The document discusses common obstetric injuries including perineal tears, vaginal tears, cervical tears, ruptured uterus, and hematomas. It describes the clinical features and management of various degrees of perineal tears. For third degree tears involving the anal sphincter, repair should be done within 1 week. Larger hematomas require incision and drainage while stable ones can be managed conservatively. Vaginal and cervical lacerations need exploration and suturing to control bleeding.

1. Dr.Parul Sinha

2.  To know the common types of injuries
encountered in practice
 To know their clinical manifestations
 To know their management
• vulval hemetoma
• perineal tear
• Rupture Uterus

3.  Obstetric Injuries
 Injuries due to coitus
 Direct trauma
 Injuries due to foreign bodies and
instruments

4.  Perineal tears.
 Vaginal tears.
 Cervical tears.
 Rupture of uterus.
 Vaginal and pelvic Haematoma..
 Fistulae.

5.  Rupture of the uterus during labour is one
of the obstetrical emergencies.
 Genital injuries usually manifest as vaginal
bleeding after delivery in the presence of
well contracted uterus.
 The bleeding may be internal bleeding as in
haematomas or ruptured uterus.

6.  Periurethral lacerations
 Periclitoral lacerations
 Vaginal lacerations
 Cervical lacerations/ cervical
tear

7. • Occurs due to pressure from delivering head
to the anterior perineum by the intact
posterior perineum.
• If light bleeding- pressure with a pad for 1-2
minutes arrest the bleeding
• If significant bleeding- repair to be done
using fine continuous sutures.
• If stitches are taken urethral catheter be
placed.

8.  Gross perineal tear is usually due to mismanaged
2nd stage of labour.
Degree of perineal tear –
 1st degree perineal tear- it involves the vaginal
mucosa and subcutaneus tissue and forchette.
 2nd degree perineal tear- it involves the vaginal
mucosa , subcutaneous tissue (connective tissue)
varying degree of perineal body tear but it is not
reaching up to external anal sphincter.

9.  1st & 2nd perineal tears are termed as
incomplete perineal tear.
 3rd degree perineal tear- in this injury to
perineum involves –post vaginal wall tear of
whole of the perineum as well as complete
transection of anal sphincter .

10.  4th degree perineal tear- involving the
vaginal mucosa, perineum, anal sphincter,
anal and rectal mucosa
 3rd & 4th degree perineal tear are complete
perineal tear.

13.  Prevention- proper conduction of 2nd stage of
labour is preventive i.e,
 Early extension of head during delivery to be
avoided
 Slow delivery of fetal head in between
contraction
 To perform timely episiotomy when indicated
 To take care of perineum during delivery of
shoulder.

14.  Recent perineal tear should be repaired
immediately following delivery of placenta.
 In case of delay more than 24 hrs immediate
repair to be withheld.
 In case of 2nd degree it should done after
antibiotic coverage and when ever wound
becomes clean.
 In case of complete perineal tear when delay
is >24 hrs then repair to be done after 3rd
month of delivery.

15.  It is just like episiotomy repair i.e. stitch the
vaginal mucosa, subcutaneous tissue and skin-
suture maternal 1 or 1-0
 1st stitch the vaginal mucosa by continuous
suture
 Stitching should be started 1cm beyond the
apex of vaginal mucosa.
 Then stitch the subcutaneous tissue by
interrupted suture

16.  Skin by interrupted suture.
 If tear was deep perform a rectal examination
make sure that no stitch in rectum
 Clean the stitch line and perineum
 Dressing of stitch line.

18.  Patient is to be put in lithotomy position
 All aseptic precaution to be taken
 Local anaesthesia or preferable GA.
 Suture material used is 1-0 vicryl or chromic
cut gut
 The rectal mucosa is sutured 1st from above
downward with interrupted suture
 Then stitch the rectal muscle and para-rectal
fascia by interrupted suture

19.  Now explore the torn end of anal sphincter
with the help of allies forceps
 Torn end of sphincter are sutured in midline by
figure of eight stitch
 It is supported by another layer of interrupted
suture
 Stitch the vaginal mucosa, perineal muscles
and skin by interrupted suture.

20.  Just like episiotomy cleaning and dressing of
wound after each urination and defecation.
Special care to be taken in repair of complete
perineal tear-
 Liquid diet on 1st day
 Low residual diet (such as milk, rice, bread,
egg, fish, potato, sweets, fruit juice)for 4 days.
 Lactose 8ml twice a day for one week to
soften the stool

21.  Broad spectrum antibiotics along with
metronidazole (400mg) TDS for 5-7 days
 Avoid giving enema and rectal
examination for two weeks

22.  Minor degree of cervical tear during 1st
delivery is common.
 It is commonest cause of traumatic PPH
 Left lateral cervical tear is more common

23. I. Iatrogenic- In cases of operative vaginal
delivery or breech extraction through
incomplete dilatation of cervix
II. Rigid cervix following previous cervical
operation
III. Precipitate labour

24.  Cervical tear or vaginal tear should be
suspected when PPH occurs in-spite of
well contracted uterus.
 Explore the cervix and vagina for tear
under good light.

25. Exploration of cervix
 With all aseptic precaution
 Evacuation of bladder if full
 Place the patient in lithotomy position
 Insert speculum and retract the posterior
vaginal wall

26.  Ask the assistant to push down the fundus of uterus
gently.
 Hold the anterior lip of cervix with sponge holder
and trace whole of the cervix with another sponge
holder forceps in clock wise manner and identify the
cervical tear
 Now grasp both margins of the tear of cervix by the
sponge holder.

27.  Stitch the cervical tear by interrupted
mattress suture by taking the whole
thickness of cervix, suture material is 1-0
chromic catgut with round body needle.
 The repair should be started 1 cm above
the apex of the tear.

28.  Mattress suture prevents rolling of the edges.
 If the cervical tear is extending to the lower
segment or vault with broad ligament
haematoma : laparotomy is needed.

30.  After the proper exposure haemostatic suture
and vaginal tear suturing to be done
 If multiple laceration- pack the vagina for 24
hrs - After removing the packing see for
bleeding

31.  Vulva injuries- vulval laceration, perineal
laceration and hematoma need to be drained
and proper haemostatic suture should be given
 Sometime local packing is required.

32. Haematomas are divided into:
1.Infralevator ( which lie below the
levator ani muscle e.g.
a.vulval and perineal haematomas.
b.Paravaginal haematomas.
c. Haematoma of the Ischiorectal fossa.
2. Supralevator (above the levator ani muscle):
Spread beneath the broad ligament or bulge into
the wall of the upper vagina

33.  This may be caused by rupture of a vulval varix.
 More often it occurs after perineal repair when a
vessel is in spasm at the time of repair & relaxes
and bleeds later.
 It can occasionally occur after normal labour with
apparently intact perineum.

34.  The haematoma appears suddenly as a very tender
purple swelling on one side of the vulva.
 It may reach 10 cm or more in diameter.
 There is severe perineal pain and some times
shock.
 So any woman complains of sever perineal pain
after delivery, the perineum should always be
inspected before giving her analgesics.

35. Vulval hematoma

37.  If the swelling is increasing in size and more than
5cm , it should be incised and the clot turned out.
 If the bleeding vessel can be identified it should be
ligated ( but this is unlikely).
 A drain is left in the cavity and a firm dressing is
applied.
 If the haematoma is less than 5cm and not
expanding it can be managed by observation using
ice- packs and pressure dressings to limit
expansion

38.  This is an uncommon accident after delivery.
 A deep vessel is torn at the time of delivery, goes
into spasm and then relaxes and bleeds later.
 A haematoma forms above the pelvic diaphragm
and spread into the base of the broad ligament.
 It may also seen with uterine rupture.

41.  Pain and deterioration in the woman’s general
condition.
 There will be progressive anemia and slight
fever.
 When the haematoma is large enough it can be
palpated on abdominal examination and it will
displace the uterus upwards and to one side.

42.  It usually undergoes gradual absorption, but it will
take several weeks if it is large.
 Infection is rare but may occur and leads to abscess
formation.
 Most cases are treated conservatively with blood
transfusion and antibiotics.

43. vesico-vaginal fistula:
-This may occur as a result of pressure by the
presenting part in prolonged labour or by direct
injury during operative procedures such as forceps
or caesarean section.
 In obstructed labour prolonged pressure between
the head and the pubic bone may cause local
ischaemia and subsequent necrosis of the anterior
vaginal wall and the base of the bladder leading to
a vesico-vaginal fistula.

44.  Recto-vaginal fistula result from third degree
perineal tear with improper healing.
 The patient will complain of urinary or fecal
incontinence.
 These fistulae are uncommon now with proper
obstetric care.
 Treatment by surgical repair.

46. 1) Perineal tears should be repaired:
a) 24 hours later
b) 48 hours later
c) 36 hours later
d) Immediately

48. 2) Most suitable method of treatment of 4
inches size episiotomy haematoma is by-
a) Evacuation
b) Magsulf compression
c) Cold compress
d) marsupialisation

50. 3) In a patient with third degree perineal tear,
presenting after 1 week, repair should be
done:
a) Immediately
b) 2 weeks
c) After 6 weeks
d) After 12 weeks

52. 4) A woman delivers a 4 kg baby with a midline
episiotomy and suffers a third degree tear.
Inspection shows which of the following
structures is intact:
a) Anal sphincter
b) Perineal body
c) Perineal muscles
d) Rectal mucosa

54. 5) IIIrd degree perineal tear is involvement of :
a) Vaginal mucosa
b) Urethral mucosa
c) Levator ani muscles
d) Anal sphincter

56. 6) Which of the following is the best
treatment for vulvar hematomas that are
extremely painful, bit stable in size:
a) analgesics
b) Ice compress
c) Incision and drainage
d) Angiographic embolization

58. 7) Concerning vaginal lacerations involving the
middle or upper third of vagina, which of the
following is true:
a) These are often the result of forceps delivery
b) These result from uterine overdistension
c) These are usually associated with injuries to
the levator ani muscles
d) All of the above