BIRTH INJURY.

BIRTH INJURY. Injuries related to childbirth may arise as a woman and the newborn (see. Generic neonatal injury) in the pathological course of childbirth, insufficient skilled obstetric care. By birth trauma in women include ruptures of the perineum, vulva, vagina; hematoma of the vulva and vagina; cervical fractures; uterine rupture, traumatic necrosis of the cervix; inversion of the uterus ; pelvis injury (most often a discrepancy pubic bones or fractures of the pubic symphysis), injury of the bladder and rectum, obstetric fistula, such as genitourinary.

Perineal tears during childbirth can be spontaneous (not related to obstetric intervention) and violent (depending on obstetric interventions). Factors contributing to the rupture of the perineum, are high and rigid crotch, her scarring, anatomically narrow pelvis, as well as the improper provision of manual aids in pelvic or cephalic presentation fetus, the eruption of the fetal head is bigger than usual size when the extensor (perednegolovnyh, facial) previa , a large fetal head, its increased density and lack of configuration, operational intervention delivery (forceps, extract the fetus for pelvic end), and others.

There are three degrees of perineal tear. When I degree perineal damaged posterior commissure of the labia majora and the skin of the perineum. II degree at rupture, in addition, broken superficial and deep muscles of the perineum, except for the external sphincter of the anus. When you break the III degree also violated the integrity of the external sphincter of the anus (partial rupture of III degree), and sometimes the wall of the rectum (the full III degree tear). perineal rupture diagnosis is set during the inspection of the vulva after the successive stage of labor. When I degree perineal tears in the edges of the wound is applied 2 - 3 silk suture, holding the thread at the bottom of the wound. When you break the crotch of II degree, first applied to catgut sutures damaged muscles of the perineum and its fascia, then silk sutures on the skin of the perineum and the posterior commissure of the labia majora or subcutaneous catgut suture. When you break the crotch of III degree, first sew the damaged rectum, then the external anal sphincter, and then operate in the same way as in the breaking of II degree.

Within 10-12 days postpartum women are not allowed to sit in order to avoid stress on welds region. In the first 3 - 4 days prescribed mineral oil to 1 tablespoon 3 times a day (as a purgative). Silk sutures are removed on the 5 th day. Field seams at the toilet of external genitals are left dry and powdered with powder of an antiseptic agent.

Breaks vulva. Often in conjunction with perineal ruptures occur in the area of ​​the labia minora, urethra and clitoris strongly bleeding tears. All of them (except for minor plane cracks) subject to stitching blood vessels and bleeding - chipping and dressing; anesthesia is required. When stitching damage near the urethra to prevent him bandaging it introduced metal cannula. When the clitoris ruptures seams should be applied superficially, as a puncture corpus cavernosum resulting in profuse bleeding.

vagina breaks containment divided into breaks in the upper, middle and lower third of the vagina, on the pathogenesis - on spontaneous and violent. When you break the upper third of the vagina is more common uterine separation from the vaginal vault, the clinical picture at the same time reminiscent of uterine rupture. Sometimes it breaks the upper third of the vagina accompanied by a deep lesion parameters (for example, when a rough introduction spoons forceps), bleed much and even after suturing often heal by secondary intention. Isolated ruptures the middle third of the vagina is rare, it is very dangerous for infection (extensive abscess, necrosis of the walls, etc..). Most often they are a continuation of the lower third of the vagina breaks. vaginal tears in the lower and middle thirds accompanied by bleeding, sometimes significant.

Tears of the vagina diagnosed when inspecting it with a vaginal mirrors after successive stage of labor is complete and immediately sutured. Bleeding vessels are ligated.

Prevention perineal tears, vulva and vagina is reduced to the proper management of labor, especially when teething vrezyvanii and fetal presenting part (slow elimination of the fetal head smallest size); careful implementation of obstetric interventions in compliance with all necessary rules in accordance with the delivery mechanism; timely dissection of the perineum with the threat of rupture. Reduce injuries birth canal soft tissue contributes psychoprophylactic preparing pregnant women for childbirth.

Hematoma of the vulva and vagina. Bleeding in the subcutaneous tissue of the labia or paravaginalnuyu fiber possible with fast delivery, the protracted period of the expulsion of the fetus, forceps, etc. Bruises are caused by damage to blood vessels or varices deep tissue, and the integrity of the vaginal mucosa and vulvar skin is not broken.

Clinically hematoma seen the emergence and rapid increase in tumor formation in the area of the labia, vagina, feeling of pressure or fullness, severe morbidity. Hematoma of the vulva is defined as education tugoelastichnogo purple color in the labia. vaginal hematoma diagnosed more often in vaginal examination, they sometimes protrude from the genital slit.

Treatment is usually conservative. For large hematomas shown to bed, cold to the area of ​​the external genitalia, compression band (with a hematoma of the vulva), tight tamponade of the vagina (for vaginal hematoma), inside prescribe calcium gluconate, ascorbic acid and vitamin E, with significant blood loss - Antianemic means. Large, fast growing hematoma opened, cut away and the bleeding vessels are wound open way or sew it, followed by drainage. The same should be done if there is necrosis hematoma on sites that are a gateway to infectious agents. When festering hematoma, accompanied by a rise in body temperature, increased heart rate, it must be immediate autopsy.

Prevention hematomas vulva and vagina is wearing a special brace pregnant with varicose knots vulva, correct conducting of labor and careful conduct of obstetric interventions and operations, the timely treatment of disorders of the hemostatic system and cardiovascular diseases.

Cervical Tears can be spontaneous and violent. Spontaneous fractures are more common in fast delivery, a large fetus, abnormalities of the head insertion (extensor, asinkliticheskih), prolonged labor, accompanied by prolonged compression of the soft tissues of the cervix and its rigidity inflammatory changes, surgical procedures on the cervix in the past. Small rips or tears of the cervix in the external os is almost inevitable, but they often remain undetected even if the examination of the cervix using a vaginal mirrors immediately after birth and rarely cause significant bleeding. When abnormal birth, especially for obstetric intervention, cervical fractures are far more common, often accompanied by considerable bleeding and other complications.

There are three degrees of cervical tears: I degree - a gap of up to 2 cm; Grade II - tear length of more than 2 cm but not reaching the vaginal vault; III stepen- gap, reaching the vaginal vault or rolling on the vault. cervical breaks all three degrees accompanied by external bleeding, which is especially pronounced at the discontinuities of III degree, often formed hematoma parameters in connection with the internal bleeding. Cervical Gaps III level sometimes move into tears uterine isthmus.

Clinically, small cervical fractures are asymptomatic, large and deep ruptures occur bleeding in the successive period the birth and early postpartum period. Before the birth of the placenta source of bleeding from the genital tract, as a rule, can not be established. If the uterus after birth the placenta is well reduced and the bleeding continues, it is necessary to eliminate bleeding from the soft birth canal ruptures (cervix or vagina).

Diagnosis is established after inspection of the cervix and vagina using vaginal mirrors (this inspection is mandatory after the birth end). For ease of inspection of the cervix impose a bullet or fenestrated forceps on the edge of her throat, and then, gradually moving them sequentially examine all the "fringe" throat. When you break the III degree of the cervix shows finger vaginal examination, during which specify whether the lower uterine segment of the gap becomes.

Even small cervical tears must be sewn up, as they are the gateway to pathogens of puerperal infection and the cause of various diseases of the cervix, including precancerous. Management of women with fractures of cervical III level, turning into the isthmus of the uterus ruptures, should be the same as when the uterus ruptures (laparotomy, clarifying the degree of discontinuity, ligation of vessels and suturing the gap).

Prevention of cervical fractures is reduced to the proper management of labor and careful implementation of obstetric interventions.

Uterine rupture - a serious and rare complication of childbirth. uterine rupture promote mechanical obstacles in childbirth, often associated with the size discrepancy fetal presenting part of the pelvis and mothers; pathological changes in the wall of the uterus (eg, scar, inflammatory changes, congenital anomalies).

The most common cause of uterine rupture is a defective scar on the uterus after cesarean section. Inferiority scar can be caused by incorrect technique sewing, small period elapsed after surgery, surgical wound healing by secondary intention, and his scar hyalinosis. thinning, as well as the location of the placenta in the rumen. An important role in the occurrence of inferiority myometrium play post-partum and post-abortion septic disease.

Called spontaneous fractures, occurring without any intervention from outside in childbearing; nasilstvennymi- caused by obstetric intervention (for example, when turning on the fetal foot, forceps); mixed - resulting from obstetric interventions in women with risk of spontaneous rupture. Complete uterine rupture captures all of its layers, part-time - only the mucosa and muscle layer. Complete ruptures occur more frequently in areas of the body, the bottom part of the lower uterine segment, ie where the peritoneum is closely connected to the uterus wall. Incomplete discontinuities occur in areas of the uterus, where the peritoneum loosely connected with the muscle layer, usually in the sides of the lower uterine segment. The most frequently observed in the lower uterine segment gaps at the front or side surface thereof. Gaps in the body and the bottom of the uterus, usually occur in old scar after undergoing surgery (cesarean section, extirpation of myoma nodes, etc.).

When threatened uterine rupture at the scar during pregnancy first appeared nausea , vomiting , pain in the epigastric region, and then the abdomen. Onset of the disease often mimics the pattern of acute appendicitis. During childbirth these symptoms joins uterine inertia or discoordination. Which began on the uterine scar rupture during labor is manifested by nausea, vomiting, dizziness, constant stress due to uterine hematoma formation in the rumen, the symptoms of fetal hypoxia. May appear bloody discharge from the genital tract.

Typical signs of threatening uterine rupture caused by mechanical obstacles are stretching of the lower uterine segment and expressed his pain on a background of extremely strong, sharply painful (sometimes convulsive) labor; tension and soreness round ligament of the uterus; swelling of the edges of the uterine mouth, vagina and vulva as a result of compression of; difficulty urinating due to compression of the bladder and urethra; attempts to push with high standing fetal head; state high ring contraction (the navel), and therefore the uterus acquires an hourglass shape.

Began rupture of the uterus is characterized by the addition to the above signs of fear, anxiety and extreme excitement mothers, the advent sukrovichnyh or bleeding from the genital tract, admixture of blood in the urine, the deterioration of the fetus (changes in heart rate and locomotor activity). There are no painful attempts at promoting fruit, high-standing head of the fetus and the full opening of the uterine mouth.

Take a uterine rupture is characterized by severe pain in the abdomen and the complete cessation of labor (a sudden "the calm after the storm"); symptoms of shock and internal bleeding (pale skin, weak and frequent pulse , drop in blood pressure, dizziness , and sometimes loss of consciousness); the appearance of symptoms of peritoneal irritation; fetal death and total or partial release of his into the abdominal cavity (cessation of heartbeat, clear sounding out through the abdominal wall of the fetal parts and became the presenting part of the mobile, and next to it - a small, dense, cut the uterus); external bleeding is usually minor. Incomplete rupture formed a hematoma in the pelvis loose tissue, usually between the sheets of the broad ligament of the uterus or uterine peritoneal under cover. The appearance of hematomas accompanied by severe abdominal pain, sometimes radiating to the sacrum and leg; in the lower abdomen is determined by the rapidly increasing painful one-sided education, the uterus is deflected in the opposite direction (in the formation of a hematoma in the broad ligament). Incomplete uterine rupture shock phenomena may be expressed weakly or not at all manifest, and is dominated by symptoms of internal bleeding. With the gradual "spread" the diseased tissue of the uterus sudden sharp pain characteristic of uterine rupture, may be absent, the fight does not stop immediately, but gradually, and the fruit can sometimes be born vaginally.

Diagnostic difficulties arise in the uterine rupture at the scar, especially in its lower segment. Such "atypical" fractures can be accompanied by severe symptoms and sometimes are not diagnosed. In these cases, in addition to symptoms of peritoneal irritation and internal bleeding, often ill-defined, should attract the attention of flatulence rise and diffuse abdominal pain. Often difficult diagnosis of incomplete uterine rupture. Leading symptoms at the same time is a sign of internal bleeding, but they are not always clearly expressed, as the blood poured out not into the abdominal cavity, and parauterine or paravesical fiber and detaches the peritoneum. The formation of such subperitoneal rapidly growing hematoma next to the uterus and often emphysema fiber, determined by palpation of the abdomen in the iliac region (symptom crunch of snow), allows to suspect a partial rupture of the uterus. The final diagnosis is established by manual examination of the uterus after fetal extraction or laparotomy.

The differential diagnosis of uterine rupture accomplished performed with rapidly progressive complete detachment normally situated placenta, which may be accompanied by shock and internal bleeding. However placental abruption uterine shape does not change abruptly, only moderately painful sometimes formed protrusion of the uterine wall at the site of detachment, a part of the fetus through the abdominal wall are not determined, peritoneal irritation symptoms usually absent.

When threatened uterine rupture is an urgent need to stop the activities of a generic and complete birth surgically. For a quick termination of labor used deep anesthesia, usually endotracheal ether oxygen to the muscle relaxants and produce surgical delivery. When a live fetus and there are no signs of infection do Caesarean section. When stillbirth plodorazrushayuschie perform surgery (craniotomy - with cephalic presentation fetus, decapitation or embryotomy - the transverse position of the fetus and its small size); for large fruit size is preferred cesarean section. Strongly contraindicated operations such as fetal twist on the leg, followed by its extraction, forceps delivery, as this usually occurs uterine rupture.

At the beginning and an accomplished uterine rupture requires laparotomy. Before the operation is carried out immediately and the complex antishock antianemic events. They continue during and after surgery. After opening the abdominal cavity are removed the fetus and placenta. If the uterus is small, the line break (or torn edges it can be easily excised), or if the rupture occurred recently and the risk of infection is low, it is permissible stitching rupture. With extensive discontinuities, particularly crush the tissue and the presence of infection, produce, usually hysterectomy.

The prognosis for complete uterine rupture adverse to the fetus, his death occurs during hypoxia phenomena associated with placental abruption. The outcome for the mother determined by the volume of blood loss and the severity of the shock.

Prevention of uterine rupture is mainly related to activities carried out even in the antenatal clinic. Based on the data carefully collected history and physical examination to distinguish a special group of pregnant women who have a uterus can rupture during labor. It includes pregnant women with narrow hips, large fruit, malposition, multiparas reduced tone of the abdominal wall and uterus of pregnant women with the burdened obstetric history (post-abortion and postpartum inflammatory diseases, prolonged labor , uterine inertia, etc.), As well as survivors surgery on the uterus, especially caesarean section. They were mounted closely monitored if necessary hospitalized during the second half of pregnancy and are usually fed in a maternity hospital for 2 - 3 weeks before delivery. When expressed scarring of the uterus and identify inferiority postoperative scar on the uterus hospitalization carried out for 6 -8 weeks before delivery. The hospital is scheduled plan for the management of labor, establish the need for caesarean section before onset of labor. If a surgical delivery is not shown, develop a plan of careful management of labor, scheduled delivery methods and tactics in the event of certain complications.

Traumatic necrosis of the cervix - a rare complication of childbirth associated with prolonged compression of the cervix between the fetal head and pelvic walls pregnant. Necrosis from compression occur more frequently when clinically or anatomically narrow pelvis, uterine inertia, stiffness and scar the cervix changes. In most cases the necrosis is formed in the front wall of the cervix, at least at the rear. Necrotizing site usually does not go into the gap and is located at the site of cervical infringement. After birth, cervical necrotizing land rejected, usually formed fistula. Quite rare in traumatic cervical necrosis observed spontaneous vaginal amputation of part or one of her mouth (front or rear). It happens in nulliparous older than 30 years with rigid cervix and prolonged labor large fruit.

Stretching and rupture of the pubic symphysis in obstetric practice are rare. These complications occur, usually during childbirth, in which surgical interventions are used, as well as functionally narrow pelvis.

When stretched, the pubic symphysis of a woman a few hours or days appear dull pain in the pubic region, aggravated by movement of the legs. Rupture of the pubic symphysis during childbirth is accompanied by sharp pain, sometimes exploding distinctive crunching chords, after which there is a rapid lowering of the fetal presenting part. Perhaps the appearance of subcutaneous hematoma in the pubic area, signs of damage to the bladder and urethra. Postpartum women can not lift the legs and turn to the side. On palpation can detect the mobility of the pubic bone and the wide lag of them from each other.

When you stretch and break the pubic symphysis prescribed strict bed rest with pelvic suspending (position "in a hammock"), cold in the pubic area, tight bandaging of the pelvis, restorative treatment. In the case of hematoma infection it opened and drained, conduct anti-inflammatory therapy. Forecast favorable with the right treatment, at the earliest possible formation rising nonunion and stable gait disturbance ( "duck walk").

Preventing damage to the pubic symphysis is the careful conduct of birth. When obstetric operations should strictly take into account the conditions and indications ,, not apply rough traumatic techniques. In case of discrepancy the size of the pelvis mother and the fetal head is necessary to carry out a caesarean section in a timely manner.

Obstetric fistula is the result of a long pressing head fetal tissues of the vagina or cervix to the bones of the pelvis of pregnant. In rare cases, the fistula may result from obstetric interventions. Depending on the localization of the fistula can be cervicovaginal, vesico-cervical, cervical ureterovaginal, vesicovaginal and rectovaginal.

Clinically, they appear after the rejection of necrotic areas usually 3 -8 th day after the birth the spontaneous separation of urine or feces through sexual way. Anticipate fistulas during childbirth may be at their protracted course, prolonged dry gap and standing fetal head over 3-4 hours in the same pelvic plane. It is sometimes observed swelling of the vagina, vulva, urinary retention , blood in the urine and bleeding from the vagina. To prevent such complications should avoid standing fetal head in one pelvic plane departed at amniotic fluid more than 2 - 3 hours, and the need to move to action, up to surgery.

Obstetric fistula are found during the inspection of the vagina and cervix using a vaginal mirrors. Occasionally resorting to fistulography after administration of contrast media into the bladder or rectum, or cystoscopy. Fistula Treatment operative. Sometimes there is a spontaneous recovery. Surgery can be performed no earlier than 4 - 6 months after birth. Prior to that necessary to carry out the toilet vulva daily, lubricate it with vaseline oil, emulsions with sulfonamides, or 5 - 10% methyluracyl ointment. Preventing fistula is reduced to the proper conduct of delivery. See. Also bleeding during childbirth.