Maternal and infant

1. Dr. Dina Nawfal
Senior lecturer Obstetrician and Gynecologist
M.B.Ch.B / F.I.C.M.S (Obst.&Gyn.)
Ibn-Sina University of Medical & Pharmaceutical
Sciences

2. Maternal Obstetrical injuries:
• Obstetrical trauma that occurs during child birth
have a devastating effect on the emotional and
physical wellbeing of a woman.
• Identification of risk factors can identify means of
preventing such injury.
• Patient selection to prevent such injuries is
important and the presence of well trained staff
available for any intervention needed.

4. Uterine rupture
• A non surgical disruption or tear of the
myometrium with or without serosa of the uterus
with or without expulsion of the fetus and
placenta.
•It is life threatening condition for both the fetus
and the mother require urgent intervention by the
senior Obstetrician.
•Occurs usually during labor and might occur during
early pregnancy.

5. Uterine rupture causes and incidence:
• Incidence 0.6% after previous one cesarean
scar. ( scar dehiscence ).
•Causes:
1. scarred uterus from previous surgery.
( cesarean scar, perforation of the uterus, myomectomy,
forceps delivery).
2. Spontaneous rupture uterus:
(hyperstimulation of the uterine muscles by oxytocin,
trauma, obstructed labor, congenital uterine anomalies
like pregnancy in rudementry horn of the uterus).

6. Signs of threatened (impending) uterine
rupture
• Excessive uterine activity.
• Over distended lower uterine segment and appearance of
contractile bandle’s ring.
• Edematous cervical margins.
• Difficult urination and bloody urine by foley’s catheter.
• Warning vaginal bleeding.
• Abnormal fetal heart rate pattern.

7. contractilebandle’sring.

8. Signs of Uterine rupture
•Acute abdominal pain
•Features of shock and internal bleeding.
•Easily palpable fetal parts.
•High up station of the presenting part.
•Negative fetal heart sound.

9. Management:
• Call for help the most senior resident and senior obstetrician and
anesthetist and neonatologist are involved in the management.
• Oxytocin should be stopped if used.
• blood is withdrawn for cross match prepare 6 units of blood.
• Oxygenation and iv access by wide bore cannula with crystaloid
solution give blood as needed.
• Take the lady straight forward to the theatre room.
• Management by laparotomy if possible repair the site of rupture or
to perform hysterectomy (emergency)

21. Genital tract hematomas
• Hematoma:
defined as an abnormal blood collection of more than
2.5cm outside the blood vessels.
It carries serious morbidity and mortality specially in
concealed hematomas.
Types:
1. Supralevator hematoma.
2. Infralevator hematoma.

23. Incidence of genital tract hematomas:
• 1/1000
• Supralevator less than infralevator.
• infralevator type of hematoma may involve:
( vulva, vagina or both )

24. Supralevator hematoma:
means blood collection above the supralevator muscles.
The blood may collect upwards to the uterus side or
collect downwards to the upper vaginal side wall.

25. Aetiology of genital tract hematomas:
• When the genital tract directly injured by
episeotomy or forceps delivery or indirectly through
the passage of the fetus through the birth canal.
• coagulopathy is a rare cause.
• Vulval varicosities.

26. Diagnosis of genital tract hematomas:
Symptoms:
• perineal pain, restlessness, bleeding,tenesmus, retention of
urine, collapse, pyrexia.
• If the bleeding is concealed the symptoms and signs of
hypovolemic shock may revealed.
Signs:
• Visible vulvovaginal swelling on local examination
• The uterus may be deviated to one side and higher up in
case of supralevator hematomas.
• Signs of hypovolemia ( pallor, tachycardia, hypotension, cold
sweaty clammy skin)

27. Treatment:
• High index of suspescion is needed for diagnosis of such
obstetric complication and the aim is to stop further
blood loss and to resume good hemostasis.
• Surgical evacuation of hematoma is needed blood and
blood products are needed immediately for transfusion
to replace the blood loss.
• Surgical intervention is needed for large hematomas or
when the woman is hemodynamicaly unstable.

28. Conservative treatment
• indicated if:
• 1. hematomas smaller than 5cm
• 2. hemodynamically stable woman.
• 3. static hematomas.
• Keep the lady inpatient and observe for 24 hours for
the vital signs and further new symptoms if occur,
• otherwise discharge home and keep her on icepack,
antibiotic cover and pain killers and recheck for the
next few days later.

29. Perineal lacerations:
•

30. Definition and types:
• Perineal tears:
• Laceration of skin and soft tissue in which the
vagina is separated from the anus.
• Usually occurs during vaginal delivery or by direct
trauma to the perenium.
• Types:
• 1. first degree perineal tear.
• 2. second degree perineal tear.
• 3. third degree perineal tear.
• 4. fourth degree perineal tear.

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32. ‫اﻟﻤﺸﺎﻋﺮ‬‫ﻟﻮﻻ‬‫ﺑﺲ‬‫ﻳﻔﺎرق‬‫ﺑﻴﻔﻜﺮ‬‫واﻟﻲ‬

33. ‫ﻳﺎ‬‫ﻣﻌﺎك‬‫ﺗﺎﺧﺬﻧﻲ‬‫ﻳﺎ‬‫ﺗﺠﻴﻨﻲ‬‫ﻳﺎ‬
…‫اﻧﺴﺎك‬‫أزاي‬‫ﺗﻌﻠﻤﻨﻲ‬

35. Management
• identification of the tear immediately after delivery
and repair by well trained staff to minimize the
complications later on.
• If the perineal injury diagnosed within 24 hours after
delivery suturing done in proper way.
• if the injury diagnosed after 24 hours of delivery the
suturing postponed till 6 weeks after delivery.
• Keep the woman after suturing on antibiotic cover and
analgesics.

36. Fetal injuries during labor
• Birth trauma is defined as impairment of the fetal
body function or structure due to adverse influences
that occur at birth.
• Frequency of birth injuries in UK is about 7 in 1000 live
birth babies in well equipped hospitals.

37. Causes of Birth Trauma
• Primigravida.
• Precipitated labor.
• Short maternal stature.
• Malpresentation.
• Fetal macrosomia.
• Forceps and ventouse delivery.
• Fetal anomalies.

38. Examples of birth trauma
Cephalhematoma Fetal facial palsy

39. Fracture of humerus

40. Erbs Palsy

41. Types of fetal injuries
• Head and neck injuries.
• Nerve injuries.
• Facial injuries.
• Fractures.
• Soft tissue injuries.
• intra-abdominal injuries.
• Hypoxic-ischemic encephalopathy.

42. Preventing birth trauma
•Providing good ANC specially for high risk
pregnancies.
•Safe delivery at appropriate place.
•Appropriate handling of the newborn babies.
•Appropriate Neonatal Care with a well
trained staff.