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The incidence of tr.pph is 20% Trauma to the genital tract usually occurs following operative delivery. Blood loss from episiotomy wound Blood loss in cesarean section- 800 to 1000 ml. Trauma usually involves cervix, vagina, perineum, paraurethral region and rarely rupture of uterus. Concealed ± vulvovaginal or broad ligament hematoma
Good perinial support during second stage. Episiotomy Utero vaginal canal is to be explored after placenta is expelled and hemostatic sutures placed against offending sites.
Vulva : Lacerations of vulval skin posteriorly and paraurethral tear on inner aspect of labia minora are common sites ± should be repaired by interrupted catgut sutures after introduction of rubber catheter into bladder.
face to pubis or face delivery. outlet contraction with narrow pubic arch. previous operations.Perineum Causes : ± Overstretching due to large baby. ± Inelastic perineum as in rigid perineum in elderly primi. scar. ± Rapid stretching of the perineum due to rapid delivery of head during uterine contraction. . shoulder delivery and forceps delivery. ppt labour and delivery of aftercoming head in breech.
. lower part of vagina but perineal body remains intact. Degrees : ± First degree ± lacerations of remnants of hymen. fourchette. ± Second degree ± lacerations of post vaginal wall and perineal body excluding anal sphincter.
± Fourth degree ± involving anal sphincter complex and rectal mucosa. .± Third degree ± posterior vaginal wall and perineal body tear including anal sphincter complex without involvement of anal canal or rectum.
Identified and sutured by interrupted sutures. Levator ani aproximated infront of rectum vagina sup. In case of delay beyond 24hrs repair withheld antibiotics should be started. Fourth degree : rectal wall sutured by two layers of inverted interrupted catgut including mucosa. ± Incomplete : First degree : Continuous locked or interrupted sutures Second degree : interrupted sutures with catgut including torn ends of lev. Complete tear repaired after 3 months. anal sph.ani ± Complete : Third degree : Torn ends of ext. Management : ± Recent tear should be repaired immediately. Muscles of perineum. .
antibiotics should be given .Post op care Iv fluids for 48hrs Clear fluids for next 24hrs Soft low residue diet for 48hrs Regular diet after that Laxative not used for 4-5 days Proph.
Colporrhexis ± rupture of vault of vagina.Vagina Tears are repaired by interrupted or continuous sutures using chromic catgut number O.only vault involved. . Secondary ± with cervical tear. Primary .
± Detachment. ± Strong uterine contractions. ± Rigid cervix.Cervix Commonest cause of traumatic pph Causes : ± Iatrogenic ± attempted forceps delivery or breech extraction through incompletely dilated cervix. ± Manual dilatation of cx .
Types : ± Unilateral : Dextrorotation of uterus Lot ± Lateral ± Stellate multiple tears extending radially from ext. os ± Annular detachment .
Pelvic cellulitis 5. 2.Deep cervical tears involving major vessels. Complications : ± Early ± 1. 3.Rupture uterus due to upward extension . Diagnosis : ± Excessive bleeding immediately following delivery in presence of hard and contracted uterus.Broad ligament hematoma.Thrombophlebitis.Pelvic hematoma 4. 6.
.Cervical incompetence Treatment : ± Repair under GA.± Late ± 1.Ectropion 2.
Types ± ± 1. ± 2.Pelvic Hematoma Collection of blood anywhere in the area between pelvic peritoneum and perineal skin is called pelvic hematoma. . Supra levator hematoma. Infra levator hematoma.
Rupture of para vaginal venous plexous following instrumental delivery . ± 3.ILH Etiology ± 1.Failure to take precaution while suturing apex of tear.Improper hemostasis during repair of tears or epi wound ± 2.
severe pain on perineal region ± Rectal tenesmus Management : ± Small hematoma managed conservatively ± Large ± incised longitudinally evacuation of clotted blood bleeding points ligated gap closed in layers . Symptoms : ± Appear 12-48hrs later ± Collection of blood limited by lev. Ani above but laterally may extend to fill ischiorectal fossa ± Persistent.
Extension of cervical laceration 2.Lus rupture 3. Diagnosis : Unexplained shock with features of internal hemorrhage following delivery.Spontaneous rupture of para vaginal venous plexus.SLH Causes : 1. . Vaginal examination reveals occlusion of vaginal canal by a bulge or boggy swelling.
cervical or uterine tears may lead Clinical symptoms: ± Hypovolimia. shock ± Swelling on one side of uterus increasing over period of days may reach upto lower pole of kidney or upto diaphragm ± Uterus is felt seperately and deviated to opposite side ± Fever ilius and uni lateral leg edima ± Upper vaginal. cervical or uterine tears may lead .Broad ligament hematoma Causes : ± Upper vaginal.
.Rupture of uterus Dissolution in the continuity of uterine wall antime beyond 28 weeks of pregnancy is called rupture of the uterus.
causes Spontaneous : usually complete involves upper segment ± During pregnancy Previous damage thereby weakening of uterine walls following dnc or manual removal of placenta grand multi para Conganital malformation of uterus(bicornuate) Couvelaire uterus ± During labour : Obsturcted labour Grand multi para .
Fall or blow on abdomen. Iatrogenic : ± During pregnancy : Injudicious administration of oxytocin. ± During labour : Internal podalic version. Forcible external version under GA. Manual removal of placenta. Use of PG for induction of abortion or labour. . Application of forceps or breech extraction through incompletely dilated cervix. Distructive operation.
Scar rupture : ± During pregnancy : Weekening of scar due to implantation of placenta over scar Classical or hysterotomy scar ± During labour : Classical or hysterotomy scar .
Pathology Types : ± Complete Peritoneal coat involved usually occurs following disruption of scar in upper segment ± Incomplete Peritoneal coat not involved results from rupture of lower segment ± Rupture over previous scar is almost always located at the site of scar .
Dehiscence : ± Disruption of part of scar and not the entire length ± Fetal membranes remain intact ± Bleeding is almost nil or minimal Rupture includes ± Disruption of the entire length of scar ± Rupture of the membranes with ± Varying amount of bleeding from the margin or from its extension ± In incomplete rupture both fetus and placenta remain inside uterine cavity ± In complete rupture fetus with or without placenta escapes out of uterus .
Diagnosis During pregnancy : ± Scar rupture : Classical or hysterotomy ± dull abdominal pain over scar with slight vaginal bleeding varying degrees of tenderness on uterine palpation FHS may be irregular or absent sense of something giving way accompanied by acute abdominal pain and collapse .
slight vaginal bleeding. rapid pulse and tender uterus ± rupture usually confined to high parous women onset usually acute with acute pain abdomen with fainting attacks and may collapse. Features of shock acute tenderness on abdominal examination. if rupture is complete and absence of FHS Iatrogenic : ± Acute pain abdomen. if rupture is complete and absence of FHS . Features of shock acute tenderness on abdominal examination. palpation of superficial fetal parts. Spontaneuos : ± rupture usually confined to high parous women onset usually acute with acute pain abdomen with fainting attacks and may collapse. palpation of superficial fetal parts.
± Spontaneous obstructive rupture : Usually in multi para.one contracted uterus and other fetal ovoid. comes at quick intervals may be continuous confined to supra pubic region. There is no classical feature of LS scar rupture hence called silent rupture. absence of FHS. constant pain is changed to dull aching pain with cessation of uterine contractions P/A reveals superficial fetal parts. absence of uterine contoure. The patient is dehydrated and exhausted. Sense of something giving way. two separate swellings. . Evidence of fetal distress or FSH may be absent on P/V presenting part is found jammed in pelvis and vagina becomes dry and edematous. During Labour : ± Scar rupture : Classical or hysterotomy Lower segment scar rupture ± onset insidious. Pain becomes severe.
Patient at height of uterine contraction is suddenly seized with agonizing worsting pain followed by relief with cessation of uterine contraction ± Presence of shock. evidence of interanl hemmorage. Spontaneous non obstructive rupture: ± Usually in high parus. tenderness over uterus varying amoutn of vaginal bleeding Iatrogenic : ± Sudden deterioration of general condition of patient following instrumental delivery .
previous CS.Prophylaxis At risk mothers should have hospital delivery. hysterotomy or myomectomy b)uncorrected transverse lie c)multiparity with pendulous abdomen d)grand multi parity GA not to be given in external version Undue delay in progress of labour in multipara should be weaved with caution Judicious selection of cases with previous history of CS for vaginal delivery Avoiding forceps delivery or breech through incompletely dilated cervix . these are a)contracted pelvis.
Treatment Resuscitation Laparotomy ± Hysterectomy : Indicated in spontaneous obstructive rupture ± Repair : applicable to scar rupture where margins are clear ± Repair and steralization .
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