TASHKENT MEDICAL ACADEMY
DEPARTMENT OF OBSTETRICS AND
GINECOLOGY
BIRTH TRAUMA
MOTHER
Lector prof.,doctor of medicine Babadjanova G.S
TASHKENT-2013
Purpose:
To make out the questions of diagnostics and new methods of
treatment,profilactics.
Object:
To give the new classification
To say theories of etiology and patogenesis
Clinics of difference
Methods of treatment
Bases of profilactic
Birth trauma MOTHER
The birth canal of the mother during childbirth under considerable tension, so that may be
damaged. Most of these injuries can be worn in the form of superficial cracks and scratches that
do not give any symptoms and self-heal in the first days postpartum, while remaining
undetected. Sometimes the damage to the soft birth canal mother arising tensile fabric or as a
result of surgical interventions, are so significant that a cause of serious complications, the
consequences of which are detected at the time of delivery and the postpartum period, which are
dangerous to the woman's life and in some cases lead to a prolonged disability and disability.
Distinguish breaks the body of the uterus, cervix, vagina, vulva, perineum, hematoma vulva and
vagina, acute inversion of the uterus, tensile and tear of joints pelvis, urinary and intestinalgenital fistula.
Uterine rupture
Rupture of the uterus is called a violation of the integrity of its walls. Uterine rupture can occur
during pregnancy and childbirth, and is a severe manifestation of obstetric injuries. Its frequency,
according to various authors, ranging from 0.015% to 0.1% of all births. Based on the literature
in the last decade has changed the structure of uterine rupture. Reduce the frequency of breaks
due to mechanical causes (malposition, clinically narrow pelvis, etc.), violent explosions, as a
consequence of gross and negligent obstetric interventions. Often rupture occur on the
background of aggravated obstetric history, persistent primary weakness of labor or after
undergoing surgery on the uterus, which is 17 to 60% of all uterine ruptures. To increase the
number of women with a uterine scar does not only increase the cesarean section rate, but does
not reduce the number of abortions, in which there is often a complete or partial uterine
perforation, sometimes unrecognized, and inflammatory processes. In addition, the number of
conservative and cosmetic surgery on the uterus with uterine cancer in younger women, and the
number of other intrauterine interventions and operations. According to the literature, the scar on
the uterus have 4-8% of pregnant women and mothers, and each C-section 3.5 is repeated. Due
to the deficiency of a uterine scar operate routinely 40-50% of pregnant women, but only reoperate with 55-85% of women with a uterine scar. Major trauma, shock, massive bleeding,
infection joining require support not only qualified surgical assistance and targeted resuscitation
and long-term, intensive care. Therefore salvation pregnant or mothers is not always possible.
Mortality in uterine rupture now reaches 3-4%. Involvement in the gap adjacent to the uterus of a
burden the fate of patients. The outcome of the disease affect the delay of surgical care,
antishock activities, including transfusion of blood and blood substitutes. Especially dangerous
rupture that occurred at home. The cause of death of women in the 66-90% are shock and
anemia, at least - septic complications.
Uterine rupture during pregnancy and childbirth is a severe manifestation of obstetric injuries. Its
frequency costavlyaet 0,015-0,1% of all births. High mortality rates for uterine rupture - 12,818,6%. This is due to a major trauma, massive blood loss, shock, septic complications requiring
surgical intervention is always qualified, targeted resuscitation and prolonged intensive care.
Classification of uterine rupture, developed L.S.Persianinovym in 1964, now updated and
modified MA Repina taking into account features of modern obstetrics.
1. In pathogenesis.
Spontaneous rupture of the uterus: 1) the morphological changes of the myometrium, and 2) the
mechanical obstruction of fetal birth, and 3) a combination of morphological changes of the
myometrium and the birth of mechanical obstruction of the fetus.
Violent rupture of the uterus: 1) pure (at rodorazreshayuschih vaginal surgery, with external
injury), 2) mixed (with various combinations of violent factor, the morphological changes of the
myometrium, mechanical obstruction of birth). 2. The clinical course. The risk of uterine rupture.
Threatening uterine rupture. Accomplished uterine rupture. 3. By the nature of the damage. A
partial rupture of the uterus (not penetrating into the abdominal cavity).
Complete rupture of the uterus (penetrating into the abdominal cavity). 4. Localization.
The gap in the lower uterine segment: 1) break the front wall, and 2) the lateral gap, 3) break the
back wall, and 4) separation of the uterus from the vaginal vault. The gap in the body of the
uterus: 1) break the front wall, 2) break the back wall. The gap in the bottom of the uterus.
The practical significance of the classification set out dictates the need for with the risk of
uterine rupture. Shape it:
- Pregnant women with a uterine scar after prior cesarean delivery, conservative myomectomy,
uterine perforation during the abortion;
- Pregnant women with a history of obstetric history (multipara, who had several abortions
complicated course of post-abortion period);
- Pregnant women and mothers, threatened the clinical discrepancy between the head of the fetus
and the mother's pelvis (large fruit, narrow pelvis, incorrect insertion of the fetal head, fetal
hydrocephalus);
- Pregnant women with multiple pregnancy, high-water, the transverse position of the fetus;
- Women with abnormal labor and the abuse of the use rodostimuliruyuschih therapy.
The special features of uterine rupture at the present stage is the reduction of the frequency of
spontaneous uterine rupture due to mechanical causes. Rare are enforced breaks (rough injury,
illiterate conduct of obstetric interventions, inappropriate use rodostimuliruyuschih funds).
However, the role of the adult uterine ruptures caused by cicatricial changes its walls. This is
associated with an increase in the frequency of cesarean section to 9-10% in Russia and 20%
abroad, a large number of abortions, often complicated by perforation of the uterus,
inflammation of the uterus, as well as the increasing number of conservative and plastic surgery
with uterine young women.
Etiology and pathogenesis of uterine rupture
There are two theories to explain the development of this obstetric pathology: mechanical and
gistopaticheskaya. Now it is proved that these two factors are relevant in the pathogenesis of
rupture. Structural changes in the muscle of the uterus can be seen as the cause of that predispose
to injury of the uterus, and mechanical obstacles - how to identify the gap factor. In 1875
Bundle advanced mechanical theory of uterine rupture. According to this theory, uterine rupture
is a consequence of a strong stretching of the lower uterine segment in relation to the size
mismatch of the presenting part of the fetus to the mother's pelvis. The head of the fetus violates
the cervix, preventing its displacement up. After the outpouring of water during the growing
labor fetus moves distended lower segment of the uterus. In going beyond the stretch fabrics or
with little intervention hyperinflate rupture of the uterus. The clinical picture of imbalance
between the fetus and the mother's pelvis can occur when an anatomical narrowing of the pelvis,
the transverse position of the fetus, the fetal head extensor previa, especially at the front form,
the inserted asinkliticheskih fetal head, high, standing straight sagittal suture, hydrocephalus,
large fruit, prolonged pregnancy, when the head fetus is not capable of configuration, tumors in
the pelvic area, the restrictions of the different departments of scar soft birth canal, abnormal
position of the uterus after surgery, retaining its position, exostosis, cervical dystocia. Clinical
presentation of uterine rupture on Bundle - is a violent labor, which manifests itself as a threat,
the beginning and accomplished break. At the beginning of this century, NC Ivanov, and then Y.
Verbov, studying the structure of the uterus after the break, put forward another theory.
According to this theory are the cause of the break deep lesions in the muscles of the uterus
inflammatory and degenerative, leading to functional disability body, which manifests itself in
the form of weakness and incoordination of labor in some cases and leads to the rupture of the
uterus in other cases. Consequently, the main clinical manifestation of these breaks will not be
violent, but weak or diskoordination labor. Increasingly, such breaks occur in multiparous and
multiparous women. Causes pathological changes in the myometrium may be uterine scars after
surgery (conservative myomectomy, cesarean section, excision tube angle for ectopic pregnancy,
uterine damage induced abortions), infantilism and genital abnormalities, inflammatory diseases
of the uterus and appendages, adenomyosis, heavy, Delayed delivery, parity births (birth to 5),
polyhydramnios, multiple pregnancy, placenta previa, and increment, destroying molar and
chorionepithelioma. The possibility of uterine rupture increases with the application against this
background of operational methods of delivery. However, a healthy uterus can become defective,
if not carefully maintain labor, hard to encourage generic activities. It is now believed that in the
etiopathogenesis of uterine rupture are present both mechanisms, ie breaks occur at the same
time the existence gistopatic changes in its wall, and any obstacle to expulsion. With more
severe restructuring uterine wall even slight mechanical action can lead to rupture of the latter.
According to M. Repina now have a place in the gistopatic spontaneous uterine rupture is rare
pure trauma, fractures of the uterus are not. Unequivocally determine that the cause of uterine
rupture is not always possible, as there is always a set of adverse factors.
Structural changes of the uterus get off regarded as a predisposing factor
a mechanical barrier - as a factor detected. Of the relationship of these factors, the prevalence of
an independent clinic of uterine rupture.
On the theory of bundles, uterine rupture is a consequence of its lower segment overdistension
associated with the presence of the presence of obstructed fetal head (narrowing of the pelvis, a
large fetus, hydrocephalus, abnormal insertion of the fetal head, malposition, cicatricial changes
in the cervix or vagina, exostosis , fixed in the pelvis, or ovarian tumors of the uterus).
Gistopatic character breaks due to deficiency of the myometrium with a uterine scar, infantilism,
developmental defects, injury myometrium with abortion at metroendometritah.
In recent years, produce new factors, called "biochemical trauma and cancer." This condition
occurs when prolonged labor, diskoordination labor, when the violation of energy metabolism,
the accumulation of oxidized compounds muscle becomes flabby and tears easily.
Clinic rupture overestimate the cause that leads to rupture, stage, location, nature of the damage.
The rate and severity of hemorrhagic shock (the main cause of death of patients) influences
background, which came uterine rupture: concomitant chronic parenchymal organs, toxemia of
pregnancy, the depletion of physical and spiritual strength mothers, joining infection.
CLINIC rupture
The clinical picture of uterine rupture is very diverse, which is explained by a number of factors
affecting it. The clinical picture depends on the prevalence of mechanical or gistopatic causes
uterine rupture in case of a combination, stage of the process (threatening, begin, commit),
localization gap (the body, the lower segment, the bottom), the nature of injury (complete,
incomplete). When an accomplished break clinic depends on penetrating a gap in the abdominal
cavity of the uterus or not, from a full or partial release of the fetus in the parametrial space or
peritoneal cavity, the caliber of the damaged vessels, the magnitude and speed of bleeding. The
speed and severity of hemorrhagic shock greatly depend on the background on which the
accident occurred. Concomitant diseases of the cardiovascular system, parenchymal organs,
gestosis, physical and mental exhaustion of pregnancy and childbirth, joining infections
contribute to the rapid development of irreversible changes in the body. A large variety of
symptoms of uterine rupture during labor is difficult to systematize. The most typical clinical
picture is observed in the so-called uterine rupture by bandl, that is, if there are obstacles to the
nascent fruit (threatening, the beginning and accomplished break). Threatening rupture of the
uterus - is a state where there is no gap, no laceration of the uterus. The clinical picture of this
condition is most pronounced in a mechanical barrier to the expulsion of the fetus and a little less
in pathological changes in the uterine wall. The clinical picture is characterized by threatening
uterine rupture following symptoms: rapid labors, strong, painful contractions, not jerky. The
uterus is stretched in length, the bottom of it declined towards the middle line, round ligaments
are stretched, painful, can be asymmetrical in oblique arrangement of the contraction of the ring.
Contraction ring is set high above the vagina, often - at the navel, and obliquely, so that the
uterus takes the shape of an hourglass. The lower segment of the uterus thinned, hyperinflate,
palpation is labor - sharply painful, causing determine the presenting part is not possible. There
is swelling of the cervix due to pressing her to the wall of the pelvis, the opening of the cervix
seems full, but the edges loosely hanging down into the vagina, swelling of the cervix can spread
to the vagina and vulva. Due to pressing the urethra or bladder of the fetal head is swelling
perivecical fiber, self-urination difficult. Often, there are knee-jerk attempts at high-standing
head of the fetus, the full opening of the cervix and the absence of membranes. Restless behavior
of mothers. If time does not help, then go into a threatening rupture began uterine rupture. To
start breaking characteristic accession to the symptoms of uterine rupture threatens new
symptoms caused anguish starting endometrium. Due to the appearance of hemorrhage in the
muscle contractions of the uterus become convulsive character fights off the uterus does not
relax, there serum or bloody discharge from the vagina, in the urine - an admixture of blood. Due
to violent, spasmodic contractions fruit begins to suffer (increase or decrease in heart rate of the
fetus, increasing physical activity, with cephalic presentation - the appearance of meconium in
the waters, sometimes fetal death). Woman in labor - excited, screaming, because of the strong,
ongoing pain. Complains of weakness, dizziness, anxiety, fear of death. In cases where there is a
scar on the uterus, uterine rupture diagnosis threat makes the information about the operation, the
postoperative course. Information on this and additional studies conducted outside of pregnancy
(ultrasound, hysterosalpingography) and during pregnancy (U.S.) can pre-define the uterine scar.
On the inferiority of the scar can be thought of, if the previous cesarean delivery was done in less
than 2 years ago, in the postoperative period had a fever, abscess of abdominal wall, if there was
corporal incision on the uterus, if during the pregnancy were abdominal pain or poor blood
allocation long before birth. During labor, the insolvency of the scar on the uterus are a pain in
his field, or in the abdomen, is the continuing struggles, pain on palpation of the scar, the
definition of its thinning and / or niches. In the absence of immediate assistance rupture of the
uterus. By definition G. Genter, done uterine rupture, characterized by the onset of ominous
silence in the delivery room after hours of screaming and restless behavior of mothers. At the
time of breaking new mother feels a sharp pain in his stomach, burning, as if something snapped,
broke. Immediately terminate labor. Parturient stops screaming, becomes lethargic, depressed.
Integument pale, cold sweat appears, quickens the pulse, ie the picture of pain and hemorrhagic
shock. Uterine rupture during the incident changed the shape of the uterus and abdomen,
abdominal tension disappears, the contraction ring, voltage round uterine ligaments, there is
flatulence, pain on palpation, especially in the lower abdomen. The fruit is partially or
completely out into the abdominal cavity, it can often be palpated at the anterior abdominal wall.
Fruit itself becomes mobile and fixed earlier head moves away from the entrance to the pelvis.
Next to the fruit can be determined reduce uterus. The heartbeat of the fetus, usually disappears.
External bleeding may be scanty, as a complete break blood flows freely into the abdominal
cavity, and an incomplete fracture formed retroperitoneal hematoma, which are located to the
side of the uterus, shifting it up, can spread to the walls of the pelvis and perirenal fat. To expel
the fetus in the abdomen or in the parametrial space breaks occur uterine vessels, and bleeding
may be significant. Rarely vessels remain intact, and the bleeding will be small. The above
picture is dependent on the location, size and nature of the damage of the uterus. In the
pathogenesis of shock, in addition to bleeding, the principal role to the painful and traumatic
components. Currently dominate the clinical picture erased uterine rupture when expressed
vaguely described syndrome that is often associated with the use of anesthesia in childbirth, with
the introduction of antispasmodic drugs. Therefore, the presence of one or two symptoms, more
severe compared to other indistinct symptoms can help identify this difficult disease. Signs of
rupture include: symptoms of peritoneal irritation or independent of abdominal pain, especially
in the lower parts, bloating, nausea, vomiting, palpation abdominal wall hematoma growing near
the uterus and extends up the side wall of the pelvis, the sudden deterioration of the mothers or
puerperal, accompanied by increased heart rate, a fall in blood pressure, pale skin, weakness in
the stored consciousness, mobility, fixed before the entrance to the pelvis, the fetal head, the
sudden appearance of blood discharge after cessation of labor, lack of fetal heart, palpation of the
parts under the anterior abdominal wall. In unclear cases of suspected uterine rupture after
abdominal forceps, fetus destroid operations reference manual shows a survey of the walls of the
uterus and cervix examination by mirrors. From the above It follows that completely
asymptomatic uterine rupture does not happen. Only a careful study of history, attention to the
complaints of pregnancy and childbirth, the correct assessment of features of current delivery
possible in some cases to avoid the severe obstetric pathology.
Clinic threatening uterine rupture.
Mechanical rupture of the uterus, described bundles, called typical, and is characterized by the
following symptoms: new mother is very restless, screaming in pain, which almost does not
decrease between contractions, face hyperemic and expresses fear. Tachycardia, slightly elevated
temperature, tongue dry. Violent contractions that take character attempts. The uterus does not
relax between contractions, stretched out, the contraction ring is located at the navel or above the
uterus has an unusual hourglass shape, palpation
tense, painful in the lower divisions, round ligament sharply pointed. Part of the fruit is generally
not possible to probe. Fetal heart rate is measured or not. There is swelling of the external
genitalia as a result of infringement of the front lip of the cervix, because of inexperience, a
doctor may be regarded as incomplete disclosure. Generic tumor on fetal pronounced, and
therefore difficult to determine the nature of the insertion head.
Widespread use at the present time of anesthesia during labor and antispasmodic drugs can lead
to delayed diagnosis threatening uterine rupture, as symptoms of rupture is unclear. Therefore,
the basis for the diagnosis of uterine rupture threatens to be a sign of imbalance between the
fetus and the mother's pelvis, risk factors for failure of the uterus.
Diagnosis of uterine rupture gistopatic menacing nature in scarring of the uterus is much easier
knowing the fact the operation and condition of the scar on the basis of history. Symptoms of a
defective scar following:
- Cesarean section performed in less than 2 years before the current pregnancy;
- Postoperative course with fever;
- Suppuration of the anterior abdominal wall sutures in the postoperative period;
- Scarring from corporeal cesarean section;
- The presence of abdominal pain and poor spotting long before birth, diagnosis is facilitated by
ultrasound.
In sorts characteristic signs are: 1) pain in the scar on the uterus or in the lower abdomen,
remaining outside the scrum, 2} tenderness of uterine scar or its parts, thinning, the presence of
niches, and 3) concern mothers without adequate power struggle; 4) the ineffectiveness of labor,
and 5) the emergence of non-productive any attempts at hair placed head.
Clinical manifestations of the threat of uterine rupture with other structural changes in the walls
similar to those at break of scar. In such cases, uterine rupture is preceded by uterine inertia,
which is a reflection of the functional morphological changes in the uterus, stimulate of labor
(especially dangerous intravenous infusion of oxytocin and unjustified appointment stimulate of
labor ).
Clinic accomplished uterine rupture.
In a typical uterine rupture occurs "calm" after a stormy clinical picture: the bout suddenly
stopped, the pain subside. In the eyes of changing shape of the abdomen, the contours of the
uterus (bad form), gradually developed flatulence, stomach becomes painful, especially in the
lower divisions. A complete break of the uterus and expulsion of the fetus in the abdomen easily
palpated his part, the fruit becomes mobile, fixed head moves upward. Next to the fruit can be
probed contractions. Fetal heartbeat disappears. There are growing signs of shock and anemii
from bleeding.
In the pathogenesis of shock in uterine rupture is important blood loss, pain and traumatic
components. The bleeding may be external, internal and combined. At partial tears formed
subperitoneal hematoma, located at the side of the uterus, it displaces the air, and in the opposite
direction. In some cases, hematoma extend far up, grabbing the perirenal area. In this case, as a
painful bruise palpable tumor testovatoy consistency, with irregular contours, blending in with
the walls of the pelvis.
Increased bleeding associated with hypotonic condition of the uterus and the development of
DIC syndrome. Blood loss can be at once a very significant and lead to rapid death of patients.
Often blood loss and hemorrhagic shock is increasing slowly, since the source of bleeding are
often small caliber vessels that feed this portion of the uterus. Less often the source of bleeding
is uterine artery or its branches.
Uterine rupture can occur after childbirth, with its symptoms can be blurred. Suspected uterine
rupture help the following symptoms: bleeding during delivery of uncertain origin, signs of fetal
hypoxia, degradation of mothers immediately after birth. In this case, you should make a manual
examination of the uterus. In order to avoid uterine rupture this operation, you must also make
after plodorazrushayuschih operations combined cephalic fetus after birth in women with a
uterine scar. Clinical signs of uterine rupture accomplished by scar: 1) rapid growth occurring in
the rumen of pain and soreness, and 2) of vaginal bleeding, and 3) the accession of pain and "a
feeling of heaviness in the epigastrium, nausea, vomiting, 4) brief fainting, light paresis intestine,
indistinct symptoms of peritoneal irritation, and 5) changes in the fetal heart.
The clinical picture may not be burdened with shock and anemia in the limitation of the gap
region of the old scar and can be erased by adhesions in the scar area, while there are only slight
pain in the lower abdomen.
Treatment of uterine rupture depends on the stage of the process (threatening or commit), but
always - is the immediate laparotomy.
In the presence of a uterine scar is one tactic - immediate chrevovosechenie because you can not
reliably distinguish between the clinic and is committed threatening rupture. ECP removal of
uterine activity.
When uterine rupture mechanical genesis medical tactics varies somewhat with threatening and
committing uterine rupture. Thus, the threat of uterine rupture task of the doctor is to prevent the
occurrence of the gap, which is achieved in the following ways:
- Immediately remove uterine activity. For this purpose a ftorotanom inhalation anesthesia,
which should be deep enough (halothane overdose may cause atonic uterine bleeding);
- Term of delivery by caesarean section or abdominal plodorazrushayuschey by surgery (with a
dead fetus or doubtful of its viability) in the case of the conditions for its implementation.
Treatment of uterine rupture is accomplished in all of the following measures: 1) surgery 2)
adequate anesthesia, 3) infusion-transfusion therapy, adequate blood loss and the severity of the
patient, and 4) the correction of blood coagulation.
Surgery was performed immediately after diagnosis with endotracheal anesthesia with
mechanical ventilation. The goal of surgical treatment:
a) removal of the source of bleeding, and b) a remedy injury anatomic relationships, and c) the
elimination of the entrance gate to the introduction of infection into the abdominal cavity and
retroperitoneal space. Produced only the lower midline laparotomy, the abdominal cavity is
removed fruit last and with electric pumps blood and amniotic fluid, determine the nature of the
damage and produce hemostasis.
The volume of transactions is strictly individual and chosen according to the severity of the
patient, location of damage, the extent of damage, the presence of infection, etc. In the absence
of contraindications and appropriate conditions should strive to maintain menstrual and
reproductive function.
Minimum volume of operation, suture rupture. Can the following conditions: the absence of
signs of infection, short dry interval, the presence of fresh line break (especially on old scars),
maintaining contractility of the uterus. Pre-wound edges are refreshed.
Expansion of operations to supravaginal hysterectomy or hysterectomy is necessary in the
presence of extensive wounds with ragged edges crush, break complex progress, significant
bleeding in the uterine wall.
The maximum amount of transaction-hysterectomy - selected cases: coarse povpezhdeny lower
segment, the transition to break the neck of the uterus, uterine separation of the vaginal vault,
peritonitis. In addition to hysterectomy be vented with extensive retroperitoneal hematoma,
reaching to the perinephric area and abdomen after a thorough renovation in peritonitis.
For all operations for uterine rupture advisable to leave the abdominal cavity drainage nipple for
antibiotics.
Adequate anesthetic must be given at all stages during the transportation of the patient, during a
manual examination of the uterus in cases of suspected uterine rupture - and continue in
confirming the diagnosis of uterine rupture. When changing a combined total painkillers.
Infusion-transfusion therapy is adequate blood loss and the severity of the patient. Carrying the
correction of blood coagulation.
BASIS FOR PROVIDING EMERGENCY rupture
Approach to the Patient depends on whether uterine rupture occurred or there is the threat of it.
When symptoms of threatening uterine rupture should immediately discontinue labor and
delivery to end a surgical procedure. For removal of labor used inhalation anesthesia ftorotanom.
Anesthesia should be deep to further obstetric manipulations and operations have not led to the
progression of the gap. At the same time we must remember that anesthesia ftorotanom promotes
relaxation of the uterus in the postpartum period. Delivery should produce carefully, according to
the obstetric situation. If there are no contraindications (endometritis in labor, etc.), then the head
of the fetus, located at the entrance to the pelvis shows cesarean. When a dead fetus and the fetal
head, located in the pelvic cavity - plodorazrushayuschaya operation. Podalic, extract the fetus
pelvic end, forceps, vacuum extraction is always contraindicated, since they may lead to violent
rupture of the uterus. When started, and do, uterine rupture has always shown laparotomy, whose
goal is to eliminate the source of bleeding, restoration of the anatomy of the pelvis, preventing
the spread of infection. Along with surgical treatment prior to surgery, during surgery and after it
conducted anti-shock and bleeding by conventional methods. Thus, the treatment started and
accomplished uterine rupture include urgent and simultaneous: surgical intervention.
Adequate anesthesia. Adequate blood loss and shock, infusion-transfusion therapy. Correction of
blood coagulation. On the outcome of the operation depends on: extensive destruction of the
body, massive blood loss, the severity of hemorrhagic shock, concomitant diseases, early
diagnosis, time to surgery. Belated surgery is usually associated with the expectation of
consultants, with doubt in the diagnosis, stitching breaks soft birth canal, transporting the patient.
When started, or has taken uterine rupture produced only nizhnesredinnoy laparotomy incision.
Removed from the abdominal cavity of the fetus, afterbirth, blood, amniotic fluid, determine the
source of bleeding and possible produce hemostasis. Due to the frequent combination of
accomplished with atony uterine rupture, infection and other disorders of surgical intervention it supracervical hysterectomy or amputation of the uterus. When the operation is shown
meticulous inspection of the abdominal cavity. Suturing gaps can only be young women with no
signs of infection occurred recently, small linear tears after excision of wound in the uterus.
When started uterine rupture produce caesarean section and subsequent audit of the uterus. If not
diagnosed with uterine rupture during labor, then travaileth or die from bleeding, or in the next
few days she developed symptoms of peritonitis. The latter shows the emergency surgery laparotomy, hysterectomy with tubes, followed by drainage of the abdominal cavity, the massive
antibiotic therapy. Prevention of uterine rupture is a thorough study of the special history,
examination in the antenatal clinic and timely admission to the hospital pregnant, threatened by
birth trauma. The objective of the department is prenatal doctors correct estimate aggregate
anamnesis and objective data to develop a rational plan of sorts. In the conduct of labor in
women with a history of obstetric history against overdistension of uterine anomalies and
branches of the accelerated delivery is contraindicated.
Cervical laceration
Cervical laceration occur according to different authors have given birth to 3-60%, and at first
birth is 4 times more often than in repeated births. The causes of cervical tears are different, in
most cases there is a combination of several factors. Changes in the cervix of an inflammatory
nature, scars. Rigidity of the cervix in older first-time mothers. Excessive stretching of the cervix
with a large fetus, extensor cephalic fetal head. Quick and swift delivery. Prolonged labor with
preterm rupture of membranes. Prolonged impairment of the cervix between the head of the fetus
and the pelvis. Operational delivery - forceps, vacuum extraction of the fetus, the fetus ripped
pelvic end, manual separation and isolation of the placenta. Plodorazrushayuschie operation.
Unsustainable II stage of labor - early bearing-down activities. Cervical laceration may be
spontaneous and violent. Spontaneous cervical laceration occur without surgical intervention,
violent - in operations due to the complicated process of delivery. Cervical laceration with depth
is divided into three levels:
Grade I - cervical laceration on one or both sides with no more than 2 cm
Grade II - breaks longer than 2 cm, but not reaching the vaginal vault.
Grade III - breaks, reaching the vaginal vault and going over them. The only symptom of rupture
of the cervix is bleeding from the vagina with good narrowed considerably uterus, mostly after
the birth of the fetus and placenta. Flowing blood is scarlet. Bleeding may be small or absent. If
damaged branches of uterine artery bleeding can be massive, lead to the formation of hematomas
in the paracervical and parametrial tissue, hemorrhagic shock. For the diagnosis of cervical
laceration over childbirth regardless of parity births to inspect the cervix with help of mirrors
immediately after birth. Discovered hysterocervicorrhexis sutured immediately. It is necessary to
stop bleeding, prevent postpartum parametritis often associated with not sewn rupture of the
cervix. Nezashitye breaks can manifest itself later in a woman's life, leading to the isthmiccervical incompetence, premature birth and pregnancy, the development of inflammatory and
precancerous lesions of the cervix. However, due to the swelling, heavy bleeding, cervical tissue
stretching during childbirth breaks diagnosis is difficult. Therefore, some authors suggest to
inspect the cervix with excision of necrotic tissue and stitching breaks through 6-24-48 hours
after delivery (delayed joints). Normally, to break the neck of individual nodes impose catgut
sutures through all layers of the wall of her vagina, from the top corner of the gap towards the
outer zevu. Here, the first stitch in order to impose a slightly higher hemostasis early break. Due
to the poor conditions for healing (lochia, infection, swelling and crushing tissue) stitches in the
cervix often heal by secondary intention. Therefore offer different versions seams on the cervix
(the single-row, continuous catgut sutures, double-row, single catgut sutures), various suture
(chromic catgut, Vicryl). Maintaining normal postpartum. Special care of the cervix is not
required.
Perineal rupture
Perineal tears are one of the most frequent complications of childbirth, occurs in 7-15% of birth,
and primiparous 2-3 times more likely than multiparas. Etiology perineal diverse. Caused it to be
stiff fabric primiparous than 30 years, the scars left by the previous delivery, and high crotch,
large fruit, finesse head Bigger extensor previa, a posterior occipital previa, operative delivery
(forceps, vacuum extraction, extracting the fetus pelvic end), anatomically narrow pelvis, rapid
and accelerated labor, poor obstetric benefits (premature extension and the eruption of the fetal
head). Rupture of the perineum may start with the rear or side walls of the vagina or the rear
spikes to the transition to the crotch and back of the vagina. Perineal trauma preceded by signs
that the threat of rupture - a significant bulging crotch, her cyanosis due to venous stasis, and
then - swelling and shiny fabrics and, in violation of the arterial blood flow, pale skin. On the
skin of the perineum may crack first, and then rupture. With signs of threatening perineal to
avoid injury, or make her midsection - perineotomy or her side cut - episiotomy (medial or
lateral), since it is known that the cut wounds heal better ragged.
CLINIC
By clinical perineal tears can be divided into spontaneous and violent, that occur due to technical
errors in the delivery of benefits and rodorazreshayuschih obstetric operations. In the depth of
damage of perineal trauma is divided into three levels: I level - a violation of the integrity of the
skin and subcutaneous fat posterior commissure. II degree - broken skin of the perineum, the
subcutaneous fat and muscles of the pelvic floor, including m.levator ani, rear or side wall of the
vagina. III degree - besides the above mentioned entities are broken external sphincter of the
rectum, and sometimes the anterior wall of the rectum. Rarely the central rupture of the
perineum, causing the fruit comes through the hole, and not through the sex gap. The main
symptom is perineal bleeding. Diagnose gaps in the inspection of the perineum and vagina
immediately after the birth of the placenta.
TREATMENT
Perineal treatment - is to restore its integrity by suturing. Suture of tears right after inspection of
the cervix and vaginal walls with mirrors in a small operating room. Gaps I and II degree can
sew under local infiltration anesthesia or ishiorektalnoy 0.5-0.25% solution of novocaine, at
breaks III degree shown general anesthesia. Perineal suturing I or II begin imposing a single
catgut suture wounds to the upper corner of the vaginal wall, and then connect the separate
catgut sutures torn muscles of the pelvic floor, and then impose individual units or continuous
catgut suture breaking vagina, separate units catgut sutures to the subcutaneous adipose tissue of
the perineum and separate units silk sutures or cosmetic catgut suture to the skin of the perineum.
Postoperatively surface seams should be kept clean. Area seams wipe sterile swabs and treated
with a solution of potassium permanganate or tincture of iodine. Toilet crotch conducted after
each act of urination or defecation. On day 5 after surgery travaileth give drink saline laxative
and on day 6 after stool silk sutures removed from the skin of the perineum. At perineal III
degree first stitched the rectum wall separate interrupted sutures (thin silk, catgut, Vicryl), after a
change of tools and bandages, gloves, place the individual submersible catgut sutures on the
sphincter of the rectum, and then restore the integrity of the perineum in the same order as with
tears I-II degree. At perineal III degree of postoperative travaileth for 5 days receive a liquid diet
(broth, egg, tea, juice), and mineral oil. On day 6 after birth she is given a laxative and drink on
day 7 stitches removed. Together with the perineum often takes breaks big and small labia,
vestibule tissues that can be accompanied by bleeding, especially in the clitoris. All these breaks
should be protection of individual nodes catgut sutures. For suturing the clitoris may bleed
heavily. If the tear is located in the meatus, it should be done after stitching the introduction of
the metal catheter into the bladder.
Vaginal tears
Vaginal tears are often a continuation of perineal tears, but can occur independently. Vaginal
tears can be spontaneous and violent. First occur in women with underdeveloped short or narrow
vagina with fast delivery or clinically narrow pelvis, and usually are a continuation of breaks
other parts of the birth canal. Most severe damage vagina are violent. Violent injuries are caused
by vaginal obstetric operations (forceps, vacuum extraction of the fetus, etc.). Vaginal tears can
be located in the lower, middle and upper third of it. The lesions may be superficial or penetrate
tissue pelvis and even the abdominal cavity, causing bruising, massive bleeding, gemorragicheky
shock. Each gap vaginal wall accompanied by bleeding. Therefore, the vaginal wall should be
assessed with the help of mirrors, even with little bleeding. Suture of tears produced by separate
catgut sutures. Deep vaginal tears penetrating the okolovlagalischnuyu fiber, sew technically
very difficult, requires a good knowledge of anatomy, general anesthesia. In deep or multiple
breaks in the postoperative period to assign antibiotics and vaginal bath with disinfectant
solution. Undiagnosed vaginal injuries heal on their own, but sometimes they can also become
infected, complicating during the postpartum period. With deep ruptures in the future may be
disfiguring narrowing the vagina, requiring complex surgery.
Acute inversion of the uterus
Acute inversion of the uterus caused by inappropriate conduct successive period, the weakness
of ligaments of the uterus, in the case of atony. Inversion of the uterus may be complete or
partial. Always accompanied by the development of shock. Diagnosis is not difficult. Acute
inversion of the uterus is an immediate reduction antishock therapy and twisted uterus in place
under deep anesthesia.
Sprain and rupture of articulated PELVIS
For some pregnant women have an excessive softening of the joints of the pelvis (symphysis,
simfiziopatiya). At birth or beyond large fruit, rodorazreshayuschih begin joint operations
softened stretch pubic bones depart from each other by a considerable distance (more than 0.5
cm). When you break the symphysis pubis can be offset pubic bone, damaged urethra, clitoris,
bladder. In this stretch, and the sacroiliac joint. In the joints formed hemorrhage, later may be an
inflammatory process. Clinically, these complications cause the appearance of pain in the
symphysis pubis, sacrum, coccyx 2-3 days after birth, which increases with the breeding and
walking legs, disturbed gait. May be signs of inflammation in trauma - flushing of the skin,
swelling of the surrounding tissues. Recognize the damage the joints of the pelvis during the
inspection and palpation of the symphysis pubis and by X-ray. Treatment can be conservative
(rest, tight bandaging pelvic girdles). When you break the symphysis pubis or serious
discrepancies, pelvic bones require surgery.
Urinary and intestinal-sex Fistulas
The formation of urinary and intestinal-genital fistula after childbirth due to improper
maintenance of the past, especially in a narrow pelvis. Fistulas are not dangerous to a woman's
life, but are a serious injury and make it invalid. Fistulas are formed due to the long distances of
the fetal head in the same plane (over 2 hours), resulting in poor circulation in the surrounding
tissue with subsequent necrosis. Fistulas occur 6-7 days after birth, that is, after discharge from
the hospital. In addition, fistulas may occur during the healing coded perineal trauma secondary
intention, with injury of the bladder and bowel during laparotomy. The main clinical
manifestation of fistulas - either urine through the vagina is the act of urination, or the release of
gases and liquid feces, always accompanied by a local inflammatory reaction in the vagina.
Genitourinary fistula diagnosed by examination of the vagina and cervix using mirrors and
cystoscopy, gastro-sexual - as seen from the vagina with the help of mirrors, a digital rectal exam
and rectoscopy and barium enema. Small vaginal-rectal fistula may close themselves subject to
proper diet and hygiene. When not closed urinary and intestinal-genital fistula needed plastic
surgery, which is quite complex and can be made no earlier than 4-6 months after birth.
Ruptures of the cervix (cervical cancer).
The frequency of cervical cancer is 25% of all complications of childbirth. CC require sewing
because of this may be followed by: directly after the break - bleeding (sometimes excessive),
and long-term periods - cervicitis, spreading inflammation of the internal genitalia, education
ectropion cervical erosion and other precancerous lesions.
Etiology and pathogenesis. Cervical cancer can be spontaneous in normal spontaneous labor and
enforced by force or operative delivery in the case of incomplete disclosure of uterine os.
Risk are pregnant women and new mothers in the presence of:
1. large fruit,
2. extensor INSERTING fetal head,
3. term pregnancy,
4. wide shoulder girdle and breech presentation;
5. for rapid delivery,
6. Cervical dystocia;
7. morphological changes in the tissues of the neck in cases of prolonged pressing of the head of
the fetus at clinically narrow pelvis
8. infantilism
9. elderly primiparas
10. inflammatory processes
11. scarring after surgery on the cervix (diathermocoagulation, diatermoektsiziya,
hirurgichesakie cervical amputation, plastic surgery for fistula, the old division)
12. placenta previa.
CLASSIFICATION.
Isolated grade 3 cervical cancer on one or both sides:
Grade 1 - the gap up to 2 cm, Grade 2 - the gap is longer than 2 cm and not reaching 1 cm to the
vaginal vault, 3 degrees - the gap, reaching a set or a spectacular vault.
In form of cervical cancer in the majority of cases are linear, corresponding to the longitudinal
axis, and by the location - the side, single-or double-sided.
Clinic and diagnostics.
The main feature of cervical cancer - bleeding from the birth canal of varying intensity with a
well narrowed considerably uterus. The final diagnosis is established after inspection of the
cervix in the mirror after successive period, subject to the rules of aseptic and antiseptic without
anesthesia produced serial examination of the cervix in a clockwise direction. Inspection carried
out by alternately imposing on the edge throat hemorrhoids or bullet forceps, stretching the edges
of the throat.
TREATMENT.
Suturing is to break 1-3 degrees separate catgut sutures (catgut № 3-4), while not capturing the
cervical mucous. The first suture is applied above the top of the gap, choby ligate bleeding
vessel. Further down the seams have a distance of 1.5 - 2 cm, and poke puncture done at a
distance of 1 - 1.5 cm from the edge of the gap.
Prevention of cervical cancer is in the rational management of labor (use of antispasmodics, the
regulation of labor) and a competent operative delivery.