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Maternal obstetric injuries for undergraduate

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  1. 1. Maternal Obstetric InjuriesMaternal Obstetric Injuries 11
  2. 2. If was not supposed to be hard work, it would not have been called LABOR. Anonymous
  3. 3. 33 ““PovertyPoverty is lot likeis lot like childbirthchildbirth – you know it is– you know it is going to hurt before it happens, but you’llgoing to hurt before it happens, but you’ll never know how much until younever know how much until you experienceexperience it”it” Joanne Kathleen RowlingJoanne Kathleen Rowling
  4. 4. 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 44
  5. 5. A day in a labour Room……A day in a labour Room…… 55
  6. 6. 66
  7. 7. 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 prerequisitesFulfillment of prerequisites Willingness to abandon attemptWillingness to abandon attempt Ability to perform C-sectionAbility to perform C-section 77
  8. 8. Operative deliveryOperative delivery VaginalVaginal EpisotomyEpisotomy Forceps and ventoseForceps and ventose Destructive operationDestructive operation AbdominalAbdominal C SC S 88
  9. 9. Operative DeliveryOperative Delivery 99
  10. 10. Center of the cupCenter of the cup over the sagittalover the sagittal suture, about 2suture, about 2 cm in front of thecm in front of the posterior fontanel.posterior fontanel. Some tips……
  11. 11. Soft cupSoft cupMetal cup 1111 Release suction between Pushes 2 pop-offs, abandon procedure
  12. 12. Vacuum ProcedureVacuum Procedure Check for vaginal or vulvarCheck for vaginal or vulvar tissues trap between the cuptissues trap between the cup and fetal surface.and fetal surface. Gradual Vs Rapid ApplicationGradual Vs Rapid Application of Vacuum Pressureof Vacuum Pressure 1212
  13. 13. 1313
  14. 14. TractionTraction 1414
  15. 15. Problems arising fromProblems arising from EpisiotomyEpisiotomy 1515 PainPain EdemaEdema BleedingBleeding InfectionInfection Defects in woundDefects in wound
  16. 16. Before Crowning AfterBefore Crowning After 1616
  17. 17. Intrauterine manipulationIntrauterine manipulation 1717
  18. 18. Manual removal of the placentaManual removal of the placenta 1818
  19. 19. Internal podalic versionInternal podalic version 1919
  20. 20. Breech extraxtionBreech extraxtion 2020
  21. 21. Maternal ObstetricMaternal Obstetric InjuriesInjuries Lacerations of the Lower Genital Tract HEMATOMAS UTERINE RUPTURE
  22. 22. AA uterine ruptureuterine rupture is a frank opening between theis a frank opening between the uterine cavity and the abdominal cavityuterine cavity and the abdominal cavity (Complete).(Complete). RUPTUR UTERUS
  23. 23. AA uterine dehiscenceuterine dehiscence is a “window” covered by theis a “window” covered by the visceral peritoneumvisceral peritoneum (incomplete)(incomplete)..
  24. 24. Rupture can occur: at the site of a previous cesareanRupture can occur: at the site of a previous cesarean delivery or other surgical procedure involving thedelivery or other surgical procedure involving the uterine wall,uterine wall,
  25. 25. 2525
  26. 26. 2626 Causes of spontaneous rupture uterus
  27. 27. Rupture Of Previous CS ScarRupture Of Previous CS Scar 2727
  28. 28.  placenta accreta or perforating mole Obstructed labor.placenta accreta or perforating mole Obstructed labor.
  29. 29. from congenital malformation (small uterine horn),from congenital malformation (small uterine horn),
  30. 30. For early detection and intervention:For early detection and intervention: Vaginal spotting (minimal bleeding)Vaginal spotting (minimal bleeding) acute abdominal painacute abdominal pain cessation of uterine contractionscessation 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.
  31. 31. 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
  32. 32. Rupture of a previous cesarean delivery scarRupture of a previous cesarean delivery scar often can be managed by revision of the edgesoften can be managed by revision of the edges of the prior incision, followed by primary closureof the prior incision, followed by primary closure 3232
  33. 33. Regardless of the patient’s wishes for theRegardless of the patient’s wishes for the avoidance of hysterectomy, this procedure may beavoidance of hysterectomy, this procedure may be necessary in a life-threatening situation.necessary in a life-threatening situation.
  34. 34. Consideration must be given to the neighboringConsideration 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.
  35. 35. 3535 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 ‼‼‼‼‼‼‼‼
  36. 36. instrumented delivery,instrumented delivery, manipulative delivery such as a breech extraction,manipulative delivery such as a breech extraction, precipitous labor,precipitous labor, MalpresentionMalpresention ,, Macrosomia,Macrosomia, Cervical scar.Cervical scar. Lacerations of the Lower Genital Tract Predisposing factorsPredisposing factors
  37. 37. Lacerations to theLacerations to the cervixcervix that are extensive andthat are extensive and those that are actively bleeding usually requirethose that are actively bleeding usually require repair.repair. Types:Types: 1- Unilateral1- Unilateral 2- Bilateral.2- Bilateral. 3- Stellate3- Stellate 4- Annular detachment.4- Annular detachment.
  38. 38. May lead toMay lead to Rupture uterus due to upward extension.Rupture uterus due to upward extension. Cervical incompetence leading to futureCervical incompetence leading to future recurrent abortion or preterm labor.recurrent abortion or preterm labor.
  39. 39. Perineal LacerationsPerineal Lacerations
  40. 40. (first-degree through fourth-degree vaginal(first-degree through fourth-degree vaginal and periurethral lacerations) may requireand periurethral lacerations) may require repair when bleeding is significant.repair when bleeding is significant. Lacerations of the vaginavagina and perineumperineum
  41. 41. Incomplete perineal tear repair
  42. 42. repair
  43. 43. Complete perineal tear
  44. 44. Periurethral lacerationsPeriurethral lacerations may be associated withmay be associated with sufficientsufficient edemaedema to occlude the urethra,to occlude the urethra, causing urinary retention;causing urinary retention; a Foley catheter for 12 to 24 hours usuallya Foley catheter for 12 to 24 hours usually alleviates this problem.alleviates this problem.
  45. 45. HEMATOMASHEMATOMAS HematomasHematomas can occurcan occur anywhereanywhere from the vulvafrom the vulva to the upper vagina as a result of deliveryto the upper vagina as a result of delivery trauma.trauma. Hematomas may also develop at the site ofHematomas may also develop at the site of episiotomy or perineal laceration.episiotomy or perineal laceration.
  46. 46. Infra-levatorInfra-levator Broad ligamentary
  47. 47. 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
  48. 48. If the hematoma is at the site of episiotomy, the suturesIf the hematoma is at the site of episiotomy, the sutures should be removed and a search made for the actualshould be removed and a search made for the actual bleeding site, which is then ligated.bleeding site, which is then ligated.
  49. 49. DrainsDrains andand vaginal packsvaginal packs are often used to preventare often used to prevent reaccumulation of blood.reaccumulation of blood. Large amounts of blood can dissect andLarge amounts of blood can dissect and accumulate along tissue planes, especiallyaccumulate along tissue planes, especially into theinto the ischiorectal fossa.ischiorectal fossa. CarefulCareful monitoringmonitoring of hemodynamic status isof hemodynamic status is important in identifying those with occult bleeding.important in identifying those with occult bleeding.
  50. 50. Large increasingLarge increasing broad ligamentarybroad ligamentary hematomas require lhematomas require laparotomy.aparotomy.
  51. 51. 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 atShe gives history of a first vaginal delivery at home, then spontaneous abortion but thehome, then spontaneous abortion but the last labor was CS at a public hospital 2 yearslast labor was CS at a public hospital 2 years ago due to fetal distress. On examination: BPago due to fetal distress. On examination: BP 115/70, pulse 84, 36.9 temperature, fundus at115/70, pulse 84, 36.9 temperature, fundus at xiphisternum, FHR: 148, tender lowerxiphisternum, FHR: 148, tender lower abdomen in between pains, the cervix is 5abdomen in between pains, the cervix is 5 cm and 70% effaced, she suffers persistentcm and 70% effaced, she suffers persistent pain in the lower abdomenpain in the lower abdomen
  52. 52. 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 (repeat).CS (repeat). 3.3.Ventouse (assist).Ventouse (assist). 4.4.Pitocin drip (augment).Pitocin drip (augment). ……………………………………………………………………………………………………………………………… ………………………………………………………………………… ……………………………………………………………………………………………………………………………… ………………………………………………………………………… What is the main risk if you allow trial of vaginalWhat is the main risk if you allow trial of vaginal delivery?delivery? ……………………………………………………………………………………………………………………………… ………………………………………………………………………… Mention four clinical features of the risk that mayMention four clinical features of the risk that may occur?occur? ……………………………………………………………………………………………………………………………… ………………………………………………………………………… ……………………………………………………………………………………………………………………………… …………………………………………………………………………
  53. 53. Signs of uterine ruptureSigns of uterine rupture severe, localized painsevere, localized pain abnormalities of the fetal heart rateabnormalities of the fetal heart rate vaginal bleedingvaginal bleeding the vaginal examination may show thatthe vaginal examination may show that the baby is not as low in the birth canal asthe baby is not as low in the birth canal as he had been earlier.he had been earlier.

Transkript

  1. 1. Maternal Obstetric InjuriesMaternal Obstetric Injuries 11
  2. 2. If was not supposed to be hard work, it would not have been called LABOR. Anonymous
  3. 3. 33 ““PovertyPoverty is lot likeis lot like childbirthchildbirth – you know it is– you know it is going to hurt before it happens, but you’llgoing to hurt before it happens, but you’ll never know how much until younever know how much until you experienceexperience it”it” Joanne Kathleen RowlingJoanne Kathleen Rowling
  4. 4. 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 44
  5. 5. A day in a labour Room……A day in a labour Room…… 55
  6. 6. 66
  7. 7. 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 prerequisitesFulfillment of prerequisites Willingness to abandon attemptWillingness to abandon attempt Ability to perform C-sectionAbility to perform C-section 77
  8. 8. Operative deliveryOperative delivery VaginalVaginal EpisotomyEpisotomy Forceps and ventoseForceps and ventose Destructive operationDestructive operation AbdominalAbdominal C SC S 88
  9. 9. Operative DeliveryOperative Delivery 99
  10. 10. Center of the cupCenter of the cup over the sagittalover the sagittal suture, about 2suture, about 2 cm in front of thecm in front of the posterior fontanel.posterior fontanel. Some tips……
  11. 11. Soft cupSoft cupMetal cup 1111 Release suction between Pushes 2 pop-offs, abandon procedure
  12. 12. Vacuum ProcedureVacuum Procedure Check for vaginal or vulvarCheck for vaginal or vulvar tissues trap between the cuptissues trap between the cup and fetal surface.and fetal surface. Gradual Vs Rapid ApplicationGradual Vs Rapid Application of Vacuum Pressureof Vacuum Pressure 1212
  13. 13. 1313
  14. 14. TractionTraction 1414
  15. 15. Problems arising fromProblems arising from EpisiotomyEpisiotomy 1515 PainPain EdemaEdema BleedingBleeding InfectionInfection Defects in woundDefects in wound
  16. 16. Before Crowning AfterBefore Crowning After 1616
  17. 17. Intrauterine manipulationIntrauterine manipulation 1717
  18. 18. Manual removal of the placentaManual removal of the placenta 1818
  19. 19. Internal podalic versionInternal podalic version 1919
  20. 20. Breech extraxtionBreech extraxtion 2020
  21. 21. Maternal ObstetricMaternal Obstetric InjuriesInjuries Lacerations of the Lower Genital Tract HEMATOMAS UTERINE RUPTURE
  22. 22. AA uterine ruptureuterine rupture is a frank opening between theis a frank opening between the uterine cavity and the abdominal cavityuterine cavity and the abdominal cavity (Complete).(Complete). RUPTUR UTERUS
  23. 23. AA uterine dehiscenceuterine dehiscence is a “window” covered by theis a “window” covered by the visceral peritoneumvisceral peritoneum (incomplete)(incomplete)..
  24. 24. Rupture can occur: at the site of a previous cesareanRupture can occur: at the site of a previous cesarean delivery or other surgical procedure involving thedelivery or other surgical procedure involving the uterine wall,uterine wall,
  25. 25. 2525
  26. 26. 2626 Causes of spontaneous rupture uterus
  27. 27. Rupture Of Previous CS ScarRupture Of Previous CS Scar 2727
  28. 28.  placenta accreta or perforating mole Obstructed labor.placenta accreta or perforating mole Obstructed labor.
  29. 29. from congenital malformation (small uterine horn),from congenital malformation (small uterine horn),
  30. 30. For early detection and intervention:For early detection and intervention: Vaginal spotting (minimal bleeding)Vaginal spotting (minimal bleeding) acute abdominal painacute abdominal pain cessation of uterine contractionscessation 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.
  31. 31. 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
  32. 32. Rupture of a previous cesarean delivery scarRupture of a previous cesarean delivery scar often can be managed by revision of the edgesoften can be managed by revision of the edges of the prior incision, followed by primary closureof the prior incision, followed by primary closure 3232
  33. 33. Regardless of the patient’s wishes for theRegardless of the patient’s wishes for the avoidance of hysterectomy, this procedure may beavoidance of hysterectomy, this procedure may be necessary in a life-threatening situation.necessary in a life-threatening situation.
  34. 34. Consideration must be given to the neighboringConsideration 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.
  35. 35. 3535 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 ‼‼‼‼‼‼‼‼
  36. 36. instrumented delivery,instrumented delivery, manipulative delivery such as a breech extraction,manipulative delivery such as a breech extraction, precipitous labor,precipitous labor, MalpresentionMalpresention ,, Macrosomia,Macrosomia, Cervical scar.Cervical scar. Lacerations of the Lower Genital Tract Predisposing factorsPredisposing factors
  37. 37. Lacerations to theLacerations to the cervixcervix that are extensive andthat are extensive and those that are actively bleeding usually requirethose that are actively bleeding usually require repair.repair. Types:Types: 1- Unilateral1- Unilateral 2- Bilateral.2- Bilateral. 3- Stellate3- Stellate 4- Annular detachment.4- Annular detachment.
  38. 38. May lead toMay lead to Rupture uterus due to upward extension.Rupture uterus due to upward extension. Cervical incompetence leading to futureCervical incompetence leading to future recurrent abortion or preterm labor.recurrent abortion or preterm labor.
  39. 39. Perineal LacerationsPerineal Lacerations
  40. 40. (first-degree through fourth-degree vaginal(first-degree through fourth-degree vaginal and periurethral lacerations) may requireand periurethral lacerations) may require repair when bleeding is significant.repair when bleeding is significant. Lacerations of the vaginavagina and perineumperineum
  41. 41. Incomplete perineal tear repair
  42. 42. repair
  43. 43. Complete perineal tear
  44. 44. Periurethral lacerationsPeriurethral lacerations may be associated withmay be associated with sufficientsufficient edemaedema to occlude the urethra,to occlude the urethra, causing urinary retention;causing urinary retention; a Foley catheter for 12 to 24 hours usuallya Foley catheter for 12 to 24 hours usually alleviates this problem.alleviates this problem.
  45. 45. HEMATOMASHEMATOMAS HematomasHematomas can occurcan occur anywhereanywhere from the vulvafrom the vulva to the upper vagina as a result of deliveryto the upper vagina as a result of delivery trauma.trauma. Hematomas may also develop at the site ofHematomas may also develop at the site of episiotomy or perineal laceration.episiotomy or perineal laceration.
  46. 46. Infra-levatorInfra-levator Broad ligamentary
  47. 47. 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
  48. 48. If the hematoma is at the site of episiotomy, the suturesIf the hematoma is at the site of episiotomy, the sutures should be removed and a search made for the actualshould be removed and a search made for the actual bleeding site, which is then ligated.bleeding site, which is then ligated.
  49. 49. DrainsDrains andand vaginal packsvaginal packs are often used to preventare often used to prevent reaccumulation of blood.reaccumulation of blood. Large amounts of blood can dissect andLarge amounts of blood can dissect and accumulate along tissue planes, especiallyaccumulate along tissue planes, especially into theinto the ischiorectal fossa.ischiorectal fossa. CarefulCareful monitoringmonitoring of hemodynamic status isof hemodynamic status is important in identifying those with occult bleeding.important in identifying those with occult bleeding.
  50. 50. Large increasingLarge increasing broad ligamentarybroad ligamentary hematomas require lhematomas require laparotomy.aparotomy.
  51. 51. 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 atShe gives history of a first vaginal delivery at home, then spontaneous abortion but thehome, then spontaneous abortion but the last labor was CS at a public hospital 2 yearslast labor was CS at a public hospital 2 years ago due to fetal distress. On examination: BPago due to fetal distress. On examination: BP 115/70, pulse 84, 36.9 temperature, fundus at115/70, pulse 84, 36.9 temperature, fundus at xiphisternum, FHR: 148, tender lowerxiphisternum, FHR: 148, tender lower abdomen in between pains, the cervix is 5abdomen in between pains, the cervix is 5 cm and 70% effaced, she suffers persistentcm and 70% effaced, she suffers persistent pain in the lower abdomenpain in the lower abdomen
  52. 52. 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 (repeat).CS (repeat). 3.3.Ventouse (assist).Ventouse (assist). 4.4.Pitocin drip (augment).Pitocin drip (augment). ……………………………………………………………………………………………………………………………… ………………………………………………………………………… ……………………………………………………………………………………………………………………………… ………………………………………………………………………… What is the main risk if you allow trial of vaginalWhat is the main risk if you allow trial of vaginal delivery?delivery? ……………………………………………………………………………………………………………………………… ………………………………………………………………………… Mention four clinical features of the risk that mayMention four clinical features of the risk that may occur?occur? ……………………………………………………………………………………………………………………………… ………………………………………………………………………… ……………………………………………………………………………………………………………………………… …………………………………………………………………………
  53. 53. Signs of uterine ruptureSigns of uterine rupture severe, localized painsevere, localized pain abnormalities of the fetal heart rateabnormalities of the fetal heart rate vaginal bleedingvaginal bleeding the vaginal examination may show thatthe vaginal examination may show that the baby is not as low in the birth canal asthe baby is not as low in the birth canal as he had been earlier.he had been earlier.

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