Prof. S. P.

Jaiswar

Professor
Dept. Of Obstetrics &
Gynaecology
 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
 Periurethral lacerations
 Periclitoral lacerations
 Vaginal lacerations
 Cervical lacerations/ cervical

tear
• 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.
 Gross perineal tear is usually due to mismanaged
2nd stage of labour.
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.
 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 .
 4thdegree perineal tear- involving the
vaginal mucosa, perineum, anal sphincter,
anal and rectal mucosa

 3rd
& 4th degree perineal tear are complete
perineal tear.
 Prevention- proper conduction of 2 nd 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.
 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 2 nd 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 3 rd

month of delivery.
 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
 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.
 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 1 st from above

downward with interrupted suture

 Then stitch the rectal muscle and para-rectal

fascia by interrupted suture

 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.

 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

 Broad spectrum antibiotics along with
metronidozol (400mg) TDS for 5-7 days
 Avoid giving enema and rectal
examination for two weeks
 Minor degree of cervical tear is during 1 st
delivery is common.
 It is commonest cause of traumatic PPH
 Left lateral cervical tear is more common
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
 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.
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
 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.
 Stitchthe 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.
 Mattress suture prevents rolling of the edges.

 If
the cervical tear is extending to the lower
segment or vault with broad ligament
haematoma needs laparotomy.
 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 see for bleeding
 Vulva injuries- vulval laceration, perineal
laceration and hematoma needs to be drained
and proper haemostatic suture should be given

 Sometime local packing requires.

 Vulval haematoma
 Paravaginal haematoma
 Broad ligament and
retroperitoneal haematoma
 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.

 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.
 Sub peritoneal and supravaginal haematomas
not repaired vaginally
 Laparotomy is advisable
 Angiographic embolisation of internal iliac

arteries may be done.

1) Perineal tears should be repaired:
a) 24 hours later
b) 48 hours later
c) 36 hours later
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
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
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
5) IIIrd degree perineal tear is involvement of :
a) Vaginal mucosa
b) Urethral mucosa
c) Levator ani muscles
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
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 overdistension
c) These are usually associated with injuries to
the levator ani muscles
d) All of the above