maternal injuries

1. MATERNAL INJURIES

2.  Maternal injuries following childbirth process
are quite common and contribute significantly
to maternal morbidity and even to death.
Prevention, early detection and prompt and
effective management not only minimise the
morbidity but prevent many gynaecological
problems from developing later in life.

3.  VULVA: laceration of the vulval skin posteriorly and
the paraurethral tear on the inner aspect of the labia
minora are common sites.
 PERINEUM: While minor injury is quite common
especially during first birth, gross injury (3rd and 4th
degree) is invariably a result of mismanaged second
stage of labour.
 Incidence - 1 % .

5.  CAUSES:
 Over stretching.
 Rapid stretching.
 PREVENTION:
 Proper conduct in the second stage.
 Taking due care of perineum

6.  RISK FACTORS FOR THIRD DEGREE PERINEAL 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

7.  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 24
24 hours.

8. REPAIR OF COMPLETE PERINEAL TEAR:
Step 1:
 Lithotomy position –repair done with local infiltration
of lignocaine hydrochloride(10-15ml) with pudendal
block or under GA.
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 is used for EAS.

9. approximation method for repair
Step3:
 Repair of perineal muscle done by interrupted
sutures
Step 4:
 The Vaginal wall and the perineal skin are apposed
by interrupted sutures.

10.  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

11.  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.
 VAGINA
 Isolated vaginal tears
 Lacerations without involvement of the perineum or cervix
 Following instrumental or manipulative delivery

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:
left lateral is common.
CAUSES:
iatrogenic: attempted forcep or breech delivery
 Rigid cervix :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.
 DIAGNOSIS:
 Excessive vaginal bleeding immediately following delivery in presence
of a hard and contracted uterus , raises the suspicion of a traumatic
bleeding

15. 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. 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 .

20.  SIGNS:
 Variable degrees of shock
 Local examination : tense swelling at the vulva
 TREATMENT:
 Small hematoma <5cm 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

21.  Supralevator hematoma
 Causes:
 Extension of cervical laceration
 Lower uterine segment rupture
 Spontaneous rupture of paravaginal venous plexus
 DIAGNOSIS:
 Unexplained shock with features of internal haemorrhage following
delivery raises the suspicion
 Swelling above the inguinal ligament pushing uterus to the
contralateralside

22.  Vaginal examination:
Occlusion of the vaginal canal by a bulge (or)
Boggy swelling felt through the fornix
 Rectal examination:
Boggy mass
Ultrasonography

23. 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

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

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

27.  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.