Genital Tract InjuriesIntroduction ‘The female genital tract consists of the external genitalia and the internal genitalia with vagi uterus, fallopian tubes, and ovaries. Itis composed of the following layers respectively: + Skin, © Superficial fascia. + Perineal muscles; external anal sphincter, superficial and deep perineal muscles, bulbocavernosus, and ischiocavernosus ocoo Genital tract injury: The maternal genital tract may get variety of injuries during child birth process. These injuries are quite common and contribute significantly to maternal morbidity and even to death These include: © Vaginal tears. + Hematoma of the vulva. + Perineal tears * Cervical tears + Rupture of the uterus Etiology + Lack of perineal elasticity: o Elderly primigravida. Excessive scarring from a previous operation as posterior colpoperineorrhaphy. © Friability due to perineal oedema. + Marked perineal stretch: Allowing head extension before crowning. © Macrosomic baby. o Face to pubis delivery. © Forceps delivery. © Narrow subpubic angle pushing the head backward. Rapid perineal stretch: © Precipitate labour. Rapid delivery of the after-coming head in breech presentationTrauma to the perineum during vaginal childbirth, Delivery may lead to overstretching of the vagina, causing tears in the perineal tissue between the vagina and rectum. Lacerations are classified into four categories: «First degree tear: laceration is limited to the fourchette and superficial perineal skin or vaginal mucosa «Second degree tear: laceration extends beyond fourchette, perineal skin and vaginal mucosa to perineal muscles and fascia, but not the anal sphincter + Third degree tear: fourchette, perineal skin, vaginal mucosa, muscles, andanal sphineter are tom. «Fourth degree tear: fourchette, perineal skin, vaginal mucosa, muscles, anal sphincter, and rectal mucosa are tom. Superficial layer External anal sphincter muscle:-encircles the anus and is attached behind by a few fibres to the coceyx. + Transverse pernicious muscles pass from ischial tuberosities to centre of perineum. + Bulbocavernosus muscles:-pass from the perineum forwards around the vagina to the corpora cavernosa of the clitoris. * Ischiocavernosus muscles: - pass from ischial tuberosities along the pubic arch to the carpora cavernosa .Deep muscle layer Superficial Pelvic Floor Muscles Deep muscle layer + composed of three pairs of muscles, which together are known as the lavetor ani muscles Fach lavetor ani muscle consist of following:- + The pubococeygious muscle passes from the pubis to the coccyx. + The illiococcygious muscle passes from fascia covering obturator intenous muscle to the coceyx. % The ischiococcygious muscle:-passes from the ischium to the coccyx‘aginal Lacerations Causes: + Primary lacerations less common and caused by: © Forceps application. © Destructive operations. Vacuum extraction if the cup sucks a part from the vaginal wall. + Secondary lacerations: more common and are due to extension from perineal or cervical tears. ©. Incorrect application of obstetric forceps o Cephalopelvic disproportion Management + Immediate repair: Continuous locked cut gut sutures are taken starting from above the apex to control bleeding from the retracted blood vessels. Tight pack: may be needed to control bleeding from a raw surface area. Foley's catheter should be inserted before packing and both are removed after 12-24 hours. * Observe & document color and amount of urine. Haematoma of the Genital Tract Vulval Haematoma Causes: Traumatic due to: © Incomplete hemostasis during repair of episiotomy or tear. © Direct trauma as kick or falling down. * Spontaneous: due to rupture of a varicose vein. Symptoms ‘The hematoma usually appears 12-48 hours after delivery. ‘The collection of blood is limited by the levator ani above but laterally it may extend to fill the ischiorectal fossa reaching a volume of 500 ml or more. ‘There is a progressive enlarged, painful, tender, tense, bluish swelling at the vulva. Management: «Small not- increasing hematoma: is managed conservatively as it usually resolves spontaneously. Prophylactic antibiotic may be given to guard against secondary infection. + Large increasing hematoma: © Itis incised longitudinally,© evacuation of the clotted blood, © bleeding points are ligated, © The gap is closed in layers. Vaginal Hematoma Causes: Deep vaginal lacerations. Sign & Symptoms ‘+ The blood is collected paravaginally above the levator ani muscle. + Itmay not be visible externally. « Itmay not be painful until reaching a large size. * Intense pain in the vulva, vagina and perineum in infralevator hematoma * Rectal pressure and pain radiating down the leg * Manifestations of hypovolaemia and anemia may be present. + Patient may collapse due to severe bleeding Management: Small hematoma is managed conservatively Large increasing hematoma more than Scm in diameter needs to be evacuated Any bleeding point needs to be caught and ligated If cavity is large after evacuation then vaginal packing is done for 12 hours Close monitoring and recording of vitals Replace the blood if needed with proper documentation Nareotic analgesics is given for pain © Prophylactically antibiotics are given Cervical Lacerations Etiology * Forceps, ventouse or breech extraction before full cervical dilatation. * Manual dilatation of the cervix. «Improper use of oxytocins. ‘© Precipitate labour. Predisposing Factors + Cervical rigidity. «Scarring of the cervix. * Ocdema as in prolonged labour. Placenta Previa due to increased vascularity. . Diagnosis Postpartum hemorrhage, in spite of well contracted uterus.* Vaginal examination: The tear can be felt. + Speculum examination: using a posterior wall self retaining speculum or vaginal retractors and 2 ring forceps to grasp the anterior and posterior lips of the cervix so the tear can be visualized. Complications * Postpartum hemorrhage. « Rupture uterus due to upward extension. Infection: cervicitis and parametritis. + Cervical incompetence leading to future recurrent abortion or preterm labour. «© Ureteric injury: from the extension of the tear or during its repair. Management: Immediate repair; is carried out under general anesthesia with good light exposure. . ‘© The vaginal walls are held apart with retractors. ‘© Interrupted cut gut or vicry! sutures are taken starting from above the apex of the tear to control bleeding from the retracted blood vessels. If the apex is not easily seen a traction on a stitch taken as high as possible in the tear will show the apex Retroperitoneal Hematoma ‘Causes: Upper vaginal, cervical or uterine tears which usually involve the vaginal or uterine artery. Clinical features: « Hypovolemia, anemia or shock: is usually present due to large amount of internal hemorrhage. «Swelling on one side of the uterus which increasing over a period of hours or days and may reach up to the lower pole of the kidney or even the diaphragm. « The uterus is felt separate and deviated to the opposite side. Management: + Small not-increasing hematoma: is managed conservatively as vulval hematoma. «Large increasing hematoma: needs Laparotomy. Incision in the anterior leaflet of the broad ligament. Evacuation of the blood clots. Securing hemostasis, bilateral internal artery ligation or hysterectomy may be indicated. . e000 Complications+ Postpartum hemorrhage. * Puerperal infection. + Incontinence of stool and flatus in unrepaired or imperfectly repaired 3rd or 4th degree tear. + Residual recto-vaginal fistula in imperfectly repaired 4th degree tear. « Future genital prolapse. © Dyspareunia due to tender vaginal scar. Prevention + Proper management of second stage of labor. + Episiotomy in the proper time. ‘Treatment: Any perineal tear should be repaired within 24 hours.. > First degree tear: The vaginal wall is repaired with continuous locked or interrupted ‘Sutures and the skin with interrupted sutures. > Second degree tear: “The perineal muscles are approximated by interrupted chromic cut gut sutures including the torn ends of the levator ani. + The vagina is sutured by continuous locked or interrupted sutures. 4 The superficial perineal muscles are sutured by interrupted chromic catgut. 4 The skin is sutured with interrupted sutures > Third degree tear: The tom ends of the external anal sphincter is identified and sutured together by interrupted catgut. “The levator ani muscles are approximated in front of the rectum. “The vagina, superficial muscles and skin are sutured as before. > Fourth degree tear: The rectal wall is sutured by 2 layers of inverted interrupted catgut not including the mucosa, 4 The external sphincter, levator ani, superficial muscles and skin are sutured as before. Rupture of the Uterus Incidence About 1:4000, 95% of cases occur in multipara particularly grand multipara.‘Causes: + During pregnancy o Spontaneous: + Rupture of a uterine scar: e.g. previous C.S. especially upper segment, myomectomy, hysterotomy, uteroplasty or perforation. + Abruptio placenta with severe concealed hemorrhage. + Anterior sacculation in case of incarcerated retroverted gravid uterus or posterior sacculation due to previous ventrofixation of the uterus. + Rupture ofa rudimentary hom at the 4th- Sth month. + Perforating vesicular mole. o Traumatic + Perforation during vaginal evacuation. = External trauma. © During labour: © Spontaneous: * Obstructed labour. = Rupture of a uterine scar. «Grand multipara: due to degeneration and over thinning of the uterine muscles. o Traumatic: = Internal version: particularly after drainage of liquor. « Manual separation of the placenta. * Destructive operations. «Extending cervical tear due to e.g. forceps or ventouse applications before full cervical dilatation. o Improper use of oxytocins. Weak uterine scar may be a result to: «Imperfect suture with improper coaptation of the edges. * Bad hemostasis results in blood clot formation which prevents good coaptation and predisposes to wound infection. * Wound infection. ‘© Subsequent implantation of the placenta over it. ‘® Subsequent over distension of the uterus e.g. polyhydramnios or multiple pregnancy. © Upper segment caesarean section scar is weaker than lower segment scar. + Repeated vaginal deliveries after a previous C.S. weaken the scar. Types ‘Complete: involving the whole uterine wall including the peritoneum. * Incomplete: not involving the peritoneal coat. Sites It depends upon the cause of rupture.In obstructed labor: © Itis usually in lower uterine segment. © Usually oblique or transverse. More on the left side due to; + Dextrorotation of the uterus. * Left occipito-positions are more common. © Extended tear may pass laterally injuring the uterine vessels leading to broad ligament hematoma formation. This rupture may involve the ureter or bladder. In rupture scar: ° Atthe site of the scar, Clinical features Before actual rupture the following manifestations may be detected: Lower abdominal pain. Tender uterine scar. Vaginal spotting (minimal bleeding). Actual rupture Symptoms ° Sudden severe abdominal pain: Itis differentiated from labour pain being continuous. If the patient was in labour there is cessation of uterine contractions. Shoulder pain on lying down due to irritation of the phrenic nerve by accumulating blood under the diaphragm. Silent rupture: minimal symptoms may occur in rupture lower segment scar due to presence of fibrosis and minimal internal hemorrhage. Signs on General examination: Variable degrees of collapse are present according to amount of blood loss. This may appear postpartum in case of traumatic rupture uterus, o Abdominal examination: Scar of the previous operation. Foetal parts are prominent and felt easy. The presenting part recedes upwards. + Abnormal foetal attitude and lic. + FHS usually not heard. + The uterus is felt separated from the foetus . In incomplete rupture, the foetus still inside the uterus with suprapubic painful tender swelling which is an accumulated blood in the vesico-uterine pouch. o Vaginal examination: The presenting part recedes upwards.Vaginal bleeding may be present. Contracted pelvis may be detected. A cervical tear may be found extending to the lower uterine segment and a broad ligament hematoma may be present. ‘Management: Prophylactic: Early detection of causes of obstructed labour as contracted pelvis and malpresentations. Proper use of oxytocins. Version is not done if liquor amnii is drained. Forceps application and breech extraction should not be done before full cervical dilatation, Elective caesarean section for susceptible scars for rupture as upper segment C-sections Exploration of the genital tract after difficult or instrumental delivery. ‘Curative: Blood transfusion and antishock measures. Immediate laparotomy, Deliver the foetus and placenta. Explore the rupture site: © If itis amenable for repair and the patient did not complete her family @ repair is done. © If'it is not amenable for repair® hysterectomy. Subtotal hysterectomy is less time consuming so itis done if there is no cervical tear Exploration of the other viscera mainly the bladder. Internal iliac artery ligation may be needed in case of broad ligament hematoma as the uterine artery is usually retracted and difficult to be identified Vaginal repair: may be amenable if there is slight extension of a cervical tear with accessible apex. Complications (Maternal) Shock. Hemorrhage. Paralytic ileus. Bladder, ureter or visceral injuries. Infection. Death due to asphyxia from detachment of the placenta. Key Concepts of Nursing management © Teach perineal massage with lubricant, for use by first-time mothers in the last 6 weeks of Pregnancy.@ Avoid Valsalva pushing in the second stage of labor unless a clear reason exists to expedite the delivery. ¢ If an epidural is used, encourage a rest period of 1-2 hours after complete cervical dilatation prior to the commencement of any pushing. @ Encourage upright or lateral positions for giving birth; help the woman identify and assume a position that is most comfortable for her at the time. # Avoid episiotomy unless a compelling indication (such as severe fetal jeopardy) exists. © Control the expulsion of the baby at birth by using “hands on” with crowning and by delivering, the baby’s head slowly and between contractions. @ Use the “Fleming method” of suturing. Leave the subcuticular layer unsutured if itis not gaping, and if itis, use a continuous stitch, keeping below the skin. # Use Dexon or Vicryl as the preferred suture materials for repair of any childbirth lacerations. Provide oral ibuprofen for relief of perineal pain after birth in Women with episiotomies or third- or fourth-degree lacerations. © And rectal ibuprofen for relief of perineal pain after birth in women who have episiotomies or second-degree perineal lacerations. © Encourage the women to do pelvic floor exercise Nursing_diagnosis © Altered comfort related to repair of injury © Potential fluid volume deficit related to blood loss Potential for infection related to surgical repair of injury Anxiety related to injury Knowledge deficit regarding self care and nutritional needs Nursing management: «Provide comfortable position, observe general condition and vitals. Maintain adequate atmosphere for rest and sleep © Establish rapport , provide psychological support and information about treatment protocol The perineal wound is kept clean and sterile by using antiseptic solution after each micturition or defecation. * Inthe complete perineal tear: © Intravenous fluid for 48 hours, clear fluids for the next 24 hours, soft, low residue diet for an additional 48 hours, regular diet after that, laxatives are not used in the first 4-5 days, but stool softeners are allowed. 0000 © Encourage and assist the women for early ambulation «Assist the mother in breast feedingeee eee ‘Advise the mother about maintenance of personal hygiene Advise to take low residual diet consisting of milk, bread, biscuit, egg, and fish. Prophylactic broad-spectrum antibiotics is given because the development of infection will pose a high risk of anal incontinence and fistula formation. Metronidazole to cover the possible anaerobic contamination from fecal matter. Assessment of uterus per abdomen and measure its size after 1* post partum day Encourage the mother to evacuate her bladder frequently. Advise the mother about postnatal exercises and their importance Motivate to adopt small family norm, provide information about contraceptive methods Follow up regularlyReferences: From books 1. Dickason, Schult,Silverman Maternal infant Nursing care,C .V. Mosby : P. 221-244 2. Parulekar V . Shashank Text Book for midwives VORA medical publications: P 509- 538 3. Dutta’s D.C Text Book of Obstetrics New Central Book Agency (P) Ltd: P- 4222-431 From net : 1. http:/Avww.emedicinehealth.com/pregnancy_bleeding/pageS 2. http:/Avww.gfmer.ch/Obstetrics_simplified/matemnal_obstetri