Birth Canal Injuries

By P.N NGUGI
MSC/BScN/RN
 Injuries of the maternal birth canal
 One should suspect traumatic bleeding in women having
excessive bleeding after expulsion of placenta and uterus is well
contracted.

 In such cases the perineum and lower genital tract should be

explore under good light.

Common birth canal injuries are –

I. Perineal tear

II. vaginal and cervical tear

Lacerations
 Periurethral lacerations
 Periclitoral lacerations
 Vaginal lacerations
 Cervical lacerations/ cervical tear
Priurethral / Periclitoral
lacerations
• Occurs due to pressure from delivering head to the
anterior perineum by the intact posterior perineum.

• If light bleeding- pressure with a pad for 1-2 minutes

arrest the bleeding

• If significant bleeding- repair to be done using fine

continuous sutures.

• If stitches are taken urethral catheter be placed.

 Perineal tear
 Gross perineal tear is usually due to mismanaged 2nd stage of labor.

Degree of perineal tear –

 1st degree perineal tear- it involves the vaginal mucosa and subcutaneus tissue
and forchette.
 2nd degree perineal tear- it involves the vaginal mucosa , subcutaneous tissue
(connective tissue) varying degree of perineal body tear but it is not reaching
up to external anal sphincter.
 Perineal tear
 1st & 2nd perineal tears are termed as incomplete perineal tear.

 3rd degree perineal tear- in this injury to perineum involves –post vaginal
wall tear of whole of the perineum as well as complete transection of
anal sphincter .
cont…..

 4th degree perineal tear- involving the vaginal mucosa, perineum,

anal sphincter, anal and rectal mucosa

 3rd & 4th degree perineal tear are complete perineal tear.
 Treatment of the perineal tears

 Prevention- proper conduction of 2nd stage of labour is preventive i.e,

 Early extension of head during delivery to be avoided
 Slow delivery of fetal head in between contraction
 To perform timely episiotomy when indicated
 To take care of perineum during delivery of shoulder.
 Repair of perineal tears
 Recent perineal tear should be repaired immediately following delivery of
placenta.
 In case of delay more than 24 hrs immediate repair to be with held. care of
in 2nd degree it should done after antibiotic coverage and when ever
wound become clean.
 In case of complete perineal tear when delay is >24 hrs then repair to be
done after 3rd month of delivery.
 Repair of incomplete tear cont…..

 It is just like episiotomy repair i.e. stitch the vaginal

mucosa, subcutaneous tissue , and skin-suture maternal
1 or 1-0
 1st stitch the vaginal mucosa by continuous suture
 Stitching should be started 1cm beyond the apex of
vaginal mucosa.
 Then stitch the subcutaneous tissue by interrupted suture
Repair of incomplete tear
cont…..

 Skin by interrupted suture.

 If tear was deep perform a rectal examination make sure that no stitch in
rectum

 Clean the stitch line and perineum

 Dressing of stitch line.

 Repair of recent complete perineal tear i.e,
within 24 hrs
 Patient is to be put in lithotomy position
 All aseptic precaution to be taken
 Local anaesthesia or preferable GA.
 Suture material used is 1-0 vicryl or chromic cut gut
 The rectal mucosa is sutured 1st from above downward with interrupted
suture
 Then stitch the rectal muscle and para-rectal fascia by interrupted suture
 Repair of recent complete perineal tear
i.e, within 24 hrs cont……
 Now explore the torn end of anal sphincter with the help of allies forceps
 Torn end of sphincter are sutured in midline by figure of eight stitch
 It is supported by another layer of interrupted suture
 Stitch the vaginal mucosa, perineal muscles and skin by interrupted suture.
 After care
 Just like episiotomy cleaning and dressing of wound after each
urination and defecation.
Special care to be taken in repair of complete perineal tear-
 Liquid diet on 1st day
 Low residual diet (such as milk, rice, bread, egg, fish, potato,
sweets, fruit juice)for 4 days.
 Lactose 8ml twice a day for one week to soften the stool
 After care cont…..
 Broad spectrum antibiotics along with metronidozol (400mg) TDS
for 5-7 days
 Avoid giving enema and rectal examination for two weeks
 Cervical tear

 Minor degree of cervical tear is during 1st delivery is common.

 It is commonest cause of traumatic PPH

 Left lateral cervical tear is more common

 Cause of cervical tear

I. Iatrogenic- in case of operative vaginal delivery or

breech extraction through incomplete dilatation of
cervix
II. Rigid cervix following previous cervical operation
III. Precipitate labour
 DIAGNOSIS
 Cervical tear or vaginal tear should be suspected when PPH is there in-
spite of well contracted uterus.

 Explore the cervix and vagina for tear under good light.
 How to explore
Exploration of cervix

 With all aseptic precaution

 Evacuation of bladder if full

 Place the patient in lithotomy position

 Insert speculum and retract the posterior vaginal wall

How to explore cont…..

 Ask the assistant to push down the fundus of uterus gently.

 Hold the anterior lip of cervix with sponge holder and trace
whole of the cervix with another sponge holder forceps in
clock wise manner and identify the cervical tear

 Now grasped the both margin of the tear of cervix by the

sponge holder.
 How to explore Cont….
 Stitch the cervical tear by interrupted mattress suture by taking the
whole thickness of cervix, suture material is 1-0 chromic catgut
with round body needle.

 The repair should be started 1 cm above the apex of the tear.

How to explore cont…..

 Mattress suture prevents rolling of the edges.

 If the cervical tear is extending to the lower segment or vault with broad
ligament hematoma needs laparotomy.
 Vaginal tear

 After the proper exposure haemostatic suture and

vaginal tear suturing to be done if multiple laceration,
then pack the vagina for 24 hrs.
 After removing the packing check for bleeding
 Vaginal tear Cont….

 Vulva injuries- vulval laceration, perineal laceration and

hematoma needs to be drained and proper haemostatic
suture should be given

 Sometime local packing requires.

HEMATOMAS
 Vulval haematoma

 Paravaginal haematoma

 Broad ligament and retroperitoneal haematoma

Vulval haematomas

 Small vulval haematomas (≤5 cm) may be treated

conservatively with analgesics, observation and ice
packs
 If pain is not controlled, enlarging or large haematoma
need to incise and evacuate.
 Regional / general anaesthesia needed.
 Incision is made over the most prominent area and clots
evacuated.
Vulval haematomas contd...

 Discreet bleeding points are ligated although frequently

none are found
 Oozing areas may be oversewn with figure-of-eight
sutures
 Vaginal packing be done
 Foley catheter is placed
 Broad spectrum antibiotics be given.
Vulval haematomas contd...

 Sub peritoneal and supravaginal haematomas not

repaired vaginally
 Laparotomy is advisable
 Angiographic embolisation of internal iliac arteries may
be done.
CERVICAL EDEMA

 Pushing early sometimes causes cervical swelling as

well.
 It is believed that uterosacral ligament tension that
causes the early urge to push.
 There may be deflexion (chin up) or occiput posterior
presentation with that tight or twisted ligament as well.
Vulvar oedema

 Vulvar edema is swelling of the vulvar tissue due to

accumulation of fluid in the interstitial space.
 It can be a unique entity unto itself but usually is a
symptom of another condition.
 The edema may be related to retention of fluid or
lymphatic material.
causes

 Vulvar edema is associated with a variety of conditions.

 The edema can result from inflammatory conditions,
infections, infestations, trauma, pregnancy, tumors and
iatrogenic causes.

 Redness and swelling on the labia and other parts of the

vulva.
 Intense itching.
 Clear, fluid-filled blisters.
 Sore, scaly, thick, or white patches on the vulva.
treatment

 Limiting your exposure to irritants should help ease the

swelling.
 You could also use an over-the-counter (OTC) cortisone
cream to reduce your symptoms.
 If the swelling continues, you should see your doctor.
 They may recommend a sitz bath or a prescription
topical cream for treatment.
complications

 unusual vaginal discharge

 itching
 irritation
 pain during sex
 pain while peeing
 light bleeding or spotting
Symphysiotomy

 Partial incision of the cartilage of the symphysis pubis

such that the two pubic bones separate by about 2 cm,
allowing enough room for passage of an entrapped, live
foetus.
 This procedure should be done in combination with
episiotomy
 Indications
 This life-saving technique may be useful as a procedure of last resort:
 – In situations where caesarean section is indicated but not feasible1 :
 • Head engaged and arrested for more than an hour, and vacuum extraction alone
has already failed or is likely to do so.
 • Foeto-maternal disproportion due to a pelvis that is slightly too narrow: after the
trial of labour has failed, and at least 3/5 of the head has descended into the pelvic
cavity.
 – In the event of shoulder dystocia when other manoeuvres have failed.
 – In the event of entrapped after coming head in a breech when other manoeuvres
have failed.
Conditions

- Membranes ruptured, full dilation.

– The foetal head is not palpable above the symphysis pubis or by less
than 2/5
Contra-indications

– Head not engaged.

– Brow presentation.

– Dead foetus perform an embryotomy

– Cervix not fully dilated.

– Severe cephalo-pelvic disproportion, with head above the symphysis by

more than 2/5
Position of the foetal head
Equipment

 – Scalpel, suturing equipment, delivery set with

episiotomy scissors
 – Vacuum extractor
 – Foley catheter
 – Sterile drape, compresses and gloves
 – 10% povidone iodine
 – 1% lidocaine
Technique
– Patient in lithotomy position, abduction supported by two
assistants who maintain an angle of less than 90° between
the patient's thighs (Figure 5.18).
Figure 5.18 - Supported lithotomy position                              
– Shave the incision site; swab the pubic and perineal region with 10%
povidone iodine.
– Place a sterile fenestrated drape over the symphysis.
– Insert the Foley catheter, which allows location of the urethra throughout the
procedure.
– Local anaesthesia: 10 ml of 1% lidocaine, infiltrating the skin and
subcutaneous tissues superior, anterior, and inferior to the symphysis, along
the midline, down to the cartilage. Infiltrate the episiotomy region as well.

– With the index and middle fingers of the hand inserted into the vagina, push
the urethra to the side (Figures 5.19 and 5.20).
Place the index finger in the groove formed by the cartilage between the two
pubic bones, in such a way that it can feel the scalpel's movements.
The catheterized urethra must be pushed out of scalpel's reach.
Post-operative care

– Have the mother rest on her side (avoid forced abduction of the thighs) for 7 to 10
days.
Mobilization with aid is possible as of Day 3 if the woman can tolerate the discomfort.
No heavy work for 3 months.

– Remove the Foley catheter after 3 days, except if haematuria present during
catheterization or in case of obstructed labour

– Routine treatment for pain as for caesarean section

Complications

– Bleeding at the site of the wound: compression bandage.

– Local infection: daily dressings and antibiotherapy (amoxicillin PO: 1 g 3 times daily for
5 days).
– Stress incontinence: uncommon and temporary.
– Gait problems: prevented through bed rest.
– Injury to the urethra or bladder: leave the catheter in place for 10 to 14 days and
consult a specialist.
– Osteomyelitis: extremely rare if rigorous sterile technique has been used.

NB
Caesarean section is not feasible because surgical conditions are inadequate or surgical
intervention would take too long or there is a high risk of trauma to mother and foetus or
the woman refuses caesarean section.
Multiple Choice Questions
1) Perineal tears should be repaired:

a) 24 hours later

b) 48 hours later

c) 36 hours later

d) Immediately
d) Immediately
2) Most suitable method of treatment of 4 inches size
episiotomy haematoma is by-

a) Evacuation

b) Magsulf compression

c) Cold compress

d) marsupialisation
A ) Evacuation
3) In a patient with third degree perineal tear,
presenting after 1 week, repair should be done:
a) Immediately
b) 2 weeks
c) After 6 weeks
d) After 12 weeks
d) After 12 weeks
4) A woman delivers a 4 kg baby with a midline episiotomy and suffers a
third degree tear. Inspection shows which of the following structures is
intact:
a) Anal sphincter
b) Perineal body
c) Perineal muscles
d) Rectal mucosa
d) Rectal mucosa
5) IIIrd degree perineal tear is involvement of :

a) Vaginal mucosa

b) Urethral mucosa

c) Levator ani muscles

d) Anal sphincter
d) Anal sphincter
6) Which of the following is the best treatment
for vulvar hematomas that are extremely
painful, bit stable in size:
a) analgesics
b) Ice compress
c) Incision and drainage
d) Angiographic embolization
c) Incision and drainage
7) Concerning vaginal lacerations involving the middle or upper third of vagina, which
of the following is true:
a) These are often the result of forceps delivery
b) These result from uterine over distension
c) These are usually associated with injuries to the levator-ani muscles
d) All of the above
a) These are often the result
of forceps delivery