Obstetric injuries

1. Injuries of
Birth Canal
Lecturer : Suyundukova Begaiym Sharypbekovna

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 minimize the
morbidity but prevent many gynecological
problems from developing later in life.

3. • PERINEUM
While minor injury is quite common especially during first
birth, gross injury (third and fourth degree) is invariably a
result of mismanaged second stage of labor.
First degree: Injury to perineal skin only
Second degree: Injury to perineum involving perineal
body (muscles) but not involving the anal sphincter
Third degree: Injury to perineum, involving the anal
sphincter complex (both external and internal)
Fourth degree: Injury to perineum involving the anal
sphincter complex

5. Risk factors :
• Big baby (weight ≥ 3 kg)
• Nulliparity
• Outlet contraction with narrow pubic arch
• Shoulder dystocia
• Forceps delivery
• Scar in the
perineum(perineorrhaphy,episiotomy)
• Face to pubis delivery
• Midline episiotomy
• Precipitate labor

6. MANAGEMENT
• Recent tear should be repaired immediately
following the delivery of the placenta. This
reduces the chance of infection and minimizes
the blood loss. In cases of delay beyond 24 hours,
the repair is to be withheld. Antibiotics should be
started to prevent infection. The complete tear
should be repaired after 3 months if delayed
beyond 24 hours. In case of any doubt to grade
of 3rd degree tear, it is advisable to classify to the
higher degree rather than lower degree.
• Repair of complete perineal tear

9. • The aftercare of the repaired perineal injuries is similar to that
following episiotomy . Special care following repair of complete
tear—(1) A low residual diet consisting of milk, bread, egg, biscuits,
fish, sweets, etc. is given from third day onward. (2) Lactulose 8 mL
twice daily beginning on the second day and increasing the dose to
15 mL on the third day is a satisfactory regime to soften the stool.
(3) Any one of the broad-spectrum antibiotics (IV cefuroxime 1.5 g)
is used during the
• intraoperative and the postoperative period. Metronidazole 400 mg
thrice daily is to be continued for 5–7 days to cover the anaerobic
contamination of fecal matter. The woman is advised physiotherapy
and pelvic
• floor exercises and she is reviewed again 6–12 weeks postpartum.
In case of persistent incontinence of flatus and feces, endoanal
USG and anorectal manometry should be considered to detect any
residual defects (20–30%). Consultation with a colorectal surgeon
may be needed.

10. VAGINA
• Isolated vaginal tears or lacerations without
involvement of the perineum or cervix are not
uncommon.
• These are usually seen following instrumental or
manipulative delivery. In such cases, the tears are
extensive and often associated with brisk
hemorrhage.
• TREATMENT: Tears associated with brisk
hemorrhage require exploration under general
anesthesia with a good light. The tears are
repaired by interrupted or continuous sutures
using chromic catgut.

12. CERVIX
• Minor degree of cervical tear is invariable during first
delivery and requires no treatment. Extensive cervical tear
is rare. It is the commonest cause of traumatic postpartum
hemorrhage. Left lateral tear is the commonest.
CAUSES:
• Iatrogenic—Attempted forceps delivery or breech
extraction through incompletely dilated cervix.
• Rigid cervix—This may be congenital or more commonly
following scar from previous operations on the cervix like
amputation, conization or presence of a lesion like
carcinoma cervix.
• Strong uterine contractions as in precipitate labor or
extremely vascular cervix as in placenta previa.
• 􀂄 Detachment—Detachment of the cervix may be annular
which involved the entire circumference of the cervix. This
occurs following prolonged labor in primary cervical
dystocia.

14. • DIAGNOSIS: Excessive vaginal bleeding
immediately following delivery in presence of
a hard and contracted uterus—raises the
suspicion of a traumatic bleeding. Exploration
of the uterovaginal canal under good light not
only confirms the diagnosis but also helps to
know the extent of the tear.

15. TREATMENT:
• Only deep cervical tear associated with
bleeding should be repaired soon after
delivery of the placenta. Repair should be
done under general anesthesia, in lithotomy
position with a good light.

16. RUPTURE OF THE UTERUS
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. Small rupture to the wall
of the uterus in early months is called
perforation either instrumental or perforating

17. ETIOLOGY
• The causes of rupture of the uterus are
broadly divided into:
• Spontaneous
• Scar Rupture
• Iatrogenic

18. SPONTANEOUS
• During pregnancy: It is indeed rare for an apparently
uninjured uterus to give way during pregnancy.
• The causes are:
• Previous damage to the uterine walls following
dilatation and curettage operation or manual removal
of placenta.
• Rarely in grand multiparae due to thin uterine walls.
• Congenital malformation of the uterus (bicornuate
variety) is a rare possibility.
• In Couvelaire uterus
• Spontaneous rupture during pregnancy is usually
complete, involves the upper segment and usually
occurs in later months of pregnancy

19. • During labor: Spontaneous rupture which occurs
predominantly in an otherwise intact uterus
during
• labor is due to:
• Obstructive rupture—This is the end result of an
obstructed labor. The rupture involves the lower
segment and usually extends through one lateral
side of the uterus to the upper segment.
• Nonobstructive rupture—Grand multiparae are
usually aff ected and rupture usually occurs in
early labor. Weakening of the walls due to
repeated previous births as mentioned earlier
may be the responsible factor. Th e rupture
usually involves the fundal area and is complete.

21. SCAR RUPTURE:
• During pregnancy: Classical cesarean or
hysterotomy scar is likely to give way during
later months of pregnancy.
• During labor: The classical or hysterotomy scar
or cornual resection for ectopic pregnancy is
more vulnerable to rupture during labor.
Although rare, lower segment scar
predominantly ruptures during labor.

22. IATROGENIC OR TRAUMATIC
• During pregnancy: Injudicious administration of
oxytocin. Use of prostaglandins for induction of
abortion or labor. Forcible external version
especially under general anesthesia. Fall or blow
on the abdomen.
• During labor: Internal podalic version—especially
following obstructed labor. Destructive
operation. Manual removal of placenta.
Application of forceps or breech extraction through
incompletely dilated cervix. Injudicious
administration of oxytocin for augmentation of
labor

24. • Pathologically, it is customary to distinguish
between complete and incomplete rupture
depending on whether the peritoneal coat is
involved or not.
Incomplete rupture usually results from rupture of
the lower segment scar or extension of a cervical
tear into the lower segment with formation of a
broad ligament hematoma.
Complete rupture usually occurs following
disruption of the scar in upper segment. It may also
be due to spontaneous rupture of both obstructive
and nonobstructive type.

25. FETUS AND PLACENTA: In incomplete rupture,
both the fetus and placenta remain inside the
uterine cavity or part of the fetus may occupy in
between the layers of broad ligament. In
complete rupture, the fetus with or without the
placenta usually escapes out of the uterus. The
uterus remains contracted. Blood loss is not
much unless major vessels are affected.

26. DIAGNOSIS OF RUPTURE UTERUS.
It is indeed difficult to categorize a universal clinical
feature applicable to all the varieties of uterine rupture.
Scar rupture: Classical or hysterotomy—The patient
complains of a dull abdominal pain over the
scar area with slight vaginal bleeding. There is varying
degrees of tenderness on uterine palpation. FHS
may be irregular or absent. The features may not be
always dramatic in nature (silent phase). Sooner or
later, the rupture becomes complete. There is a sense of
something giving way accompanied by acute
abdominal pain and collapse

27. • Rupture following fall, blow or external
version or use of oxytocin—There is history of
such an accident followed by acute pain
abdomen and slight vaginal bleeding. Rapid
pulse and tender uterus raise the suspicion of
rupture. The confirmation is done by
laparotomy. This is too often confused with
accidental hemorrhage.

28. • Spontaneous obstructive rupture: This type of
spontaneous rupture has got a distinct premonitory
phase prior to rupture.
• There is a sense of something giving way at the height
of uterine contraction.
• (The constant pain is changed to dull aching pain with
cessation of uterine contractions. General
• examination reveals features of exhaustion and shock.
Abdominal examination reveals—
• superficial fetal parts, absence of FHS, absence of
uterine contour and two separate swellings,
one contracted uterus and the other—fetal ovoid. Vaginal
examination reveals— recession of the
• presenting part and varying degrees of bleeding

29. • MANAGEMENT OF RUPTURE UTERUS
PROPHYLAXIS: The following guidelines are helpful to
prevent or to detect at the earliest the tragic occurrence
of rupture uterus:
• The at-risk mothers, likely to rupture, should have
mandatory hospital delivery. These are—
Contracted pelvis. Previous history of cesarean section,
hysterotomy or myomectomy. Uncorrected transverse
lie. Grand multiparity. Known case of hydrocephalus.
• General anesthesia should not be used to give undue
force in external version.
• Undue delay in the progress of labor in a multipara
with previous uneventful delivery should be viewed
with concern and the cause should be sought for

30. • Judicious selection of cases with previous history of
cesarean sections for vaginal delivery (VBAC) .
• Judicious selection of cases and careful watch are
mandatory during oxytocin infusion either for
induction or augmentation of labor.
• There is hardly any place of internal podalic version in
singleton fetus in present day obstetrics. It should
never be done in obstructed labor as an alternative to
destructive operation or cesarean delivery.
• Attempted forceps delivery or breech extraction
through incompletely dilated cervix should be avoided.
• Destructive vaginal operations should be performed by
skilled personnel and exploration of the uterus should
be done as a routine following delivery.
• Manual removal in morbid adherent placenta

31. LAPAROTOMY: Any of the three procedures may be
adopted following laparotomy.
• 􀂄 Hysterectomy: Hysterectomy is the surgery for
rupture uterus unless there is sufficient reason to
preserve it. This is especially indicated in
spontaneous obstructive rupture, so common in
the developing countries. Considering the low
general condition and disturbed morbid
anatomical changes near the cervicovaginal
region, it is preferable to perform a quick subtotal
hysterectomy, rather than total hysterectomy.
Chance of injury to the ureters or bladder is
thereby minimized.
However, if the condition permits and/or there is
colporrhexis, a total hysterectomy may be done.

32. • Repair: This is mostly applicable to a scar rupture
where the margins are clean. Repair is done by
excision of the fibrous tissue at the margins. One
may have to repair a spontaneous obstructive
rupture in odd circumstances (desirous of having
child), if possible.
• Repair and sterilization: This is mostly done in
patients with a clean cut scar rupture having
desired number of children

33. Uterine inversion occurs when
the uterine fundus collapses
into the endometrial cavity,
turning the uterus partially or
completely inside out. It is a
rare complication of vaginal or
cesarean delivery, but when it
occurs, it is a life-threatening
obstetric emergency. If not
promptly recognized and
treated, uterine inversion can
lead to severe hemorrhage and
shock, resulting in maternal
death.

34. PATHOGENESIS
• The pathogenesis of uterine inversion is incompletely understood. It
has been attributed to use of excessive cord traction and fundal
pressure (Credé maneuver) during the third stage of labor,
especially in the setting of uterine atony with fundal placental
implantation . However, evidence is inconsistent, and a causal
relationship between management of the third stage and puerperal
uterine inversion is unproven . It is likely that other factors play a
role since spontaneous inversions occur and inversion is rare even
though cord traction and the Credé maneuver are commonly
performed.
• Hemorrhage may occur because the invaginated fundus may not
contract normally and the inverted endometrium is stretched,
which exacerbates bleeding from any areas of placental separation.
RISK FACTORS
• Risk factors for inversion, which are present in fewer than 50
percent of cases, include macrosomia, rapid or prolonged labor and
delivery, short umbilical cord, preeclampsia with severe features,
use of uterine relaxants, nulliparity, uterine anomalies or tumors
(leiomyoma), retained placenta, and placenta accreta spectrum

35. CLINICAL FEATURES
• Patient presentation — Puerperal uterine inversion can follow
vaginal or cesarean delivery, including inversion through the
hysterotomy incision. The clinical presentation depends on
the extent and time of occurrence of the inversion. Signs and
symptoms include one or more of the following:
• ●Mild to severe vaginal bleeding
• ●Mild to severe lower abdominal pain
• ●A smooth, round mass protruding from the cervix or vagina
• ●Urinary retention
• The most common presentation is complete uterine inversion
with severe postpartum hemorrhage, often leading to
hypovolemic shock. Shock out of proportion to blood loss has
been described and attributed to increased vagal tone from
stretching of the pelvic parasympathetic nerves (neurogenic
shock), but this is controversial and may just reflect
underestimation of blood loss

36. • DIAGNOSIS
• The diagnosis of acute uterine inversion is based upon
clinical findings, typically including vaginal bleeding
potentially resulting in shock, lower abdominal pain,
and the presence of a smooth round mass protruding
from the cervix or vagina. Hypotension out of
proportion to blood loss may occur. On abdominal
examination, lack of palpation of a normally positioned
fundus is the key finding
• Radiographic imaging (eg, ultrasound, magnetic
resonance) is rarely necessary, but has been used to
confirm inversion when the diagnosis was uncertain
and the patient was hemodynamically stable.
Importantly, in patients with significant vaginal
bleeding, treatment should not be delayed for
radiologic confirmation.

37. • Degrees of Uterine Inversion
• First-degree - the inverted fundus extends to, but not
through, the cervix.
• Second-degree - the inverted fundus extends through
the cervix but remains within the vagina.
• Third-degree - the inverted fundus extends outside the
vagina.
• Total inversion - the vagina and uterus are inverted.
Classification
• Acute: Twenty-four hours or less after delivery
• Subacute Longer than 24 hours postpartum)
• Chronic: Longer than 1 month postpartum

39. • Call for help and call for an anesthesiologist immediately.
• Hemodynamic stability is achieved by a large-bore cannula,
and crystalloid and blood are given to combat hypovolemia.
• The recent uterine inversion with the placenta already
separated from it may often be replaced by manually
pushing up on the fundus with the palm and fingers in the
direction of the long axis of the vagina. A delay will render
replacement more difficult and also increase the risk of
hemorrhage.
• If the placenta is still attached, it is usually not removed
until fluids are given, and uterine-relaxing anesthetics, for
example, a halogenated inhalation agent, have been
administered. Other tocolytic agents such as magnesium
sulfate or beta-mimetic and nitroglycerine have been used
successfully for uterine relaxation and repositioning. Any
portion of the inverted uterus prolapsed beyond the vagina
is replaced within the vagina.

40. • After the placenta is removed, steady pressure with the
fist is applied to the inverted fundus in an attempt to
push it up into the dilated cervix. Alternatively, two
fingers can be extended rigidly to push the center of
the fundus upward. Undue force is not applied to avoid
perforation of the uterus with the fingertips. This is
followed by the administration of uterotonic agents,
which help uterine contraction, thereby preventing
recurrence of the inversion.
• An appropriate antibiotic is administered to prevent
infection.
• Other options include hydrostatic reduction and
surgical correction if manual repositioning is
unsuccessful due to a dense constriction ring.

41. • Immediate uterine repositioning is essential for acute puerperal
inversion.
• Measures to reposition the uterus may include
• Preparing theatres for a possible laparotomy.
• Cautious administration of tocolytics to allow uterine relaxation;
however, this may aggravate haemorrhage:
• Nitroglycerin (0.25-0.5 mg) intravenously over 2 minutes; or
• Terbutaline 0.1-0.25 mg slowly intravenously; or
• Magnesium sulfate 4-6 g intravenously over 20 minutes.
• Attempting prompt repositioning of the uterus. This is best done
manually and quickly, as delay can render repositioning
progressively more difficult. Reposition the uterus (with the
placenta if still attached) by slowly and steadily pushing upwards
towards the umbilicus, commonly referred to as Johnson's method.
Maintain bimanual uterine compression and massage until the
uterus is well contracted and bleeding has stopped.
• If this fails, hydrostatic replacement should be attempted under
spinal or general anaesthetic:

43. • O'Sullivan's technique involves an infusion of
warm saline into the vagina, making a water
seal with the operator's hand and the vulva.
• An SOS Bakri tamponade balloon has also
been successfully used to replace the inverted
uterus and to maintain its position

45. • If this is unsuccessful, a surgical approach is
required. Laparotomy for surgical
repositioning is more usual (find and apply
traction to the round ligaments). Incision of
the cervical ring may be required. A vaginal or
even laparoscopic approach can be used,
although this is more likely in the non-
obstetric inversion

46. • If this is unsuccessful, hysterectomy, which
may be life-saving, is the final option.
• If placenta is still present, careful examination
and removal are required to ensure it is not
abnormally adherent.