MATERNAL INJURIES أ.د. - PowerPoint Presentation

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MATERNAL INJURIES

أ.د.

ربيعة محسن علي

Most maternal injuries occur during the second stage of

labour

but the diagnosis is made in the

third stage

after the

delivery of the baby

. Some of the commoner ones are described below.

PERINEAL TEARS

The

perineum is the region between the

vaginal opening

and the anus. The perineum may get injured when there is overstretching or rapid stretching during the

delivery of the baby

. An inelastic perineum due to the presence of a scar can also lead to a

perineal

tear. Some of the causes of overstretching of the perineum leading to

perineal

tear are:

A big baby - usually babies more than 4000

kgs

or 9 ounces are considered big.

Malpresentation

of the baby like

occipitoposterior

position or face presentation.

Average sized baby with a narrow maternal vaginal outlet

Forceps delivery or other instrumental deliveries

Shoulder

Dystocia

Degrees of perineal tear: There are three degrees of

perineal

tear.

First Degree

perineal

tear:

This is only a mild degree of laceration or tear of the skin at the edge of the

vaginal opening

. The lower part of the

vagina

as well as the

perineal

skin may be torn but the major muscles of this region are not affected.

Second degree perineal tear:

This involves rupture of the muscles of the perineum with deep tears in the

vaginal wall

. The tear may extend right up to the anus, but does not involve the anal sphincter.

Third degree

perineal

tear:

In a complete

perineal

tear, the tear extends from the

vaginal

opening through the

posterior vaginal wall

and the

perineal

muscles

upto

the anus with injuries to the external anal sphincter. The anal or the rectal canal may or may not be involved.

Management/Treatment of Perineal

Tears

Prevention is the best management. The

second stage of

labour

should be properly conducted. An

episiotomy

should be performed wherever deemed necessary to prevent tear of the perineum.

Immediate Repair:

A first degree or second degree tear should be immediately repaired, preferably within the first 24 hours.

Delayed Repair:

If the tear is diagnosed after 24 hours, then the woman is given antibiotics and the wound dressed so that infection , if any, is controlled. Then the tear is repaired

.

Third Degree tear:

A third degree tear is always repaired after 3 months of the

delivery of the baby

to allow the tissues to regain the pre-pregnant state.

VAGINAL TEARS

Vaginal

Tears

can occur at any part of the

vaginal wall

, but are seen mostly at the junction between the lateral and posterior walls. These tears may be superficial with only minor lacerations of the vaginal mucosa. But, sometimes the tears may be deep enough to expose the inner muscles.

Vaginal tears can also occur at the region around the

urethra

- the opening through which urine comes out. These are then called

'

Paraurethral

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.

Treatment / Management of vaginal Tears The vagina

should always be examined under proper light immediately after the delivery of the baby for any such tears. All tears should be repaired immediately

CERVICAL TEARS

Minor

tears of the

cervix

are very common during delivery, especially in a woman who is delivering her first child. But sometimes, major lacerations which can cause severe bleeding may also occur . In fact, cervical tears are the commonest form of

traumatic post partum hemorrhage

. Cervical tears are commonest at the lateral angle, between the anterior and posterior lips of the

cervix

.

Causes of Cervical tear:

Delivery through an

undilated

cervix

whether spontaneously, or by forceps.

Precipitate

labour

.

Rigid

cervix

due to previous operations like the LEEP procedure,

conisation

, or cervical amputation.

Very vascular cervix as can occur in low level

placenta

previa

.

Treatment / Management of Cervical Tears

The aim of treatment is to control bleeding as early as possible by repairing the tear. Minor lacerations without active bleeding does not require to be repaired - they heal spontaneously with no ill effects.

Major cervical lacerations or tears need to be repaired in the Operating theater under anesthesia, good light and proper exposure of the tear.

VULVAL HEMATOMA

Collection

of blood anywhere in the

vulval

region is called

vulval

hematoma. Although

vulval

haematomas

can also occur after an injury due to any cause, it is commonly seen after the

vaginal delivery of a baby

.

A

Vulval

hematoma can occur either spontaneously or after improper repair of an episiotomy wound. Blood from a rupture of the deep veins of this region collects in a closed space with no opening for it to drain out.

Symptoms of Vulval

Hematoma:

A steadily increasing swelling to one side of the vagina.

The swelling is tense and tender to the touch.

The woman complains of severe pain, more so on sitting down.

There may be difficulty in passing urine if the swelling presses on the urethra.

The bleeding can be severe enough to cause the patient to go into shock.

Treatment / Management of Vulval

Hematoma

The aim of treatment is to

ligate

the bleeding blood vessels as early as possible and support the patient with IV drips and medicines so that she does not go into shock.

An incision is made at the most distended point of the hematoma.

The incision is then deepened and the blood clots scooped out.

The bleeding vessels are identified and tied up.

The incision is closed by applying different layers of stitches.

A drain may be put in the wound for 24 hours to allow any oozing blood to flow out.

Proper antibiotics are prescribed and the patient kept under close observation.

Blood transfusion is given if necessary.