obstetrics studies from first moscow state medical university

1. BIRTH CANAL TRAUMA.
UTERUS RUPTURE
BY :
MUHAMMAD KHADHARI BIN KAMARUDDIN
GROUP 94

2. Definition of birth canal:
- The passageway through which the fetus
is expelled during parturition, leading
from the uterus through cervix, vagina
and vulva.
- Vagina, vulva and perineum are often
injured during expulsion stage of labor
WHAT IS BIRTH CANAL?

3. Bones
-pelvic minor
STRUCTURES OF BIRTH CANAL
Soft tissue
- Uterus, vagina and
external reproductive organs

5. The types of trauma in birth canal is
classified based on localisation :
- Cervix
- Vagina
- Perineum
BIRTH CANAL TRAUMA

6. CERVICAL LACERATIONS
- Cervical tears are most presented in the lateral cervical
sides
- Rupture of the cervix is characterized by persistent
bleeding from a contracted firm uterus
There are 3 degrees of cervical lacerations:
1. First degree lacerations
- Length of cervical rupture not over 2cm
2. Second degree lacerations
- Length of rupture >2cm but does not extend to vaginal
fornices
3. Third degree lacerations
- Ruptured area extends to the vaginal fornices
- If extends to vaginal fornices : very dangerous

7. - Rigidity of cervix
- Abnormal structure due to scarring from
previous surgery
- Rapid delivery of head in breech
presentation
CAUSES OF CERVICAL
LACERATIONS

8. TREATMENT OF CERVICAL
LACERATIONS
• Deep cervical tears should be repaired immediately
• Treatment varies with the extent of the lesion.
When the laceration is limited to the cervix – or even when it
extends somewhat into vaginal fornix
• We can view the cervical
tears at the vulva by applies
firm downward pressure on
the uterus while the operator
exerts traction on the lips
of the cervix with
fenestrated ovum or sponge
forceps

9. VAGINAL LACERATIONS
- Usually longitudinal
- Lacerations frequently extend deep into the
underlying tissues and may give rise to
significant hemorrhage
- Causes of vaginal lacerations can be
traumatic or spontaneous:
- The repair of vaginal tears is in placing of interrupted
catgut suture in the edges of the wound
TRAUMATIC SPONTANEOUS
Injuries during forceps
delivery
Fetal malpresentation (Esp
fetal head extension)
Insufficient distensibility of
vaginal wall
Large fetal head

10. - Classification of perineal lacerations:
- 1. First degree
- 2. Second degree
- 3. Third degree
- 4. Fourth degree
PERINEUM LACERATIONS
Delivery may lead to overstretching of the vagina, causing tears
in the perineum, between the vagina and rectum.

11. - The least severe
- Superficial tear that involve perineal
skin ,underlying tissue and superficial
muscle ( musculus constrictor ani)
FIRST DEGREE LACERATION

12. SECOND DEGREE LACERATION
- Extends to more deep muscle layer of
pelvic diaphragm , muscle levator ani

13. THIRD DEGREE LACERATION
- Lacerations extend farther to involve perineal
body and circular muscle sphincter ani

14. - The most severe type
- The laceration extends through the rectum’s
mucosa to expose anorectal lumen
FOURTH DEGREE LACERATION

15. Factors predisposing
to Laceration of Perineum
Factors which increase risk of third- and
fourth-degree lacerations:
1. Nulliparity
2. Prolong second-stage of labor
3. Persistent occiput posterior position
4. Mid or low forceps
5. Asian race (height)
6. Giant baby / macrosomia
7. Rigidity of perineal muscle
8. Epidural/peridural anesthesia

16. EPISIOTOMY
- Also known as perineotomy
- Incision of perineum and posterior vaginal
wall during second stage of labor
- Purposes of episiotomy :
- Easier to repair the laceration
- postoperative pain is less and healing
improved with an episiotomy compared
with a tear
- prevent pelvic floor complications
(vaginal wall support defects and
incontinence)

17. -
Indications of Episiotomy
- When see threatening signs of perineal
laceration
- The baby is very large ( need to deliver
quickly to avoid any resistance)
- When the perineal muscles are excessively
rigid

18. -
Types of Episiotomy
Median or Midline episiotomy Mediolateral episiotomy
Incision is made at midline,
from center of the
fourchette and extends on
posterior side along
midline for 2.5 cm
begin in the midline but be
directed laterally and
downward away from the
rectum, either to left or right
about 2.5cm from the anus
(midpoint between anus and
ischial tuberosity)
Better because it wouldn’t
extend until anus

19. -
Midline episiotomy being made. Two fingers are
insinuated between the perineum and fetal head,
and the episiotomy is then cut vertically downward

20. -
Episiotomy Repair
The repair of perineal tears is same as episiotomy incisions
1. Repair of first-degree lacerations
- start from the upper angle of the wound
- The vaginal mucosa is closed by interrupted catgut
suture. And then the perineal skin are sutured
- The sutured wound should be treated with an iodine tincture
2. Repair of second-degree lacerations
- The upper angle of the wound is first sutured
- Then the lacerated perineal muscles are repaired by several
buried catgut sutures
- After that, the same technique as in the first-degree
lacerations

21. Episiotomy Repair
3. Repair of Third-degree lacerations
- rectal mucosa has been repaired with interrupted, fine
chronic catgut sutures
- The torn ends of the sphincter ani are next approximated
with two or three interrupted chromic catgut sutures
- The wound is then repaired, as in a second degree
laceration

22. Uterus Rupture
- One of the most dangerous labor complication
- A spontaneous or traumatic rupture of the uterus
with extrusion of the fetus or fetal parts into the
peritoneal cavity
- By definition, it is associated with the following:
- Clinically significant uterine bleeding
- Fetal distress
- Protrusion or expulsion of the fetus and/or
placenta into the abdominal cavity
- Need for prompt cesarean delivery
- Uterine repair or hysterectomy

23. Classification of Uterus Rupture
1. Classification by Pathogenesis
Spontaneous
- Histochemical etiology of
uterine rupture
- occurs without any function of
uterus
- Example:
(i) Anatomy anomaly
(ii) Dystrophy diseases
(connective tissue autoimmune
disease, Inflammatory disease of
uterus)
Voluntary
- result of hyperfunction of uterus
- Example:
(i) Disproportion between sizes
of presenting part and
maternal pelvis
(malpresentation)
(ii) Extra doses of uterotonic
drugs

24. Classification of Uterus Rupture
2. Classification by Layers of Uterus involved in
Rupture
Complete rupture Incomplete rupture
3. Classification by Location of Rupture
Lower segment rupture Rupture of corpus/fundus
of uterus

25. Signs of Threatened Uterine
Uterus Rupture
- Signs that occur just during the labor
- Excessive uterine activity. Uterine
contractions are very fast and painful
- Lower uterine segment is overdistended,
thinned and painful at palpation
- The margins of the cervical os becomes
edematous due to compression. The
edematous extends to the vagina and the
perineum
- Urination becomes difficult due to
compression of the bladder and urethra
between the bony pelvis and the fetal head
- Some bloody discharge maybe presented
(depends)
- Pathological contractile Bandl’s ring is
presented

26. Bandl’s ring

27. -Uterine contractions suddenly stop
-Palpation of fetus in the abdomen (outside
the uterus)
-Fetal death
-Hemorrhage then hypovolemic shock in
mother
Signs and Symptoms in the Uterine
Rupture that has happened

29. Treatments of Uterine Rupture
Whenever a threatening uterus rupture is
seen, immediate Caesarian section must be
done!

30. Managements of Uterine Rupture
- blood transfusion
- Emergency exploratory laparotomy with
cesarean delivery
- Surgical repair of uterus or removal of uterus
(hysterectomy), types of surgical treatment
depends on Type of uterine rupture :
- Extent of uterine rupture
- Degree of hemorrhage
- General condition of the mother
- Mother’s desire for future childbearing
When the tear is simple, transverse in the
lower segment, and in the absence of infection
=> Repair by suturing
When the ruptures were longitudinal on the
lateral aspects of lower and upper segments of
the uterus and the bleeding is uncontrollable
(severe) => Hysterectomy

31. THANK YOU
FOR YOUR ATTENTION
