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. In 2nd 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.
Itis just like episiotomy repair i.e. stitch the
vaginal mucosa, subcutaneous tissue , and
skin-suture material 1 or 1-0
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.
