INJURIES TO BIRTH CANAL

INJURIES TO BIRTH CANAL

          Maternal injuries following childbirth process are quite common and contribute significantly to maternal morbidity and even to death.  Avoidance, early detection and prompt and effective management not only minimize the morbidity but prevent many a glynaecological problem from developing later in life.

VULVA:

          Laceration of the vulval skin posteriorly and the paraurethral tear on the inner aspect of the labia minora are the common site.

PERINEUM:

          While minor injury is quite common specially during first birth, gross injury is invariably a result of mismanaged 2^nd stage of labour.

CAUSES:

Ø      Over stretching of the perineum.

Ø      Rapid stretching of the perineum.

Ø      Inelastic perineum

DEGREES:

First Degree: Involves laceration of the remnants of hymen, lower part of vagina and perineal body remain intack.

Second Degree: Involves laceration of the posterior vaginal wall and varying degree of tear of the perineal body excluding anal sphincture.

Third degree (Complete): Involves major laceration of the posterior vaginal wall and tear of the perinial body including the anal sphincture with or without involvement of the anal canal even the rectum.

Management

          Important consideration I regard to repair of all perinial fear are

• To have the good light.
• To have the patient in lithotomy position
• To determine clearly the full extent of the damage before starting.

          First degree tear may be repaired during the 3^rd stage at least so far as the introduction of the stitches in concerned. It may be better not to lie the stitches until after the  placenta has been expelled as it passage may not put a strain upon and cause them to cut out.

          Second and third degree fears requires more desiperate treatment and their repair should be postponed until the completion of the third stage.  Indeed if the patients conditions irreversible, it is better to wait for some hours repair done within twelve hours treat satisfactorily.

After Care:

Ø      A low residual diet like bread egg biscuit fish sweets etc is given from second day onwards.

Ø      Milk of magnesia 8ml twice daily to soften the stool.

Ø      An intestinal antiseptic like chlorostip are capsule twice daily.

CERVIX

          Minor degree of cervical tear is univariable during first delivery and requires no treatment but entries cervica fears requiring attention.

PELVIC HAEMOTOMA:

Def: Collection of blood any where is this area between the pelvic haematoma.

ETIOLOGY

Ø      Improper  haematoma during repair of vaginal or perineal tear or episiotomy  wound.

Ø      Rupture of paravaginal venous pressure either spontaneously or following instrumental delivery

SYMPTOMS

Ø      Persistant severe pain are the perineal regions.

Ø      There may be rectal bearing down efforts where occurs

SIGNS:

Ø      Variable degree of shock may be evident

Ø      Local examination reveals a term swelling at the vulva

MANAGEMENT

          Haematoma detected early should be exposed in the operation theatre under general anaesthesia taking a septic precaution simultaneously resuscitative measures are to be takes.  The wound is respond, the clots are to be scooped cut and the bleeding points to be  secured prophylactic antibiotics is to be administered.

RUPTURE OF THE UTERUS

          Dissolution in the continuity uterine wall any time beyond, 28 weeks of pregnancy is called rupture of the uterus.

CAUSES

Ø      The cause of rupture of the uterus are broadly divided into

Ø      Spontaneous

Ø      Scar rupture

Ø      Iatrogenic

SPONTANEOUS

During pregnancy

Ø      Previous damage there by weaking of the uterine wall.

Ø      Congenital malformation of the uterus

Ø      In abroptio placentae

DURING LABOUR

Ø      Obstructive rupture

This is an end result of obstructed labour due to neglect in intranatal care.

Ø      Non obstructed rupture

Grand multipara are usually affected and rupture usually occurs early labour weaking of the wall due to separated previous birth as mentioned may to be responsible factor.

SCAR RUPTURE

          With lebiral use of primarily caesarian section  constitutes singnificantly to the overall incidence of uterine rupture.

During Pregnancy

          Classical or hysterectomy scar is likely to give way during later month of pregnancy.

During Labour:

          The classical or hysterectomy scar is more valuable to rupture during labour.

Iatrogenic or Traumatic

During Pregnancy

Ø      Fall or blow an the abdomen.

Ø      Forceible external version specially under general anaesthesia.

Ø      Injurious administration of oxytocin for induction of labour.

Ø      Use of prostoglandins for induction of abortion or labour.

TREATMENT

Ø      Resuscitation

Ø      Laparotomy

          Depending upon the state of the clinical condition, either resuscitation is to be done followed by laparotomy are to be done simultaneously.

LAPROTOMY

          Any of the these procedures may be adopted following laprotomy

Ø      Hysterectomy:- It is the surgery of rupture of uterus unless there is sufficient reason to preserve it.

Repair:

          This is mostly applicable to a scar rupture where the margine are clear.

BIBLIOGRAPHY

Ø      Text Book of Obstetrics

          D.C.Dutta Pg.No.444-455.

Ø      Text Book of Midwifery

          Myles.Vol.I.Pg.No.625, 636

Ø      Text book of Clinical midwife

          Jhonstone and Kellar