Maternal Obstetric InjuriesMaternal Obstetric Injuries

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If was not supposed to be hard work, it would not have been called LABOR.

Anonymous

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““PovertyPoverty is lot like is lot like childbirthchildbirth – you know it is – you know it is going to hurt before it happens, but you’ll never going to hurt before it happens, but you’ll never know how much until you know how much until you experienceexperience it” it”

Joanne Kathleen Joanne Kathleen Rowling Rowling

Birthing is one of the most wonderful & Birthing is one of the most wonderful & treasured moments in the life of a woman.treasured moments in the life of a woman.

But birthing is not without complicationsBut birthing is not without complications

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A day in a labour Room……A day in a labour Room……

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Prevention is betterPrevention is better

Experienced providerExperienced provider

Assessment of maternal pelvisAssessment of maternal pelvis

Selection of procedureSelection of procedure

Adequate anesthesiaAdequate anesthesia

Fulfillment of prerequisites Fulfillment of prerequisites

Willingness to abandon attemptWillingness to abandon attempt

Ability to perform C-sectionAbility to perform C-section

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Operative delivery Operative delivery

VaginalVaginal

EpisotomyEpisotomy

Forceps and ventoseForceps and ventose

Destructive operationDestructive operation

AbdominalAbdominal

C SC S

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Operative DeliveryOperative Delivery

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Center of the cup Center of the cup over the sagittal over the sagittal suture, about 2 suture, about 2 cm in front of the cm in front of the posterior fontanel. posterior fontanel.

Some tips……

Soft cupSoft cupMetal cup1111

Release suction between Pushes 2 pop-offs, abandon procedure

Vacuum ProcedureVacuum Procedure

Check for vaginal or vulvar Check for vaginal or vulvar tissues trap between the cup tissues trap between the cup and fetal surface. and fetal surface.

Gradual Vs Rapid Application Gradual Vs Rapid Application of Vacuum Pressureof Vacuum Pressure

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TractionTraction

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Problems arising from Problems arising from EpisiotomyEpisiotomy

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PainPain

EdemaEdema

BleedingBleeding

InfectionInfection

Defects in woundDefects in wound

Before Crowning After Before Crowning After

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Intrauterine manipulation Intrauterine manipulation

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Manual removal of the placentaManual removal of the placenta

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Internal podalic versionInternal podalic version

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Breech extraxtionBreech extraxtion

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Maternal Obstetric Maternal Obstetric InjuriesInjuries

Lacerations of the Lower Genital Tract

HEMATOMAS

UTERINE RUPTURE

A A uterine rupture uterine rupture is a frank opening between the is a frank opening between the uterine cavity and the abdominal cavity uterine cavity and the abdominal cavity (Complete).(Complete).

RUPTUR UTERUS

A A uterine dehiscence uterine dehiscence is a “window” covered by the is a “window” covered by the visceral peritoneum visceral peritoneum (incomplete)(incomplete). .

Rupture can occur: at the site of a previous cesarean Rupture can occur: at the site of a previous cesarean delivery or other surgical procedure involving the delivery or other surgical procedure involving the uterine wall,uterine wall,

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Causes of spontaneous rupture uterus

Rupture Of Previous CS Scar Rupture Of Previous CS Scar

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placenta accreta or perforating mole Obstructed labor. placenta accreta or perforating mole Obstructed labor.

from congenital malformation (small uterine horn), from congenital malformation (small uterine horn),

For early detection and intervention:For early detection and intervention:

Vaginal spotting (minimal bleeding)Vaginal spotting (minimal bleeding)

acute abdominal pain acute abdominal pain

cessation of uterine contractions cessation of uterine contractions

maternal hemodynamic changes,maternal hemodynamic changes,

non-reassuring fetal heart patterns,non-reassuring fetal heart patterns,loss of fetal station. loss of fetal station.

Surgical repair depends onSurgical repair depends on

the extent and site of rupture,the extent and site of rupture,

the patient’s current clinical condition, the patient’s current clinical condition,

her desire for future childbearingher desire for future childbearing

Rupture of a previous cesarean delivery scar Rupture of a previous cesarean delivery scar often can be managed by revision of the edges often can be managed by revision of the edges of the prior incision, followed by primary closureof the prior incision, followed by primary closure

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Regardless of the patient’s wishes for the Regardless of the patient’s wishes for the avoidance of hysterectomy, this procedure may be avoidance of hysterectomy, this procedure may be necessary in a life-threatening situation.necessary in a life-threatening situation.

Consideration must be given to the neighboring Consideration must be given to the neighboring structures, such as the broad ligament, structures, such as the broad ligament, parametrial vessels, ureter, and bladdeparametrial vessels, ureter, and bladder.r.

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If a woman in the battle to reproduce her race has ruptured her uterus ,she should be invalidated from the service, for it is not with cripples that an army takes the field” whatever ‼‼‼‼‼‼‼‼

instrumented delivery, instrumented delivery,

manipulative delivery such as a breech extraction, manipulative delivery such as a breech extraction,

precipitous labor, precipitous labor,

Malpresention Malpresention , ,

Macrosomia, Macrosomia,

Cervical scar.Cervical scar.

Lacerations of the Lower Genital Tract

Predisposing factorsPredisposing factors

Lacerations to the Lacerations to the cervixcervix that are extensive and that are extensive and those that are actively bleeding usually require those that are actively bleeding usually require repair. repair.

Types: Types: 1- Unilateral1- Unilateral 2- Bilateral. 2- Bilateral. 3- Stellate 3- Stellate 4- Annular detachment. 4- Annular detachment.

May lead toMay lead to

Rupture uterus due to upward extension. Rupture uterus due to upward extension.

Cervical incompetence leading to future Cervical incompetence leading to future recurrent abortion or preterm labor. recurrent abortion or preterm labor.

Perineal LacerationsPerineal Lacerations

(first-degree through fourth-degree vaginal (first-degree through fourth-degree vaginal and periurethral lacerations) may require and periurethral lacerations) may require repair when bleeding is significant.repair when bleeding is significant.

Lacerations of the vaginavagina and perineumperineum

Incomplete perineal tear repair

repair

Complete perineal tear

Periurethral lacerations Periurethral lacerations may be associated with may be associated with sufficient sufficient edemaedema to occlude the urethra, to occlude the urethra, causing urinary retention; causing urinary retention;

a Foley catheter for 12 to 24 hours usually a Foley catheter for 12 to 24 hours usually alleviates this problem.alleviates this problem.

HEMATOMASHEMATOMAS

HematomasHematomas can occur can occur anywhereanywhere from the vulva from the vulva to the upper vagina as a result of delivery to the upper vagina as a result of delivery trauma. trauma.

Hematomas may also develop at the site of Hematomas may also develop at the site of episiotomy or perineal laceration.episiotomy or perineal laceration.

Infra-levatorInfra-levator

Broad ligamentary

Observation to limit haematomasObservation to limit haematomas

1. Ice packs1. Ice packs

2. Pressure dressings2. Pressure dressings

3. Appropriate analgesia3. Appropriate analgesia

ManagmentManagmentManagmentManagment

Need for surgical interventionsNeed for surgical interventions

1. Haematomas >5cm in diameter1. Haematomas >5cm in diameter

2. Rapidly expanding2. Rapidly expanding

If the hematoma is at the site of episiotomy, the sutures should be If the hematoma is at the site of episiotomy, the sutures should be removed and a search made for the actual bleeding site, which is then removed and a search made for the actual bleeding site, which is then ligated. ligated.

DrainsDrains and and vaginal packs vaginal packs are often used to prevent are often used to prevent reaccumulation of blood. reaccumulation of blood.

Large amounts of blood can dissect and Large amounts of blood can dissect and accumulate along tissue planes, especially accumulate along tissue planes, especially into the into the ischiorectal fossa. ischiorectal fossa.

Careful Careful monitoringmonitoring of hemodynamic status is of hemodynamic status is important in identifying those with occult bleeding.important in identifying those with occult bleeding.

Large increasing Large increasing broad ligamentary broad ligamentary hematomas require lhematomas require laparotomy. aparotomy.

casecase

32-years-old comes to DR in labor (G4P2+1). 32-years-old comes to DR in labor (G4P2+1). She gives history of a first vaginal delivery at She gives history of a first vaginal delivery at home, then spontaneous abortion but the home, then spontaneous abortion but the last labor was CS at a public hospital 2 years last labor was CS at a public hospital 2 years ago due to fetal distress. On examination: BP ago due to fetal distress. On examination: BP 115/70, pulse 84, 36.9 temperature, fundus at 115/70, pulse 84, 36.9 temperature, fundus at xiphisternum, FHR: 148, tender lower xiphisternum, FHR: 148, tender lower abdomen in between pains, the cervix is 5 abdomen in between pains, the cervix is 5 cm and 70% effaced, she suffers persistent cm and 70% effaced, she suffers persistent pain in the lower abdomenpain in the lower abdomen

Choose the best route of delivery, and why? Choose the best route of delivery, and why? 1.1.Allow vaginal delivery.Allow vaginal delivery. 2. 2.CS CS (repeat).(repeat).3.3.Ventouse (assist).Ventouse (assist). 4.4.Pitocin Pitocin drip (augment).drip (augment).……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………What is the main risk if you allow trial of vaginal What is the main risk if you allow trial of vaginal delivery? delivery? …………………………………………………………………………………………………………………………………………………………………………………………………………Mention four clinical features of the risk that may Mention four clinical features of the risk that may occur? occur? ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Signs of uterine ruptureSigns of uterine rupture

severe, localized pain severe, localized pain

abnormalities of the fetal heart rateabnormalities of the fetal heart rate

vaginal bleedingvaginal bleeding

the vaginal examination may show that the vaginal examination may show that the baby is not as low in the birth canal as the baby is not as low in the birth canal as he had been earlier. he had been earlier.