1. OBSTETRIC INJURIES TO GENITAL TRACT
Dr Samar D. Sarsam

2. OBSTETRIC INJURIES TO GENITAL TRACT
RUPTURE UTERUS
IT IS A MOST SERIOUS CONDITION
It usually occur during labor, rarely during preg.
Incidence 0.3%.
Causes:
-During preg:
Weak scar
Previous classical c/s.
Previous hysterotomy, metroplasty, myomectomy, perforation.
Direct trauma to abdomen.
Congenital abnormality of the uterus

3. During labor:
Obstructed labor.
Intra uterine manipulation.
Forcible dilatation of cx.
Injudicious use of oxytocin.
Previous weak scar.
Grand multiparous women
Pathology:
-complete rupture
-incomplete rupture.
Depending on whether the peritoneal coat is torn or not
weak scar is the commonest cause of rupture uterus, if the uterus is over distended, scar imperfectly sutured, sepsis, the placenta implanted over the scar.
c/s in the lower segment may stretch gradually attenuated avascular fibrosis causing relative intraperitonial bleeding when the scar give way

4. Symptoms and signs:
Rupture through scar during pregnancy, history of previous operation, scar on skin, thin abdominal wall, tender sulcus, may be silent rupture, or severe pain, shock.
Rupture during labor, dramatic symptoms, not always there is difficult labor.
Spontaneous rupture during obstructed labor, signs of obstruction, exhausted mother, tearing pain, shock, vaginal bleeding.
On examination: presenting part high, fetus extruded out of the uterus, contraction cease.
Rupture after intra uterine manipulation.
Extensive cervical laceration.
Rupture by oxytocic drugs, risk more in multip.
Direct injury to abdomen

5. Prognosis:
Mortality higher in cases of obstructed labor.
Fetal death is also more in cases of obstructed labor than in rupture in previous scar.
Treatment:
Recognize disproportion.
High risk cases deliver at hospital.
Upper segment scar deliver by c/s
Improve general condition, blood, I.V fluid, morphine, operation.
Repair or hysterectomy. + tubal ligation.
Antibiotics
Electrolyte balance.

6. LACERATION OF THE CERVIX
Caused by precipitated labor, forceps application, rapid delivery of the after coming head in breech presentation, previous scar in cx. From previous injury may tear.
Minor laceration is asymptomatic.
Deep laceration causes severe hge during and after 3rd stage of labor.
Treatment:
Suturing under G.A using interrupted catgut or vicryl inserted through the whole thickness of its wall.
We need sponge forceps to complete our work.

7. LACERATION OF THE PERINIUM AND VAGINA
There are four degrees of this type of injury:
First degree: it involves only the skin
Second degree: it involves the perineal body up to the anal sphincter, but not involving it with a corresponding vaginal tear.
Third degree: secondary tear with partial or complete disruption of the anal sphincter.
Fourth degree: third degree tear with anal epithelium.
Extensive tear in the vagina may occur without tear in the perineum so inspection is important.

8. Treatment of first and second degree tears:
By repair of all lacerations to prevent any infection.
If not sutured the possibility of uterovaginal prolapse is increased.
Start suturing from apex of the vaginal tear using continuous or interrupted suture using catgut or dexon using local anesthesia,G.A,epidural.

9. Third and fourth degree tears:
Experienced obstetric surgeon, theater, G.A, or epidural.
Early suturing with good results, if delayed the operation is difficult and incontinence is more also use catgut or dexon.
Anal mucosa is 1st repaired with the knot inside the bowel lumen.
Anal sphincter with interrupted suture, the rest as in 2nd degree tear repair.
After care – daily wash with soap and water, dried, may need a catheter.
If bowel motion is –ve by the fourth day, use glycerin suppositories not oral liquid paraffin.
If infection occurs we remove the stitches, drain, antibiotics, bathing until granulation tissue occur then 2ndry suture.

10. Repair of a second degree laceration

11. A first-degree laceration involves the fourchet, the perineal skin, and the vaginal mucous membrane. A second-degree laceration also includes the muscles of the perineal body. The rectal sphincter remains intact.

12. Layered primary closure of a fourth-degree obstetric laceration

13. VULVAL AND PARAVAGINAL HAEMATOMA
Divided into two types:
Supralevator hematoma
Infralevator hematoma
Infralevator: includes vulva, perineum, paravaginal, ischiorectal fossa.
Supralevator hematoma: it spread upwards and outwards beneath the broad ligament or partly downwards to bulge into the wall of the upper vagina and can track backwards into the retroperitoneal space.

14. Incidence: greater than 4 cm in diameter it occurs in 1/1000 deliveries.
Injury occurs with episiotomy.
In 20% of cases occur with intact perineum,
Half of women with genital hematoma have spontaneous delivery.

15. Diagnosis:
Usually obvious.
May be missed until shock occurs.
Symptoms:
Depend on rate and size of hematoma
Management:
Resuscitation, surgical evacuation if hematoma is larger than 5 cm or if expanding.
If small and not expanding, observation, ice-packs, antibiotics, analgesia.

16. SUBPERITONEAL HEMATOMA
Broad ligament hematoma, less common than genital hematoma.
It occur in 1 in deliveries.
They follow spontaneous vaginal or c/s or forceps.
50 % discovered immediately, the other half 24 hrs later
presentation abdominal pain and hge.
Management:
Conservative.
If unstable homodynamic state do surgical exploration may need hysterectomy

17. FISTULA
- Due to prolonged pressure of the presenting part in prolonged labor,
- Or direct injury during operation, forceps.
Prolonged pressure causes ischemia then necrosis of anterior vaginal wall and base of bladder causing vesicovaginal fistula.
The rectum may also be involved, rectovaginal fistula commonly caused by complete tear.
If it is due to pressure necrosis it appears after 8 days when the slough separate.
Examination, opening is found.
Small fistula may heal in the rectum by granulation tissue healing.
But for vesicovaginal fistula this is unlikely.
If direct fistula direct repair.
If pressure fistula repair 2-3 months later.

18. MATERNAL NERVE INJURY DURING LABOR
-Foot drop from paralysis of dorsiflexor muscles of the leg may follow delivery.
In few cases it is due to pressure on lateral popliteal nerve near the neck of the fibula by a leg support
-In the majority of cases different type of injury involving the 4th and 5th lumbar nerve roots.

19. Sudden prolapse of the intervertebral disc during labor, or pressure on the -----lumbosacral cord by the presenting part near the pelvic brim.
The lesion is usually unilateral and it follows difficult labor.
-Sensory loss, it follows foot drop and rarely follows epidural anesthesia.