Genital tract traumaEpisiotomy
An episiotomy is an incision through the perineum made to enlarge the
diameter of the vulval outlet and assist childbirth.
• Fetal distress.
• Rigid perineum.
• Shoulder dystocia.
• Fetal malposition e.g. occiput posterior.
• Breech delivery.
• Instrumental delivery.
• Previous pelvic surgery.
The question of informed consent needs to be addressed during
antenatal care; when the fetal head is crowning, it is not possible to
obtain true informed consent
• An episiotomy is per for med in the second stage, usually when the
perineum is being stretched and it is deemed necessary.
• If there is not a good epidural, the perineum should be infiltrated
with local anaesthetic .
• The incision can be midline or at an angle from the posterior end
of the vulva (a mediolateral episiotomy).
• A mediolateral episiotomy is usually recommended; a midlineepisiotomy is an incision in a comparatively avascular area and results
in less bleeding, quicker he aling and less pain, however, there is an
increased risk of extension to involve the anal sphincter (third/ fourth -
• A mediolateral episiotomy should start at the posterior part of the
fourchette, move backwards and then turn medially well befo re the
border of the anal sphincter, so that any extension will miss the
ComplicationsComplications include haemorrhage, infection (prophylactic
antibiotics may be indicated if contamination is suspected), extension
to the anal sphincter (third/fourth -degree tears) and dyspareunia.
1. First -degree trauma corresponds to lacerations of the skin/vaginal
2. Second -degree tears involve perineal muscles and therefore
3. Third -degree extensions involve any part of the anal sphincter
complex (external and internal sphincters):
i Less than 50 per cent of the external anal sphincter is to rn .
ii More than 50 per cent of the external anal sphincter is torn.
iii Tear involve s the internal anal sphincter (usually there is
complete disruption of the external sphincter).
4. Fourth -degree tears involve injury to the anal sphincter complex
extending into the rectal mucosa.
An increased risk of perineal trauma is associated with:• larger infants
• prolonged labour
• instrumental delivery.
Internal anal sphincter incompetence results in insensible faecalincontinence, whereas external anal sphincter incompetence causes
Perineal repair (عﻼطﻸﻟ )• Ensure adequate analgesia. This may be achieved by topping up
an epidural or by infiltration with local anaesthetic.
• Check the extent of cuts and lacerations.
• First repair the vaginal mucosa using rapidly absorbed suture
material on a large, round body ne edle. Start above the apex of the cut
or tear (as severed vessels retract slightly) and use a continuous stitch
to close the vaginal mucosa.
• Interrupted sutures are then placed to close the muscle layer.
• Closure of the skin follows. Interrupted sutures can be used;
however, a continuous subcuticular stitch produces more comfortable
• Perform a gentle vaginal examination to check for any missed
tears or inappropriate apposition of anatomy. Remove the pad that was
placed at the top of the vagina and ch eck that no swabs have been leftin the vagina.
• Finally, put a finger in the rectum to check that no sutures have passed
through into the rectal mucosa and that the sphincter is intact. If sutures
are felt in the rectum they must be removed and replaced.
Repair of third - and fourth -degree trauma should be performed or
direcdy supervised by a trained practitioner. There must be adequate
analgesia. In practice, this means either a regional or general
anaesthetic, as local infiltration does not allow relaxation of the
sphincter enough to allow a satisfactory repair. The lighting must be
adequate and an assistant is usually needed.
Repair of the rectal mucosa should be performed first. The to rn
external sphincter is then repaired. It is important to ensure that the
muscle is correctly approximated with long -acting sutures so that the
muscle is given adequate time to heal. Some surgeons opt for an end -
to -end repair, while others use an overlap technique; The remainder of
the perineal repair is as f or second -degree trauma.
Lactulose and a bulk agent are recommended for 5 — 10 days. It is
common sense to give a broad -spectrum antibiotic that will cover
possible anaerobic contamination, such as metronidazole . Adequate
oral analgesia should also be presc ribed.
At 6 -12 months, a full evaluation of the degree of symptoms should
take place. Symptomatic women should be offered investigation
including endoanal ultrasound and manometry
Further deliveries should be by C \S.
Uterine RuptureUterine rupture implies complete separation of the uterine
musculature through all of its layers, ultimately with all or a part of the
fetus being extruded from the uterine cavity. The overall incidence is
Uterine rupture may be spontaneous, traumatic, or as sociated with a
prior uterine scar, and it may oc cur during or before labor or at the time
of delivery. A prior uterine scar is associated with 40% of cases. With
a prior lower -segment transverse incision, the risk for rupture is less
than 1%, whereas the risk with a high vertical (classical) scar is 4% to
DIAGNOSIS AND MANAGEMENTThe signs and symptoms of uterine rupture are highly variable.
Typically, rupture is characterized by the sud den onset of intense
abdominal pain and some vaginal bleeding. Impending rupture may be
heralded by hy perventilation, restlessness, agitation, and tachycardia.
After the rupture has occurred, the patient may be free of pain
momentarily and then complain of diffuse pain thereafter. The most
consistent clinical findin g is an ab normal fetal heart rate pattern. The
patient may or may not have vaginal bleeding, and if it occurs, it can
from spotting to severe hemorrhage. The presenting part may be found
to have retracted on pelvic exami nation, and fetal parts may be more
easily palpated abdominally. Abnormal contouring of the abdomen
may be seen. Fetal distress develops commonly, and fe tal death or long -term neurologic sequelae may occur in 10% of cases.
A high index of suspicion is required, and immediate laparot omy
is essential. In most cases, total abdominal hysterectomy is the
treatment of choice, although de bridement of the rupture site and
primary closure may be considered in women of low parity who desire
MATERNAL -FETAL RISKDelay in managem ent places both mother and child at significant risk.
The major risk to the mother is hem orrhage and shock. Although the
associated mater nal mortality rate is now less than 1%, if the mother is
left untreated, she will almost certainly die. For the fetus , rapid
intervention will minimize morbidity and mortality. The associated
fetal mortality rate is still about 30%.