LACERATION – large laceration can be
source of infection/hemorrhage
Occurs often:
1. Difficulty or precipitate birth
2. Primigravidas
3. Birth of large infants (>9LB)
4. Use of litothomy position and
instruments (forceps, vacuum)
5Laceration occurs in CERVIX, VAGINA or
PERINEUM
ASSESSSMENT – Anytime a uterus feels
firm but bleeding persist suspect a
laceration.
CERVICAL Laceration – found usually on
sides of cervix near branches of uterine
artyert. Arterial bleeding is bright red than
venous blood
-Occurs immediately after detachment of
the placenta
MANGAMENT – Surture
-Try to maintain an air of calm and stand
beside the woman at the head
-Assure her of the babys condition and
inform her longer stay in birthing room
-If cervical laceration appears extensive, its
necessary to give regional anesthesia to
relax uterine muscle and prevent pain
VAGINAL Laceration – easier to locate and
assess than cervical because its easier to
view
MANAGEMNT – A balloon tapenade may
be effective if surturing doesn’t achieve
hemostasis
-An indwelling urinary catheter may be
placed following the repair because the
packing cases such pressure on the
urethra than can interfere with voiding
-Document womans electronic record
when and where packing was place to be
certain to remove after 24-48hrs or before
discharge
PERINEAL Laceration – More likely to have
in litothomy position rather than supine
because it increases tension in perineum.
MANAGEMENT:
-Sutured and treated same as episiotomy
repair
-A diet in high fluid and stool softener is
prescribed for first weeks to prevent
constipation and hard tools
-Fourth – degree laceration can lead to
long term dyspareunia, rectal
incontinence, sexual dissatisfaction they
usually heal without further complication
*CLASSIFICATION OF PERINEAL
LACERATION*
-First degree – vaginal mucous membrane
and skin of the perineum to fourchette
-Second degree – vagina, perineal skin,
fascia, levator ani muscle and perineal
body
-Third degree – entire perineum,
extending to reach the external sphincter
of rectum
-Fourth degree – entire perineum, rectal
sphincter and some of the mucous
membrane of the rectum.
RETAINED placental Fragments –
Fragments of placenta separate and left
stull attached to the uretus
-Most likely to happen with succenturate
placenta ( a placenta with accessory lobe)
-Placenta accrete (placenta that fuses with
myometrium because of abnormal
decidua basali layer) may also be retained
-Can be identified with ultrasound exam
-Removing deeply embedded placenta can
lead to severe postpartal hemorrhage
-A bloods serum containing human
chorionic gonadotropin (Hcg) hormone
also reveals that part of the placenta is still
present
ASSESSMENT- If undetected, bleeding may
not be immediate postpartal period
-If fragment is small, bleeding may not be
detected until postpartum day 6-10
-Notice of abrupt discharge and large
amount of vaginal bleeding
-On examination, uterus is found to not
fully contracted
MANAGEMENT- Dilation and curettage
(D&C)
-Methotrexate to be prescribe to destroy
retained fragments
-Observe change from lochia serosa or
alba black to ruba
- Hysterectomy must be performed to
others
UTERINE INVERSION – Prolapse of the
fundus of the uterus through to cervix so
that the uterus turns inside out
DISSEMINATED INTRAVASCULAR
COAGULATION (DIC) – deficiency in
clotting caused by vascular injury
-Associated with premature separation of
placenta, missed early miscarriage or fetal
death in utero
SUBINVOLUTION – Incomplete return of
the uterus to its pregnant size & shape, at
4-6 weeks uterus is still enlarged and soft
-Resulted from small retained placental
fragments, mild endometritis or
accompanying problems like uterine
myoma interfering with complete
contraction
MANAGEMENT – Oral administration of
methylergonovine, 0.2 mg 4x daily to
improve uterine tone and complete
involution
-If the uterus feels tender to palpation
suggesting endometritis is present, oral
antibiotic may be prescribed.
PERINEAL HEMATOMA – collection of
blood in the subcutaneous layer of the
tissue of the perineum
Most likely to occur after rapid
spontaneous birth who have perineal
varicosities.
May seen on the site of
laceration/Episiotomy repair if vein has
punctured during surturing
ASSESSMENT- If woman reports severe
pain in perineal area or feeling of pressure
between her legs.
-It appears purplish discoloration with
obvious swelling, it can be small as 2cm or
large as 8cm in diameter.
-May feel flunctuant but seepage into area
continues and tissue is drawin taut,
palpates as firm globe and feels tender.
MANAGEMENT – Report presence of
hematoma, its estimated size, degree of
woman discomforts
-Administer mild analgesics for pain relief
-Apply ice pack covered with towel to
prevent thermal injury to the skin
-Hematoma is absorbed over next 3-4 days
-The woman may have to return birthing
room to have the site incised and bleeding
vessels ligated under local anesthesia.
-Assure woman that it will reabsorb over
next 6 weeks
-If episiotomy line was open to drain
hematoma, it may be left open and packed
with gauze rather than surtured.
-Record this packing was placed to remove
in 24-48hrs
-Surture line open this way heals by
tertiary intention on from bottom to top
rather than side to side so healing will
occur slowly than usual primary intention
sutureline.
-Instruct patient to keep clean and dry and
use sitz bath once or 2x a day