Genital tract injury presented by - PowerPoint Presentation

Slide1

Genital tract injury

presented by

Dr.Methal

A.

Alrubaie

Assistant professor

Objectives:-

*Identify the types of traumatic lesions that affect the genital tract during the process of labor.

*Describe how these lesions presented clinically.

*Explain the methods of treatment.

Vulval

injury:-

1. Labial laceration.

2

. Laceration of remnant of hymen.

3.Vulval hematoma:-It arise from rupture of

vulval

varicose or after repair of perineal tear. It is presented clinically as painful bluish swelling. It is treated by incision, evacuation of blood, ligation of bleeder & drainage with cover of antibiotics

.

Vagina & perineum

:-

It

can be divided into.:-

1.First degree perineal tear:-

It involve the perineal skin with minor part of perineal body & adjacent lower posterior vaginal mucosa

2. Second degree perineal tear:-

It involve perineal body up to anal sphincter in addition to perineal skin & adjacent posterior vaginal mucosa.

3. Third degree perineal tear:-

It involve anal sphincter & 2cm or more of anal canal in addition to above

.

First & second types are repaired using local anesthetic agent infiltration. Third degree type should be repaired under G.A. once it is diagnosed since it cause fecal incontinence if misdiagnosed or ignored.

After care:-

1. Daily washing with antiseptic solution. 2. Catheterization if urine retention develop. 3. Antibiotics. 4. Glycerin suppository to keep the stool loose.

Episiotomy:-

It is second degree perineal tear made by human after local infiltration with local anesthesia.

Aims:-

1. To ease the delivery. 2. To protect the head from

truma

.

Indications:-

1.

Occipito

-posterior malposition. 2. Breech delivery. 3. Forceps delivery. 4.Shoulderdystocia. 5. Previous repair operation of vagina. 6.Narrow pelvic outlet. 7. Tight perineum.

Types:-

1. Midline. 2.Mediolateral. 3. Lateral.

Advantages:-

1. Easy repair. 2. Rapid healing. 3. Less infection. 4. Less complications as dyspareunia & prolapse.

Problems:-

*If repaired too tight it will cause pain, edema & devitilization of tissues

. *

If repaired too loose it cause inaccurate apposition of edges with excessive scar formation. * If difficult to reach the apex of episiotomy use hand over hand technique by insert suture at the highest reaching point then pull the suture down & insert another suture above the previous one & so on until reach the apex.

Repair:-

*First layer to repaired is posterior vaginal mucosa which is sutured by interrupted suture to avoid shortening of posterior vaginal wall.

*Second layer is perineal body which if it is deep; suture in two layers the first one is the deepest. *Third layer is the skin.

A

fter care:-

*Use Dixon or chromic catgut suture which are absorbable & cause less discomfort. * Use ice packs to induce vasoconstriction so reduce the development of hematoma. * Use warm packs to the established hematoma & edema. * Use local analgesia as xylocaine. * Cover with antibiotics as

cephalosporine

& metronidazole.

Cervix:-

A. Cervical laceration:-

It can be:- .

1. Minor laceration

:- It is symptomless, require no treatment

2. Extensive laceration:-

It is caused by:- *Precipitate labor. * Use forceps on unfully dilated cervix. * Rapid delivery of after coming head in breech. * Injury to previous cervical scar.

Clinically presented as postpartum hemorrhage. It is treated by repair under G.A.

B. Cervical detachment:-

There is annular detachment of cervix if there is cervical

dystocia(failure of cervical dilatation despite efficient uterine contraction).

It occur due to prolong apposition & pressure of presenting part on cervix cause maternal circulatory .Clinically presented as puerperal infection & bleeding is uncommon.

Uterus:-

A. Rupture uterus:-

The causes can be:-

1. During labor:-

* Obstructed labor. * Oxytocin hyper stimulation. * Weak previous lower segment scar. * Intrauterine manipulation as internal version or manual removal of placenta. * Spontaneous in multiparous women of high parity.

2. During pregnancy:-

* Previous classical C/S. * Previous opening of uterine cavity in myomectomy, removal of intrauterine septum, tubal replantation. * Previous perforation during D&C.

Types:-

1. Complete (intraperitoneal):-

The serosa layer of uterus is damaged.

2. Incomplete (

extraperitoneal

):-

The serosa layer is intact.

Clinical features:-

A. Classical features:-

* Sudden sever abdominal pain. * Cessation in progress of labor. * Fetal death. * Signs of internal hemorrhage as abdominal rigidity, hypotension & tachycardia.

B. Less dramatic features:-

* Tenderness in the site of previous scar. * Slowing in progress of labor for no obvious reason. * Rapid pulse with or without fetal distress. * There may be slight trickle of blood since lower segment is avascular.

Treatment:-

Rupture uterus associated with high maternal mortality.

Incomplete rupture:-

It treated by laparotomy & repair of uterus with blood transfusion.

Complete rupture:-

Three methods:- * Subtotal hysterectomy if the if there is extensive damage. * Repair of uterus if the uterus is desirable & can be repaired. *Repair & tubal ligation if women want to menstruate & uterus can be repaired.

B. Acute inversion of uterus:-

It is defined as the body of uterus is turned inside outside either partially or completely. It is caused by pulling the

umblical

cord to deliver the placenta while it is not separated from uterus yet or pressure on fundus while the uterus is not contracted.

Clinical features:-

* Third stage neurogenic shock * Vaginal bleeding if the placenta is not separated. * Difficult to palpate fundus on abdominal examination. * There is purple colored mass in vagina.

Treatment:-

1. Manual replacement:-

This is done under G.A. replace the lateral wall of uterus first by pressure on it & lastly replace the fundus. Oxytocin infusion is given to induce contracted uterus.

2.Replacement by hydrostatic pressure:-

It is done by fill the vagina with warm saline fluid through wide tube connected to container which contain normal saline & held at height of 60cm & the vagina is closed by adhesive plaster so such fluid exert pressure & replace the fundus.

Paragenital

hematoma:-

A. Infra-

levator

hematoma:-

It include

vulval

hematoma,

perineal

hematoma, paravaginal hematoma & bleeding into

ischeo

-rectal fossa. Bleeding from para-vaginal venous plexus into surrounding tissues will track down into vulva & perineum causing painful hematoma which is treated by evacuation, drainage & blood transfusion.

Supralevator

hematoma (broad ligament hematoma):-

There is large dead space above

levator

ani

muscle so bleeding is not recognized until it is so large to cause abdominal soft mass in one of

Clinically

there is signs of internal bleeding as shock & on vaginal examination there is boggy swelling in one of lateral fornix & the uterus is shifted to opposite side.

Treated

by laparotomy with evacuation of blood with pressure. Blind insertion of suture is contraindicated since the ureter is placed in upper part of broad ligament. Hysterectomy is not done unless there is associated injury to uterus or cervix. Internal iliac artery ligation is done if pressure fail to arrest bleeding

.

Symphesis

pubis separation

:-

It is

causedby

:- 1. Trial of labor in presence of C.P.D. at pelvic prim. 2. Difficult forceps delivery.

It can be minor separation presented as maternal pelvic discomfort, treated by rest & corset. In major type there is sever pelvic pain in early pureperium with painful rolling movement ,treated by pelvic support.

Fistula:-

Two types:- 1. Urinary fistula:-as

vesico

-vaginal &

ueretro

-vaginal caused by :- * injury to bladder during C/S. * Obstructed labor. Presented clinically as true urine incontinence. 2. Fecal fistula:- as recto-vaginal fistula caused by third degree

perineal

tear & presented clinically as fecal incontinence.

Thank you