The lecture by Dr. K. Sowmya Reddy discusses maternal injuries following childbirth, focusing on various types of lacerations and tears, their causes, prevention, and treatment methods. Key topics include management of complete perineal tears, vaginal and cervical lacerations, uterine rupture, and pelvic hematoma, outlining specific surgical techniques and postoperative care. Emphasis is placed on the importance of institutional delivery and vigilant monitoring of high-risk pregnancies to prevent complications.

1. Lecture by-
Dr . K . Sowmya Reddy
Assst.Prof
Department of OBG
OMC

2. Maternal injuries following
childbirth process are quite
common.

3. VULVA
Lacerations
Paraurethral tear

4. PERINEUM
 Incidence - 1 % .
CAUSES:
i. Over stretching.
ii. Rapid stretching.
PREVENTION:
1) Proper conduct in the second stage.
2) Taking due care of perineum.

5. RISK FACTORS FOR THIRD DEGREE
PERINEL TEAR:
 Big baby(weight >= 3kg)
 Nulliparity
 Outlet contraction with
narrow pubic arc
 Shoulder dystocia
 Forceps delivery
 Scar in the perineum
(perineorrhaphy,
episiotomy)
 Face to pubis delivery
 Midline episiotomy
 Precipitate labor

6. MANAGEMENT
Recent tear : Repaired immediately following the
delivery of the placenta.
Delay beyond 24 hours: Antibiotics.
 The complete tear should be repaired after 3 months if
delayed beyond 24hours.

7. REPAIR OF COMPLETE PERINEAL
TEAR
Step 1:
 Lithotomy position –repair done with local infiltration
of lignocaine hydrochloride
Step 2:
 Rectal and anal mucosa
 The rectal muscles including the pararectal facia
 The torn ends of sphincter ani externus(EAS)
 Overlapping or end to end approximation method for
repair

8. Step3:
 Repair of perineal muscle done by interrupted sutures
Step 4:
 The Vaginal wall and the perineal skin are apposed by
interrupted sutures

9. Aftercare:
 Similar to that following episiotomy.
 Special care following repair of complete tear.
 A low residual diet
 Lactulose 8 ml
 Bread-spectrum antibiotics
 Metronidazole 400 mg thrice daily ,continued for 5-7
days
 Physiotherapy and pelvic floor exercises
 Reviewed again 6-12 weeks postpartum

10. Plan for Future Delivery:
 Need to have institutional delivery.
 Women having symptoms or with abnormal endoanal
USG and/or manometry should be delivered by
elective cesarean birth.

11. VAGINA
 Isolated vaginal tears
 Lacerations without involvement of the perineum or
cervix
 Following instrumental or manipulative delivery
 Associated with brisk hemorrhage

12. Treatment:
 Exploration under general anesthesia with good light.
 Tears are repaired by interrupted or continuous sutures.
 In addition to sutures, hemostasis may be achieved by
intravaginal plugging by roller gauze.
 Plug should be removed after 24 hours.
 Arterial embolization

13. Colporrhexis:
 Rupture of the vault of the vagina is called colporrhexis
 Primary
 Secondary
 Complete
 Treatment:
 Limited to the vault close to the cervix , repair is done
from below.
 Tear extends high up , laparotomy is to be done
simultaneously with resuscitative measures.

14. CERVIX
 Commonest cause of traumatic postpartum haemorrhage
 Causes:
 Iatrogenic: Attempted forceps or Breech extraction
 Rigid cervix: congenital or scar from previous operations
amputation, conization lesion like carcinoma cervix
 Strong uterine contractions
 Detachment:
 ANNULAR : Detachment of the cervix may be annular which involved
the entire circumference of the cervix.
 Following prolonged labor in primary cervical dystocia.
 ANTERIOR LIP : May involve only anterior lip when it is nipped
between the head and symphysispubis.

15. DIAGNOSIS:
 Excessive vaginal bleeding immediately following delivery
in presence of a hard and contracted uterus , raises the
suspicion of a traumatic bleeding
DANGERS:
 Early:
 Deep cervical tears- Severe postpartum haemorrhage
 Broad ligament hematoma
 Pelvic cellulitis
 Thrombophlebitis
 Late:
 Ectropion
 Cervical incompetence

16. TREATMENT:
 Repaired soon after delivery
 Repair should be done under general anesthesia , in
lithotomy position with a good light.
 The prerequisites are :
 Speculum
 Retractors
 Two sponge holding forceps
 Assistant.

17. PELVIC HEMATOMA
 DEFINITION: Collection of blood anywhere in the
area between the pelvic peritoneum and the peineal
skin is called pelvic hematoma.
 ANATOMICAL TYPES:
 Infralevator hematoma
 Supralevator hematoma
 Commonest one is vulval hematoma

18. PELVIC HEMATOMA
Infralevator Hematoma:
ETIOLOGY:
 Improper hemostasis
 Failure to obliterate the dead space
 Rupture of para vaginal venous plexus
Symptoms:
 Persistent , severe pain on the perineal region
 There may be rectal tenesmus or bearing down efforts
when extension occurs to the ischiorectal fossa

19. Signs:
 Variable degrees of shock
 Local examination : tense swelling at the vulva
Treatment:
 Small hematoma conservatively with cold compress
 Larger hematomas explored in theater under general
anesthesia
 Blood clots are to be scooped out and the bleeding
points are to be secured
 The dead space is to be obliterated
 A foley catheter is inserted

20. Supralevator hematoma
Causes:
 Extension of cervical laceration
 Lower uterine segment rupture
 Spontaneous rupture of paravaginal venous plexus

21. Diagnosis:
 Unexplained shock with features of internal haemorrhage
following delivery raises the suspicion
 Swelling above the inguinal ligament pushing uterus to the
contralateralside
 Vaginal examination:
 Occlusion of the vaginal canal by a bulge (or)
 Boggy swelling felt through the fornix
 Rectal examination:
 Boggy mass
 Ultrasonography

22. Management:
 Treatment of shock and Laparotomy
 Anterior leaf of the broad ligament peritoneum is
incised and the blood clot is scooped out.
 Random blind sutures should not be placed to prevent
ureteric damage
 Tie the anterior division of the internal iliac artery

23. RUPTURE OF THE UTERUS
Definition : Disruption in the continuity of the all uterine
layers(endometrium , myometrium and serosa) any time
beyond 28 weeks of pregnancy is called rupture of the uterus
 Perforation
 Rupture of a rudimentary pregnant horn
Incidence : 1 in 2000 to 1 in 200 deliveries
 Scar rupture following increased incidence of cesarean
section over the years.

24. ETIOLOGY
SPONTANEOUS:
During pregnancy : rare
 Causes:
1. Previous damage to the uterine walls, dilatation and
curettage or manual removal of placenta
2. Grand multiparae
3. Congenital malformation
4. Couvelaire uterus
 Usually complete
 Involves upper segment
 Later months of pregnancy

25. During Labor:
 Obstructive rupture: end result of an obstructed labor
 Nonobstructive rupture : grand multiparae are usually
in early labor
 Involves the fundal area and is complete

26. SCAR RUPTURE:
 The incidence of lower segment scar rupture is about
1-2%,while that following classical one is 5-10 times
higher.
 Uterine scar following hysterotomy
During Pregnancy:
 Classical cesarean or hystrotomy scar is likely to give
way during later months of pregnancy
During labour:
 The classical or hysterotomy scar or cornual resection
for ectopic pregnancy is more vulnerable to rupture
during labor

27. IATROGENIC or TRAUMATIC:
During pregnancy:
 Use of oxytocin
 Prostaglandins
 Forcible external version
 Fall or blow on the abdomen

28. During labor:
 Internal podalic version
 Destructive operation
 Manual removal of placenta
 Forceps or breech extraction in incompletely dilated
cervix
 Injudicious administration of oxytocin

29. PATHOLOGY
Types:
 Complete and Incomplete rupture depending whether the
peritoneal coat is involved or not
Incomplete Rupture :
 Rupture of lower segment scar
 Extension of a cervical tear into the lower segment
Complete Rupture :
 disruption of the scar in in upper segment
 spontaneous rupture of both obstructive and nonobstructive type

30. Sites:
 Spontaneous nonobstructive rupture: Involves the upper
segment and often involves the fundus
 Obstructive type : involves the anterior lower segment
transversely
 May involve the cervix and Vaginal wall(colporrhexis). The
bladder may be involved, at times.
 Rupture over the previous scar
 Rent over the lower segment scar may extend to one or
both the sides to involve the major branches of uterine
vessels.
 Traumatic rupture after destructive operations is similar to
that met in spontaneous obstructive variety.

31. Dehiscence and scar rupture :
Scar dehiscence:
 Disruption of part of scar
 Fetal membranes intact
 Bleeding minimal
Scar rupture :
 Disruption of the entire length
 Complete separation of all layers
 Rupture of the membranes
 Bleeding
 The uterine cavity and peritoneal cavity become
continuous.

32. FETUS AND PLACENTA :
 In incomplete rupture
 In complete rupture
PROGNOSIS :
 Depends on
 Manner in which labour is managed ,
 Type of rupture,
 Morbid pathological changes ,
 Effective management.
 20% or more maternal death rate

33. The major causes of death:
 Haemorrhage,
 Shock and sepsis.
Late sequelae:
 Intestinal obstruction
 Scar rupture in subsequent pregnancies

34. DIAGNOSIS OF RUPTURE UTERUS
 That one should be conscious of the entity for an early
diagnosis
During pregnancy :
 Scar Rupture
 Spontaneous
 Iatrogenic

35. Scar Rupture:
Classical or hysterotomy:
 Dull abdominal pain , slight vaginal bleeding
 Tenderness on uterine palpation.
 FHS may be irregular or absent (silent phase).
 There is a sense of something giving way accompanied
by acute abdominal pain and collapse.

36. Spontaneous rupture in uninjured uterus :
 High parous women
 Acute but insidious
 In acute types diagnosis is established by the presence of features
of shock, acute tenderness on abdominal examination, palpation
of superficial fetal parts, absence of fetal heart rate
 Confused with concealed accidental haemorrhage or rectus
sheath hematoma

37. Rupture following fall, blow or extranal version or use of
oxytocics
 There is history of such anaccident followed by acute
pain abdomen and slight vaginal bleeding
 The confirmation is done by laparotomy
 Too often confused with accidental haemorrhage

38. During Labor:
 Scar Rupture
 Spontaneous Obstructive
 Spontaneous NonObstructive
 Iatrogenic

39. During Labor:
Scar Rupture:
 Classical or hysterotomy scar rupture
 Lower segment scar rupture
 Insidious
 Confirmation is by laparotomy
 Features of scar rupture are not as dramatic
 “Silent Rupture”

40. Spontaneaous obstructive rupture :
 Distinct premonitory phase prior to rupture
Premonitory phase
 Patient is usually a multipara who is in labour with features of
obstruction
 On examination dehydrated exhausted pulse rate and
temperature rise
 Abdominal examination reveals tender lower segment bandl’s
ring may be visible evidence of fetal distress FHS may be
absent
 On vaginal examination, the presenting part is found jammed
in the pelvis and vagina becomes dry and edematous

41. Phase of rupture
 Sense of something giving way at the height of uterine
contraction
 The constant pain changes to dull aching pain with
cessation of uterine contractions
General examination :
 Features of exhaustion and shock

42.  Abdominal examination reveals
 Superficial fetal parts
 Absence of FHS
 Absence uterine contour
 Two separate swellings one contracted fetal ovoid
 Vaginal examination reveals
 Recession of the presenting part
 Varying degrees of bleeding.

43. Spontaneous nonobstructive rupture
 To high parous women
 The height of uterine contraction is suddenly seized
with an agonizing bursting pain followed by a relief,
with cessation of contractions
features of the catastrophe :
 Presence of shock
 Internal haemorrhage
 Tenderness the uterus
 Varying amount of vaginal bleeding.

44. Rupture following manipulative or instrumental delivery :
 Sudden deterioration of the general condition
 Exploration of uterus to feel the rent confirms the
diagnosis
 Shortening of the cord immediately following a
difficult vaginal delivery is pathognomonic of uterine
rupture

45. MANAGEMENT OF RUPTURE
UTERUS
PROPHYLAXIS:
At risk mothers should have mandatory hospital delivery these are
 Contracted pelvis
 Previous history of caesarean section
 Uncorrected transverse lie
 Grand multiparity
 Known case of hydrocephalus
 General anesthesia should not be used give undue force in
external version
 Undue delay in the progress of labour

46.  Judicious selection of cases for vaginal delivery (VBAC) ,
oxytocin infusion either for induction or augmantaion of
labour.
 Internal podalic version never be done in obstructed
labor
 Attempted forceps delivery or breech extraction through
incompletely dilated cervix be avoided
 Destructive vaginal operations should be performed by
skilled personnel
 Manual removal in morbid adherent placenta should be
done by senior person

47. TREATMENT:
 RESUSCITATION
 LAPAROTOMY
Hysterectomy :
 The surgery for rupture uterus
 Preferable to perform a quick subtotal hysterectomy
rather than total hysterectomy

48. Repair :
 Applicable to a scar rupture where the margines or
clean.
 Repair is done by excision of the margins
Repair and sterilization :

49. Broad ligament hematoma:
Open the anterior leaf
Scoop out the blood clot
Secure the bleeding points

50. VISCERAL INJURIES
BLADDER:
Causes:
 Traumatic:
 Instrumental vaginal delivery
 Destructive operations
 Forceps delivery
 Abdominal operation
 Sloughing fistula

51. Diagnosis:
 Traumatic:
 Urine dribbles
 Blood stained urine
 Margins are clear
 Sloughing fistula:
 Margins devitalized and necrosed
 Missing if a chunk of tissue

52. MANAGEMENT:
Traumatic fistula:
 Immediate local repair is preferable
 In unfavorable conditions catheter for 10-14 days
 Antiseptics
 Favorable condition spontaneous closure
 Done after 3 months
Sloughing fistula:
 Repair is to be done after 3 months

53. RECTUM
 Is rare in obstetrics
 Repair postponed for at least 3 months
URETHRA
 Traumatic resulting from instrumental delivery
 Principles in management –similar to those of bladder
injury.