3. Female genitalia
External female genitalia
Vulva, clitoris, major and minor labia ,
vagina
Internal female genitalia
Uterus, ovary
4. INJURIES TO BIRTH CANAL
• NOT SO UNCOMMON – SPONTANEOUS or
ASSISTED DELIVERIES
• DEPEND UPON THE CARE PROVIDED BY THE
OBSTETRICIAN
• AVOIDANCE, EARLY DETECTION & PROMPT
MANAGEMENT – KEY TO REDUCE
SIGNIFICANT MORBIDITY
5. CLASSIFIED
INJURIES TO BONY PARTS
i) Injury to Symphysis Pubis
ii) Injury to Sacro-coccygeal Joint
iii)Injury to Sacro-iliac Joint
INJURIES TO SOFT TISSUE
i) Injury to Vulva
ii) Perineal Tears
iii)Laceration of Vagina & Cervix
iv)Rupture of Uterus
6. The vagina
• It is the fibromusculo – membranous sheath
communicates uterine cavity with exterior at the
vulva.
• It extends from the vestibule upwards and
backwards upto the vaginal part of the cervix.
• Walls – anterior (7cm), posterior (9cm) and 2
lateral walls44.
• The lower third, resembles, figure of H, middle
third is like transverse slit and upper thirdis
rounded in shape.
7. Structures:
• Mucous coat: lined by the stratified squamous
epithelium without any glands.
• Sub mucous layer consists of loose areolar
tissue.
• Muscular layer consists of inner circular and
outer longitudinal.
• Fibrous coat from endopelvic fascia.
8. CERVIX
• The cervix is a constricted part of uterus
separated from the body by the constriction part
known as the isthamus and behind by the
transverse ridge considered as torus uterinus.
This contains a cervical canal, which
communicates the uterine cavity with the vagina.
It extends downwards and backwards from the
isthamus, protrudes through the anterior wall of
vagina which divides the cervix into supravaginal
and vaginal parts.
9. Structure of the cervix:
• Serous coat: from the peritoneum which
covers the posterior surface of supravaginal
part.
• Muscular coat: disposed smooth muscle.
Some parts produced from collagenous and
elastic fibrous tissue.
• Mucous membrane: by columnar epithelium
and stratified squamous epithelium.
10. Ligaments of cervix
• Laterally by a pair of Mackenrodt’s ligaments.
• Posteriorly by a pair of uterosacral ligaments.
These ligaments have unstriped muscles and
leashes of blood vessels and lymphatic’s.
On each side, the lymphatic drainage into
external iliac, obturator lymph nodes, internal
iliac groups and sacral groups.
12. Anatomy and Physiology
A. Pelvic floor:
Pelvic floor is a muscular diaphragm that separates the pelvic
cavity above from the perineal space below.
It is formed by the levator
ani and coccygeus muscles,
and is covered by parietal
fascia. The levator ani
muscles on either side
arise from posterior surface
of pubic symphysis, the
white line over fascia
covering obturator internus
and ischial spine.
13.
14. • The levators sweep from the lateral pelvic wall
downwards and medially to fuse with the opposite
side in the midline and form a pubo-coccygeal
raphe.
• Fibres of Levators are inserted from before
backwards and fuse with muscle fibres of
urethra, the vaginal walls, perineal body, anal
canal, anococcygeal body and the lateral borders
of coccyx.
Functions:
• To support the pelvic viscera.
• To maintain effective intra-abdominal pressure.
• To facilitate anterior rotation and downward and
forward propulsion of the presenting part during
parturition.
• Serves as a support and voluntary sphicter of
urethra, vagina and anal canal.
15. B. Urogenital diaphragm:
The urogenital diaphragm is external to pelvic
diaphragm and includes the triangular area
between the ischial tuberosities and the
symphysis. It is made
up of deep transverse perineal
muscles, sphincter
urethrae and internal
and external fascial
coverings.
16.
17.
18.
19. C. Perineum:
Perineum is a diamond-shaped space that lies
below the pelvic floor.
it is bounded by:
Superiorly: pelvic floor
Laterally: the pelvic outlet consisting of subpubic
angle, ischiopubic rami, ischial tuerosities,
sacrotuberous ligaments and coccyx
Inferiorly: skin and fascia
20. •
This area is divided into two triangles by transverse
muscles of perineum and base of urogenital diaphragm:
–
–
•
Anteriorly- Urogenital triangle.
Posteriorly- Anal triangle
Most of the support of perineum is provided by pelvic and
urogenital diaphragms.
21.
22. Perineal Body:
• The median raphe of levator ani between the
anus and vagina, is reinforced by the central
tendon of the perineum. Bulbocavernosus,
superficial transverse perineal and external anal
sphincter muscles also converge on the central
tendon. These muscles contribute to perineal
body, which provides much support to perineum.
23. PERINEAL TEAR
Gross injury is due to MISMANAGED 2ND
STAGE OF LABOUR
More common in PRIMIGRAVIDA than
MULTIGRAVIDA .
Due to extension of episiotomy, posteriory it
involves the anal sphincter from back &
obliquely upwards into the lateral vaginal
wall
ETIOLOGY:
- OVER STRETCHING OF PERINIUM
- RAPID STRETCHING OF PERINIUM
- INELASTIC PERINIUM
24. Causes and Predisposing Factors:
• Obstetric injuries:
Malpresentations such as breech
Contracted pelvic outlet
spontaneous labour
operative vaginal deliveries( forceps or vaccum)
Macrosomic babies
• Non-obstetric injuries: rape, molestation, fall,
accidental injuries like RTA, bull horn injuries etc.
25. Degrees of Perineal tear:
First degree- limited to vaginal mucosa and skin of the
introitus.
Second degree- extends to the fascia and muscles of the
perineal body.
Third degree- trauma involves the anal sphincter.
Fourth degree - extends into the rectal lumen, through
the rectal mucosa.
• A rare type of tear is central tear of the perineum when the
head penetrates first through the posterior vaginal wall,
then through the perineal body and appears through the
skin of the perineum. It usually occurs in patients with
contracted outlet.
27. First & second degree tears :Spontaneous tears originate near the midline of the
perineum, but when they are traced upwards they
are invariably found to extend into one / other
posteriolateral vaginal sulcus.
Sometimes the upper limit of the tear is felt better
– helpful to catch the upper edge of the vaginal
tear.
If a double tear is found, care must be taken to
unite the lateral vaginal walls to the loose posterior
tongue.
Tears of the anterior vaginal wall often involve the
tissues close to the urethral meatus. Later, pt. is
unable to void urine because of muscle spasm
consequent on the bruising around the urethra &
bladder neck.
28. Third degree tears:A tear has extended into the anal sphincter or
canal.
Any fecal contamination is cleared away & area
drenched with an aqueous solution of
antiseptic.
The muscle wall of the rectum & anal canal is
closed by interrupted or continuous catgut
sutures (No.0) placed so that the suture avoids
the bowel mucosa.
Disadvantage – appearance of small rectovaginal
fistula at the upper end of the wound.
30. PREVENTION
- LIBERAL USE OF EPISIOTOMY
- PROPER CONDUCT OF LABOUR DURING
2ND STAGE
- PERINEAL SUPPORT DURING 2ND STAGE
31. Repair of perineal tear :
First degree:
• Sometime doesn’t require suturing or can use
one or two interrupted suture.
Second degree:
• The vaginal mucosa is to be sutured first. The
first suture is placed at or just above the apex of
the tear. Thereafter, the vaginal walls are
opposed by interrupted sutures with chromic
catgut no. ‘Ofrom above downwards till the
fourchette is reached. The sutures should
include the deeper tissues to obliterate the
dead space.
32. • A continuous suturing may cause shortening of
the posterior vaginal wall.
Complete perineal tear:
• The rectal and anal mucosa is sutured from above
downwards by interrupted sutures. Muscle walls
including the pararectal fascia are then sutured
by interrupted sutures. The torn ends of the
sphincter ani externus are sutured with figure of
eight stitch by another interrupted suture.
• Perineal skin by interrupted suture
34. Complications if left untreated:
•
•
•
•
Infection
Hemorrhagic Shock
Cosmetic disadvantage
3rd and 4th degree tears if left untreated may
lead to fecal incontinence.
35. Episiotomy
• It is an incision on the perineum & the
posterior vaginal wall during the second
stage of labor
• It should be performed just before the
crowning of head in second stage of labour.
• It is commonly performed for spontaneous
vaginal delivery , about 2/3rd of
primigravida , 1/3rd of the multiparous
36. Objective:
• To enlarge the vaginal introitus so as to facilitate easy
& safe delivery of the fetus – spontaneous or
manipulative.
• To minimize over stretching & rupture of the perineal
muscles & fascia
• To reduce the stress & strain on the fetal head.
Indications:
• In elastic or rigid perineum.
• Anticipating perineal tear – big baby, face to pubis
delivery, breech delivery, shoulder dystocia.
• Operative delivery: forceps delivery, ventouse
delivery.
• Previous perineal surgery: pelvic floor repair, perineal
reconstructive surgery.
37. Types
Mid line: incision through the fourchette &
perineal body.
Advantage: no large blood vessels are encountered &
repair is very simple.
Disadvantage: extension of incision includes the anal
sphincter or canal itself.
Lateral incision: may cause bleeding or the
bartholian gland / duct may be injured &
considerable difficulty may be encountered in
securing an accurate realignment of the divided
structures.
38. Posterolateral incision: starting at the
midpoint of the fourchette or posterior
commissure.
It has the advantage to the damage to the
sphincter.
J shaped incision: in which after incising the
perineum in the midline until a point is
reached 2-3 cm from the anterior margin of
the anus.
48. Median
Merits :
-the muscles are not cut
- blood loss is least.
- repair is easy.
- postoperative comfort is
maximum.
- healing is superior.
- Wound disruption is rare.
- Dypareunia is rare.
Mediolateral
- relative safety from rectal
involvement from extension.
- if necessary, the incision can
be extended.
49. Demerits :
- Extension, if occurs
involves rectum.
-Apposition of the tissues
is not so good.
-Blood loss is little more.
- Not suitable in
- Relative increased
manipulative delivery or in incidence of wound
abnormal presentation or disruption.
position.
- Dyspareunia is more
50. Advantages
Maternal – Reduction in the duration of second
stage.
Reduction of trauma to the pelvic floor
muscles.
Fetal – it minimizes intracranial injuries.
51. The structures involved during mediolateral
episiotomy are :
Posterior vaginal wall
Superficial and deep transverse perineal muscle,
bulbospongiosus and part of levator ani.
Fascia covering those muscles.
Transverse perineal branches of pudendal vessels
and nerves.
Subcutaneous tissue and skin
52. Timing of the repair of episiotomy
The most common practice is to defer
episiotomy repair until the placenta has been
delivered.
Early delivery of the placenta reduces blood loss
from the implantation site because it prevents
the development of extensive retroplacement
bleeding.
Advantage is that episiotomy repair is not
interrupted or disrupted by delivery of placenta,
especially if manual removal must be performed
53. Post operative care:
• Clean wound with clean water after each
urination and defaecation.
• Keep area dry
• Apply clean pads
• Analgesics if needed
• Peri-care and peri-light
• Suture removal on 7th -10th post op day if silk is
applied.
• F/U after 6 wks if no complication
54. Complication
Immediate:
1. Extension of the incision: involves rectum,
mainly in median episiotomy or occipito
posterior.
2. Vulval haematoma.
3. Infection.
4. Wound dehiscence: infection is the primary
cause of wound disruption.
5. Injury to anal sphincter.
6. Rectovaginal fistula.
56. Prevention of perineal tear:
• Well support of the perineum at the time of
delivery of head
• Delivery by early extension is to be avoided
• Spontaneously forcible delivery is to be
avoided
• To deliver the head in between contraction
• To perform timely epsiotomy
• To take care during delivery of shoulder
57. Periurethral Tears
Vaginal tears can also occur at the region
around the urethra - the opening through
which urine comes out. These are then
called ' Periurethral tears'. The problem
with these type of tears is that there
may be profuse bleeding from even a
small tear since the region has a large
blood supply.
58. Causes
• The commonest cause for a periurethral
tear is a sudden extension of the fetal
head at the time of delivery. Normally, the
fetal head is in a position of flexion with
the chin touching the chest. At the time
of delivery, after crowning occurs, the
head is born by extension. A gradual
extension will not put much presure on the
anterior or upper part of the vagina. But a
sudden extension will cause a sudden
pressure on upper vaginal area resulting in
a periurethral tear.
59. How to prevent
• It is important for the doctor or
midwife to press gently on the fetal
head at the time of delivery and guide it
to a slow and gradual extension at the
time of birth.
60. Treatment
• Periurethral tears need to be stitched carefully
under proper light. If not repaired well or if it is
not diagnosed after the delivery, it can bleed
continuously for quite some time and cause many
other problems
• It is advisable for the woman to use cold packs on
the site of the tear for at laeast 7-10 days to
hasten healing. Using anti-inflammatory painkillers
like Ibuprofen aslo helps.
• Thankfully, during the course of a pregnancy the
body is primed to heal quickly. The immune system
is more efficient than usual and therefore wounds
will heal within a few weeks after childbirth
61. Complications if not treated
•
•
•
•
Continuous Bleeding
Infections in the tear
Severe pain and inflammation
Urine Retention due to inability of the
woman to pass urine through the inflamed
urethra
62. Vaginal lacerations
It involves middle or upper third of the vagina
but not associated with lacerations of the
perineum or cervix.
Common during forceps delivery or vaccum,
sometime even with spontaneous delivery.
Frequently extend deep into the underlying
tissues and give rise to haemorrhage, which is
controlled by appropriate suturing.
The tears are repaired by interrupted or
continuous sutures using chromic catgut no. ‘0’.
64. Cervical tear
• The cervix is lacerated in over half of vaginal
deliveries.
• Most of these are less than 0.5cm.
• Deep cervical tears may be extended to the
upper third of vagina.
• In rare instances, the cervix may be entirely or
partially avulsed from the vagina, with
colporrhexis in the anterior, posterior or lateral
fornices.
65. Cont-d
• Rarely, cervical tears may extend to involve the
lower uterine segment & uterine artery & its
major branches & even through the
peritoneum.
• Cervical lacerations upto 2 cm must be regraded
as inevitable in childbirth. Such tears heal
rapidly.
• In healing, they cause a significant change in
round shape of the external os before cervical
effacement & dilatation to that of appreciable
lateral elongation after delivery.
67. Diagnosis
A deep cervical tear should always suspected in
cases of profuse haemorrhage during & after
third stage labour, if the uterus is firmly
contracted
• Extent of the injury can be fully appreciated only
after adequate exposure & visual inspection of
cervix.
68. Treatment
• Deep cervical tears require surgical repair
when the laceration is limited to the cervix
or extends into the vaginal fornix, results
are obtained by suturing the cervix. Either
interrupted / running absorable sutures are
suitable
70. Wound healing
• Healing by primary intension occurs in clean
incised wounds such as surgical incision.
• It produces a clean, neat, thin scar.
• Healing by secondary intension refers to a wound
which is infected, discharging pus or wound with
skin loss.
71. Factors influencing wound healing
1. General:
Age
Nutrition - protein deficiency, vitamin c and
vitamin A deficiency.
Hormones – corticosteroid
Medical disorder – Anaemia , Jaundice,
Diabetes, Blood dyscrasis.
72. Cont-d
2. Local:
Position of wound, faulty technique of wound
closure.
Poor blood supply, Impairment of lymphatic
drainage.
Tension
Movement
Exposure to ionizing radiation.
Foreign bodies tissue reaction and inflammation,
necrosis
74. • spontaneous or traumatic rupture of the uterus ie., the
actual separation of the uterine myometrium/ previous
uterine scar, with rupture of membranes and extrusion of
the fetus or fetal parts into the peritoneal cavity.
• Dehiscence - partial separation of the old uterine scar;
- the fetus usually stays inside uterus and the
bleeding is minimal when dehiscence occurs
76. CAUSES:
IATROGENIC: INJUDICIOUS USE OF OXYTOCIN,
FORCIBLE ECV/ IPV, FALL OR BLOW OVER THE
ABDOMEN, , FORCEPS or BREECH
EXTRACTION
TYPES:
INCOMPLETE RUPTURE: PERITONIUM REMAINS
INTACT
COMPLETE RUPTURE: SCAR IN UPPER SEGMENTINVOLVES PERITONIUM
77. RISK FACTORS:
• Women who have had previous surgery on the uterus (upper muscular
portion)
• Having more than five full-term pregnancies
• Having an overdistended uterus (as with twins or other multiples)
• Abnormal positions of the baby such as transverse lie.
• Use of Pitocin (oxytocin) and other labor-induced medications
(prostaglandin)
• Rupture of the scar from a previous CS delivery/hysterectomy.
• Uterine/abdominal trauma
• Uterine congenital anomaly
• Obstructed labor; maneuvers within the uterus
• Interdelivery interval (time between deliveries)
78. PATHOPHYSIOLOGY
Pathologic retraction ring occurs, strong uterine
contractions w/o cervical dilatation
“tearing sensation”
Complete rupture
Incomplete rupture
Rupturing of endometrium,
myometrium and perimetrium
Rupturing of endometrium
and myometrium
Uterine contraction stops
Localized tenderness and
persisting aching pain over the
area of the uterine segment
Bleeding into the peritoneal cavity
79. Swelling of the abdomen:
•Retracted uterus
•Extrauterine fetus
Hemorrhage from torn uterine
arteries
Bleeding to the vagina
Decreased blood volume
Decreased venous return
Decreased BP
Increases gas exchange to
oxygenate better the decreased
blood volume
Decreased cardiac output
Heart attempts to circulate
remaining blood volume
Vasoconstriction of peripheral
vessels, increased heart rate
80. Cold, clammy skin
Increased respiratory rate
Uterine perfusion is decreased
Continued blood loss will continue
to fall BP
Fetal distress
Decreased brain perfusion
Decreased kidney perfusion
Decreased LOC (lethargy, coma)
Decreased urine output
Renal failure
Death of Mother and fetus
81. ASSESSMENT:
•evaluate maternal vital signs
•note an increase in rate and depth of respirations,
an increase in pulse , or a drop in BP indicating
status change
•assess fetal status by continuous monitoring
•speak with family, and evaluate their understanding
of the situation
•observe for signs and symptoms of impending rupture
-lack of cervical dilatation
-tetanic uterine contractions
- restlessness
- anxiety
- severe abdominal pain
- fetal bradycardia
- late or variable decelerations of the FHR)
82. SIGNS AND SYMPTOMS
Clinical Manifestations:
Developing Rupture
•Abdominal pain and tenderness
•Uterine contractions will usually continue but will diminish in intensity and tone.
•Bleeding into the abdominal cavity and sometimes into the vagina.
•Vomiting
•Syncope; tachycardia; pallor
•Significant change in FHR characteristics – usually bradycardia (most significant sign)
•Difficulty identifying fundal height
•Vaginal bleeding
•Maternal hemorrhage and shock
•Absent fetal heart tones
83. Violent Traumatic Rupture
•Sudden sharp abdominal pain during or between contractions.
•Abdominal tenderness
•Uterine contractions may be absent, or may continue but be diminished in intensity
and cord
•bleeding vaginally, abdominally, or both
•Fetus easily palpated in the abdominal with shoulder pain
•Tenses, acute abdominal with shoulder pain
•Signs of shock
•Chest pain from diaphragmatic irritation due to bleeding into the abdomen.
87. Deficient Fluid
Volume
Start or maintain an IV fluid as prescribed. Use a
large gauge catheter when starting the IV for
blood and large quantities of fluid replacemnt.
Maintain CVP and arterial lines, as indicated for
hemodynamic monitoring.
Maintain bed rest to decrease metabolic
demands.
Insert Foley catheter, and moniter urine output
hourly or as indicated.
Obtain and administer blood products as
indicated.
88. Fear
Give brief explanation to the woman and her support
person before beginning a procedure.
Answer questions that the family or woman may have.
Maintain a quiet and calm atmosphere to enhance
relaxation.
Remain with the woman until anesthesia has been
administered; offer support as needed.
Keep the family members aware of the situation while the
woman is in surgery and allow time for them to express
feelings.
89. Decreased cardiac
output
•Administer supplemental oxygen, blood/fluid
replacement, antibiotics, diuretics, inotropic
drugs, antidysrhythmics, steroids,
vassopressors, and/or dilators as ordered.
•Position HOB flat or keep trunk horizontal
while raising legs 20 to 30 degrees in shock
situation
•Activities such as isometric exercises, rectal
stimulation, vomiting, spasmodic coughing
which may stimulate Valsalva response should
be avoided; administer stool softener as
indicated.
90. Ineffective Tissue
Perfusion
Administer O2 using a face mask at 8-12 L/min or
as ordered to provide high oxygen concentration.
Apply pulse oximeter, and monitor oxygen
saturation as indicated.
Monitor ABG levels and serum electrolytes as
indicated to assess respiratory status, observing for
hyperventilation and electrolyte imbalance.
Continually monitor maternal and fetal vital signs
to assess pattern because progressive changes may
indicate profound shock.
91. Risk for Infection
• Observe for localized signs of infection.
•Cleanse incision or insertion sites daily
and PRN with povidone iodine or other
appropriate solutions.
•Change dressings as needed or indicated.
•Encourage early ambulation, deep
breathing, coughing and position changes.
•Maintain adequate hydration and
provide.
•Provide perineal care.
92. MEDICAL MANAGEMENT
•Immediate stabilization of maternal
hemodynamics and immediate
caesarean delivery
•Oxytocin is given to contract the uterus
and the replacement .
•After surgery, additional blood, and
fluid replacement is continued along
with antibiotic theory.
94. NURSING MANAGEMENT
•Continually evaluate maternal vital signs;
especially note an increase in rate and depth of
respirations, an increase in pulse , or a drop in
BP indicating status change.
•Assess fetal status by continuous monitoring.
•Speak with family, and evaluate their
understanding of the situation.
•Anticipate the need for an immediate
caesarean birth to prevent rupture when
symptoms are present.
•Provide information to the support person and
inform him or her about fetal outcome, the
extent of the surgery and the woman’s safety.
•Let the pt express her emotion without feeing
threatened.
95. FGM
• Female Genital Mutilation
compromises all procedures
involving partial or total
removal of the external
female genitalia or other
injury to the female genital
organs for non medical
reasons (WHO, UNICEF,
UNFPA, 1997)..
96. Procedures
*Type III- Also known as
Infibulation.
*Type IV- All other
harmful procedures to
the female genitalia for
non-medical purposes,
for example: pricking,
piercing, incising,
scraping and
cauterization.
