficult due to compression of the bladder and urethra between the bony pelvis and the fetal head

- Some bloody discharge maybe presented (depends)

- Pathological contractile Bandl’s ring is presented

Bandl’s ring

-Uterine contractions suddenly stop -Palpation of fetus in the abdomen (outside the uterus) -Fetal death -Hemorrhage then hypovolemic shock in mother

Signs and Symptoms in the Uterine Rupture that has happened

Treatments of Uterine Rupture

Whenever a threatening uterus rupture is seen, immediate Caesarian section must be done!

Managements of Uterine Rupture

- blood transfusion - Emergency exploratory laparotomy with cesarean delivery - Surgical repair of uterus or removal of uterus (hysterectomy), types of surgical treatment depends on Type of uterine rupture : - Extent of uterine rupture - Degree of hemorrhage - General condition of the mother - Mother’s desire for future childbearing When the tear is simple, transverse in the lower segment, and in the absence of infection => Repair by suturing When the ruptures were longitudinal on the lateral aspects of lower and upper segments of the uterus and the bleeding is uncontrollable (severe) => Hysterectomy

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