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  • 1. Genital Injuries Prepared by : Racha Elkassem Prepared to : Dr. Mageda Mourad
  • 2. Outline • • • • • • • • • • • • Definition Classifications Anatomy and Physiology Causes Signs and Symptoms Risk factors Diagnostic procedure Complications Treatment Prevention & Risk for reoccurrance Nursing management References
  • 3. Female genitalia External female genitalia  Vulva, clitoris, major and minor labia , vagina Internal female genitalia Uterus, ovary
  • 5. 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
  • 6. The vagina • It is the fibromusculo – membranous sheath communicates uterine cavity with exterior at the vulva. • It extends from the vestibule upwards and backwards upto the vaginal part of the cervix. • Walls – anterior (7cm), posterior (9cm) and 2 lateral walls44. • The lower third, resembles, figure of H, middle third is like transverse slit and upper thirdis rounded in shape.
  • 7. Structures: • Mucous coat: lined by the stratified squamous epithelium without any glands. • Sub mucous layer consists of loose areolar tissue. • Muscular layer consists of inner circular and outer longitudinal. • Fibrous coat from endopelvic fascia.
  • 8. CERVIX • The cervix is a constricted part of uterus separated from the body by the constriction part known as the isthamus and behind by the transverse ridge considered as torus uterinus. This contains a cervical canal, which communicates the uterine cavity with the vagina. It extends downwards and backwards from the isthamus, protrudes through the anterior wall of vagina which divides the cervix into supravaginal and vaginal parts.
  • 9. Structure of the cervix: • Serous coat: from the peritoneum which covers the posterior surface of supravaginal part. • Muscular coat: disposed smooth muscle. Some parts produced from collagenous and elastic fibrous tissue. • Mucous membrane: by columnar epithelium and stratified squamous epithelium.
  • 10. Ligaments of cervix • Laterally by a pair of Mackenrodt’s ligaments. • Posteriorly by a pair of uterosacral ligaments. These ligaments have unstriped muscles and leashes of blood vessels and lymphatic’s. On each side, the lymphatic drainage into external iliac, obturator lymph nodes, internal iliac groups and sacral groups.
  • 12. Anatomy and Physiology A. Pelvic floor: Pelvic floor is a muscular diaphragm that separates the pelvic cavity above from the perineal space below. It is formed by the levator ani and coccygeus muscles, and is covered by parietal fascia. The levator ani muscles on either side arise from posterior surface of pubic symphysis, the white line over fascia covering obturator internus and ischial spine.
  • 13. • The levators sweep from the lateral pelvic wall downwards and medially to fuse with the opposite side in the midline and form a pubo-coccygeal raphe. • Fibres of Levators are inserted from before backwards and fuse with muscle fibres of urethra, the vaginal walls, perineal body, anal canal, anococcygeal body and the lateral borders of coccyx. Functions: • To support the pelvic viscera. • To maintain effective intra-abdominal pressure. • To facilitate anterior rotation and downward and forward propulsion of the presenting part during parturition. • Serves as a support and voluntary sphicter of urethra, vagina and anal canal.
  • 14. B. Urogenital diaphragm: The urogenital diaphragm is external to pelvic diaphragm and includes the triangular area between the ischial tuberosities and the symphysis. It is made up of deep transverse perineal muscles, sphincter urethrae and internal and external fascial coverings.
  • 15. C. Perineum: Perineum is a diamond-shaped space that lies below the pelvic floor. it is bounded by:  Superiorly: pelvic floor  Laterally: the pelvic outlet consisting of subpubic angle, ischiopubic rami, ischial tuerosities, sacrotuberous ligaments and coccyx  Inferiorly: skin and fascia
  • 16. • This area is divided into two triangles by transverse muscles of perineum and base of urogenital diaphragm: – – • Anteriorly- Urogenital triangle. Posteriorly- Anal triangle Most of the support of perineum is provided by pelvic and urogenital diaphragms.
  • 17. Perineal Body: • The median raphe of levator ani between the anus and vagina, is reinforced by the central tendon of the perineum. Bulbocavernosus, superficial transverse perineal and external anal sphincter muscles also converge on the central tendon. These muscles contribute to perineal body, which provides much support to perineum.
  • 18. PERINEAL TEAR Gross injury is due to MISMANAGED 2ND STAGE OF LABOUR More common in PRIMIGRAVIDA than MULTIGRAVIDA . Due to extension of episiotomy, posteriory it involves the anal sphincter from back & obliquely upwards into the lateral vaginal wall ETIOLOGY: - OVER STRETCHING OF PERINIUM - RAPID STRETCHING OF PERINIUM - INELASTIC PERINIUM
  • 19. Causes and Predisposing Factors: • Obstetric injuries: Malpresentations such as breech Contracted pelvic outlet spontaneous labour operative vaginal deliveries( forceps or vaccum) Macrosomic babies • Non-obstetric injuries: rape, molestation, fall, accidental injuries like RTA, bull horn injuries etc.
  • 20. Degrees of Perineal tear:  First degree- limited to vaginal mucosa and skin of the introitus.  Second degree- extends to the fascia and muscles of the perineal body.  Third degree- trauma involves the anal sphincter.  Fourth degree - extends into the rectal lumen, through the rectal mucosa. • A rare type of tear is central tear of the perineum when the head penetrates first through the posterior vaginal wall, then through the perineal body and appears through the skin of the perineum. It usually occurs in patients with contracted outlet.
  • 22. First & second degree tears :Spontaneous tears originate near the midline of the perineum, but when they are traced upwards they are invariably found to extend into one / other posteriolateral vaginal sulcus.  Sometimes the upper limit of the tear is felt better – helpful to catch the upper edge of the vaginal tear.  If a double tear is found, care must be taken to unite the lateral vaginal walls to the loose posterior tongue.  Tears of the anterior vaginal wall often involve the tissues close to the urethral meatus. Later, pt. is unable to void urine because of muscle spasm consequent on the bruising around the urethra & bladder neck.
  • 23. Third degree tears:A tear has extended into the anal sphincter or canal. Any fecal contamination is cleared away & area drenched with an aqueous solution of antiseptic. The muscle wall of the rectum & anal canal is closed by interrupted or continuous catgut sutures (No.0) placed so that the suture avoids the bowel mucosa. Disadvantage – appearance of small rectovaginal fistula at the upper end of the wound.
  • 24. Symptomatology: • Immediate: – – – – – – Bleeding Traumatic PPH - hemorrhagic shock. Perineal Pain Perineal hematoma Urinary retention due to painful perineum Urinary incontinence Anorectal dysfunctions like fecal incontinence • Delayed: 1. 2. 3. 4. 5. 6. Infected perineum- perineal abscess Uterovaginal prolapse Urinary incontinence (stress and urinary fistula) Fecal incontinence ( rectovaginal fistula) Dyspareunia Feeling of slack vagina during coitus • Bleeding • Disruption of anatomical continuity
  • 26. Repair of perineal tear : First degree: • Sometime doesn’t require suturing or can use one or two interrupted suture. Second degree: • The vaginal mucosa is to be sutured first. The first suture is placed at or just above the apex of the tear. Thereafter, the vaginal walls are opposed by interrupted sutures with chromic catgut no. ‘Ofrom above downwards till the fourchette is reached. The sutures should include the deeper tissues to obliterate the dead space.
  • 27. • A continuous suturing may cause shortening of the posterior vaginal wall. Complete perineal tear: • The rectal and anal mucosa is sutured from above downwards by interrupted sutures. Muscle walls including the pararectal fascia are then sutured by interrupted sutures. The torn ends of the sphincter ani externus are sutured with figure of eight stitch by another interrupted suture. • Perineal skin by interrupted suture
  • 29. Complications if left untreated: • • • • Infection Hemorrhagic Shock Cosmetic disadvantage 3rd and 4th degree tears if left untreated may lead to fecal incontinence.
  • 30. Episiotomy • It is an incision on the perineum & the posterior vaginal wall during the second stage of labor • It should be performed just before the crowning of head in second stage of labour. • It is commonly performed for spontaneous vaginal delivery , about 2/3rd of primigravida , 1/3rd of the multiparous
  • 31. Objective: • To enlarge the vaginal introitus so as to facilitate easy & safe delivery of the fetus – spontaneous or manipulative. • To minimize over stretching & rupture of the perineal muscles & fascia • To reduce the stress & strain on the fetal head. Indications: • In elastic or rigid perineum. • Anticipating perineal tear – big baby, face to pubis delivery, breech delivery, shoulder dystocia. • Operative delivery: forceps delivery, ventouse delivery. • Previous perineal surgery: pelvic floor repair, perineal reconstructive surgery.
  • 32. Types Mid line: incision through the fourchette & perineal body. Advantage: no large blood vessels are encountered & repair is very simple. Disadvantage: extension of incision includes the anal sphincter or canal itself. Lateral incision: may cause bleeding or the bartholian gland / duct may be injured & considerable difficulty may be encountered in securing an accurate realignment of the divided structures.
  • 33.  Posterolateral incision: starting at the midpoint of the fourchette or posterior commissure. It has the advantage to the damage to the sphincter.  J shaped incision: in which after incising the perineum in the midline until a point is reached 2-3 cm from the anterior margin of the anus.
  • 35. Median Merits : -the muscles are not cut - blood loss is least. - repair is easy. - postoperative comfort is maximum. - healing is superior. - Wound disruption is rare. - Dypareunia is rare. Mediolateral - relative safety from rectal involvement from extension. - if necessary, the incision can be extended.
  • 36. Demerits : - Extension, if occurs involves rectum. -Apposition of the tissues is not so good. -Blood loss is little more. - Not suitable in - Relative increased manipulative delivery or in incidence of wound abnormal presentation or disruption. position. - Dyspareunia is more
  • 37. Advantages Maternal – Reduction in the duration of second stage. Reduction of trauma to the pelvic floor muscles. Fetal – it minimizes intracranial injuries.
  • 38. The structures involved during mediolateral episiotomy are :  Posterior vaginal wall  Superficial and deep transverse perineal muscle, bulbospongiosus and part of levator ani.  Fascia covering those muscles.  Transverse perineal branches of pudendal vessels and nerves.  Subcutaneous tissue and skin
  • 39. Timing of the repair of episiotomy  The most common practice is to defer episiotomy repair until the placenta has been delivered. Early delivery of the placenta reduces blood loss from the implantation site because it prevents the development of extensive retroplacement bleeding. Advantage is that episiotomy repair is not interrupted or disrupted by delivery of placenta, especially if manual removal must be performed
  • 40. Post operative care: • 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
  • 41. Complication Immediate: 1. Extension of the incision: involves rectum, mainly in median episiotomy or occipito posterior. 2. Vulval haematoma. 3. Infection. 4. Wound dehiscence: infection is the primary cause of wound disruption. 5. Injury to anal sphincter. 6. Rectovaginal fistula.
  • 42. Cont-d Remote: • Dyspareunia due to narrow introitus. • Chance of perineal lacerations. • Scar endometriosis.
  • 43. Prevention of perineal tear: • 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
  • 44. Periurethral Tears Vaginal tears can also occur at the region around the urethra - the opening through which urine comes out. These are then called ' Periurethral 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.
  • 45. Causes • The commonest cause for a periurethral tear is a sudden extension of the fetal head at the time of delivery. Normally, the fetal head is in a position of flexion with the chin touching the chest. At the time of delivery, after crowning occurs, the head is born by extension. A gradual extension will not put much presure on the anterior or upper part of the vagina. But a sudden extension will cause a sudden pressure on upper vaginal area resulting in a periurethral tear.
  • 46. How to prevent • It is important for the doctor or midwife to press gently on the fetal head at the time of delivery and guide it to a slow and gradual extension at the time of birth.
  • 47. Treatment • Periurethral tears need to be stitched carefully under proper light. If not repaired well or if it is not diagnosed after the delivery, it can bleed continuously for quite some time and cause many other problems • It is advisable for the woman to use cold packs on the site of the tear for at laeast 7-10 days to hasten healing. Using anti-inflammatory painkillers like Ibuprofen aslo helps. • Thankfully, during the course of a pregnancy the body is primed to heal quickly. The immune system is more efficient than usual and therefore wounds will heal within a few weeks after childbirth
  • 48. Complications if not treated • • • • Continuous Bleeding Infections in the tear Severe pain and inflammation Urine Retention due to inability of the woman to pass urine through the inflamed urethra
  • 49. Vaginal lacerations It involves middle or upper third of the vagina but not associated with lacerations of the perineum or cervix.  Common during forceps delivery or vaccum, sometime even with spontaneous delivery. Frequently extend deep into the underlying tissues and give rise to haemorrhage, which is controlled by appropriate suturing. The tears are repaired by interrupted or continuous sutures using chromic catgut no. ‘0’.
  • 51. Cervical tear • The cervix is lacerated in over half of vaginal deliveries. • Most of these are less than 0.5cm. • Deep cervical tears may be extended to the upper third of vagina. • In rare instances, the cervix may be entirely or partially avulsed from the vagina, with colporrhexis in the anterior, posterior or lateral fornices.
  • 52. Cont-d • Rarely, cervical tears may extend to involve the lower uterine segment & uterine artery & its major branches & even through the peritoneum. • Cervical lacerations upto 2 cm must be regraded as inevitable in childbirth. Such tears heal rapidly. • In healing, they cause a significant change in round shape of the external os before cervical effacement & dilatation to that of appreciable lateral elongation after delivery.
  • 54. Diagnosis A deep cervical tear should always suspected in cases of profuse haemorrhage during & after third stage labour, if the uterus is firmly contracted • Extent of the injury can be fully appreciated only after adequate exposure & visual inspection of cervix.
  • 55. Treatment • Deep cervical tears require surgical repair when the laceration is limited to the cervix or extends into the vaginal fornix, results are obtained by suturing the cervix. Either interrupted / running absorable sutures are suitable
  • 57. Wound healing • Healing by primary intension occurs in clean incised wounds such as surgical incision. • It produces a clean, neat, thin scar. • Healing by secondary intension refers to a wound which is infected, discharging pus or wound with skin loss.
  • 58. Factors influencing wound healing 1. General:  Age  Nutrition - protein deficiency, vitamin c and vitamin A deficiency.  Hormones – corticosteroid  Medical disorder – Anaemia , Jaundice, Diabetes, Blood dyscrasis.
  • 59. Cont-d 2. Local:  Position of wound, faulty technique of wound closure.  Poor blood supply, Impairment of lymphatic drainage.  Tension  Movement  Exposure to ionizing radiation.  Foreign bodies tissue reaction and inflammation, necrosis
  • 61. • spontaneous or traumatic rupture of the uterus ie., the actual separation of the uterine myometrium/ previous uterine scar, with rupture of membranes and extrusion of the fetus or fetal parts into the peritoneal cavity. • Dehiscence - partial separation of the old uterine scar; - the fetus usually stays inside uterus and the bleeding is minimal when dehiscence occurs
  • 62. Rupture uterus
  • 64. RISK FACTORS: • Women who have had previous surgery on the uterus (upper muscular portion) • Having more than five full-term pregnancies • Having an overdistended uterus (as with twins or other multiples) • Abnormal positions of the baby such as transverse lie. • Use of Pitocin (oxytocin) and other labor-induced medications (prostaglandin) • Rupture of the scar from a previous CS delivery/hysterectomy. • Uterine/abdominal trauma • Uterine congenital anomaly • Obstructed labor; maneuvers within the uterus • Interdelivery interval (time between deliveries)
  • 65. PATHOPHYSIOLOGY Pathologic retraction ring occurs, strong uterine contractions w/o cervical dilatation “tearing sensation” Complete rupture Incomplete rupture Rupturing of endometrium, myometrium and perimetrium Rupturing of endometrium and myometrium Uterine contraction stops Localized tenderness and persisting aching pain over the area of the uterine segment Bleeding into the peritoneal cavity
  • 66. Swelling of the abdomen: •Retracted uterus •Extrauterine fetus Hemorrhage from torn uterine arteries Bleeding to the vagina Decreased blood volume Decreased venous return Decreased BP Increases gas exchange to oxygenate better the decreased blood volume Decreased cardiac output Heart attempts to circulate remaining blood volume Vasoconstriction of peripheral vessels, increased heart rate
  • 67. Cold, clammy skin Increased respiratory rate Uterine perfusion is decreased Continued blood loss will continue to fall BP Fetal distress Decreased brain perfusion Decreased kidney perfusion Decreased LOC (lethargy, coma) Decreased urine output Renal failure Death of Mother and fetus
  • 68. ASSESSMENT: •evaluate maternal vital signs •note an increase in rate and depth of respirations, an increase in pulse , or a drop in BP indicating status change •assess fetal status by continuous monitoring •speak with family, and evaluate their understanding of the situation •observe for signs and symptoms of impending rupture -lack of cervical dilatation -tetanic uterine contractions - restlessness - anxiety - severe abdominal pain - fetal bradycardia - late or variable decelerations of the FHR)
  • 69. SIGNS AND SYMPTOMS Clinical Manifestations: Developing Rupture •Abdominal pain and tenderness •Uterine contractions will usually continue but will diminish in intensity and tone. •Bleeding into the abdominal cavity and sometimes into the vagina. •Vomiting •Syncope; tachycardia; pallor •Significant change in FHR characteristics – usually bradycardia (most significant sign) •Difficulty identifying fundal height •Vaginal bleeding •Maternal hemorrhage and shock •Absent fetal heart tones
  • 70. Violent Traumatic Rupture •Sudden sharp abdominal pain during or between contractions. •Abdominal tenderness •Uterine contractions may be absent, or may continue but be diminished in intensity and cord •bleeding vaginally, abdominally, or both •Fetus easily palpated in the abdominal with shoulder pain •Tenses, acute abdominal with shoulder pain •Signs of shock •Chest pain from diaphragmatic irritation due to bleeding into the abdomen.
  • 72. Aspiration risk Impaired gas exchange Altered tissue perfusion Fluid volume deficit Infection risk Anxiety and fear Anticipatory grieving Pain
  • 73. Planning and Implementation Oxygen Intravenous fluids Maternal vital signs Uterine contractions Uterine/vaginal blood loss Measure and record fundal height every 30 minutes
  • 74. Deficient Fluid Volume Start or maintain an IV fluid as prescribed. Use a large gauge catheter when starting the IV for blood and large quantities of fluid replacemnt. Maintain CVP and arterial lines, as indicated for hemodynamic monitoring. Maintain bed rest to decrease metabolic demands. Insert Foley catheter, and moniter urine output hourly or as indicated. Obtain and administer blood products as indicated.
  • 75. Fear Give brief explanation to the woman and her support person before beginning a procedure. Answer questions that the family or woman may have. Maintain a quiet and calm atmosphere to enhance relaxation. Remain with the woman until anesthesia has been administered; offer support as needed. Keep the family members aware of the situation while the woman is in surgery and allow time for them to express feelings.
  • 76. Decreased cardiac output •Administer supplemental oxygen, blood/fluid replacement, antibiotics, diuretics, inotropic drugs, antidysrhythmics, steroids, vassopressors, and/or dilators as ordered. •Position HOB flat or keep trunk horizontal while raising legs 20 to 30 degrees in shock situation •Activities such as isometric exercises, rectal stimulation, vomiting, spasmodic coughing which may stimulate Valsalva response should be avoided; administer stool softener as indicated.
  • 77. Ineffective Tissue Perfusion Administer O2 using a face mask at 8-12 L/min or as ordered to provide high oxygen concentration. Apply pulse oximeter, and monitor oxygen saturation as indicated. Monitor ABG levels and serum electrolytes as indicated to assess respiratory status, observing for hyperventilation and electrolyte imbalance. Continually monitor maternal and fetal vital signs to assess pattern because progressive changes may indicate profound shock.
  • 78. Risk for Infection • Observe for localized signs of infection. •Cleanse incision or insertion sites daily and PRN with povidone iodine or other appropriate solutions. •Change dressings as needed or indicated. •Encourage early ambulation, deep breathing, coughing and position changes. •Maintain adequate hydration and provide. •Provide perineal care.
  • 79. MEDICAL MANAGEMENT •Immediate stabilization of maternal hemodynamics and immediate caesarean delivery •Oxytocin is given to contract the uterus and the replacement . •After surgery, additional blood, and fluid replacement is continued along with antibiotic theory.
  • 80. SURGICAL MANAGEMENT •Caesarean Section •Laparotomy •Hysterectomy
  • 81. NURSING MANAGEMENT •Continually evaluate maternal vital signs; especially note an increase in rate and depth of respirations, an increase in pulse , or a drop in BP indicating status change. •Assess fetal status by continuous monitoring. •Speak with family, and evaluate their understanding of the situation. •Anticipate the need for an immediate caesarean birth to prevent rupture when symptoms are present. •Provide information to the support person and inform him or her about fetal outcome, the extent of the surgery and the woman’s safety. •Let the pt express her emotion without feeing threatened.
  • 82. FGM • Female Genital Mutilation compromises all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non medical reasons (WHO, UNICEF, UNFPA, 1997)..
  • 83. Procedures *Type III- Also known as Infibulation. *Type IV- All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization.
  • 84. Health Risks health benefits. damages healthy genital tissue and interferes with a woman’s natural bodily functions.
  • 85. Health Risks • • • • • • • • Immediate Complications Severe pain Shock Hemorrhage Tetanus Sepsis (bacterial infection) Urine retention Open sores
  • 86. Cont-d • • • • • • • • Long Term Consequences Bladder and urinary tract infections Cysts Infertility Need for later surgeries Childbirth complications Newborn deaths Decreased sexual pleasure
  • 87. International Organizations