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Lecture notes, cheat sheets
Obstetrics and gynecology. Birth trauma (lecture notes)
Directory / Lecture notes, cheat sheets Table of contents (expand) Lecture No. 16 During childbirth, ruptures of the cervix, vagina, perineum, and vulva can occur. This happens with violent and rapid childbirth, with large fetal sizes, etc. Therefore, in the early postpartum period, it is imperative to examine the soft tissues of the birth canal and suture the gaps. With a rupture of the soft tissues of the birth canal, bleeding is usually not heavy. If the birth was carried out at home, the puerperal must be taken to the obstetric hospital, where the soft tissues of the birth canal will be examined and the tears will be sutured. The causes of ruptures are most often childbirth with a large fetus, the imposition of forceps, inept protection of the perineum, and rapid childbirth. There are III degrees of ruptures of the perineum. With a rupture of the XNUMXst degree, the integrity of the posterior commissure, the vaginal wall in the region of its lower third, and the skin of the perineum are violated. With a rupture of the II degree, the skin of the perineum, the walls of the vagina and the muscles of the perineum are disturbed (except for the external sphincter of the rectum). With a rupture of the III degree, the external sphincter of the rectum is additionally damaged. There are also three degrees of rupture of the cervix. I degree - a gap on one or both sides of not more than 2 cm, II degree - a gap of more than 2 cm, but not reaching the fornix of the vagina, III degree - a gap reaching the fornix or passing to it. Rupture of the uterus A complication of pregnancy is observed in 2-3 cases per 10 births. Distinguish between complete and incomplete rupture of the uterus. A complete rupture is characterized by a violation of the integrity of all layers of the uterus. Where parts of the peritoneum do not adhere tightly to the myometrium, incomplete ruptures of the uterus occur. An incomplete rupture is usually noted in the lower segment, lateral sections. In these cases, the integrity of the mucous membrane and the muscular layer of the uterus is violated, and the blood flowing under the visceral peritoneum forms an extensive subperitoneal hematoma. There are spontaneous and violent uterine ruptures. Violent ruptures of the uterus are observed with the wrong actions of the obstetrician during the performance of obstetric benefits and operations. Spontaneous uterine ruptures are more common, resulting from inflammatory and degenerative changes in the myometrium formed after abortion, childbirth, caesarean section, removal of myomatous nodes, removal of the fallopian tube, suturing of a perforation, etc. These histopathic uterine ruptures occur in the second half of pregnancy, especially after the 30th week, or during childbirth. A mechanical obstruction to the advancement of the fetus (mismatch between the size of the presenting part of the fetus and the mother's pelvis) is the most common cause of spontaneous uterine rupture, observed mainly at the end of the dilatation period. Before uterine rupture, symptoms of impending rupture are usually noted. With histopathic and mechanical genesis of uterine rupture, the symptoms of a threatening rupture are different. Symptoms threatening rupture of the uterus in histopathic genesis: scanty bloody discharge from the genitals, constant pain in the lower abdomen, lower back (pain may be local or not localized), weakness of labor activity, a long period of irregular precursors of contractions (2-3 days). Symptoms of a threatening rupture of the uterus of mechanical origin: a discrepancy between the size of the fetus and the mother's pelvis. It manifests itself in excessive labor activity, incomplete relaxation of the uterus between contractions. Contractions are sharply painful. The lower segment of the uterus is sharply painful on palpation, there is swelling of the tissue in the bladder area above the pubis, urination is difficult. Uterine rupture is accompanied by nausea, 1-2 times vomiting, pain in the abdomen without localization or localized in the epigastric region (with uterine rupture in the fundus, tubal angles), in the hypogastric or lateral sections (with a rupture in the lower segment or uterine edge) , symptoms of irritation of the peritoneum. On palpation, pain is noted with localization in the area of the gap. When a fetal egg enters the abdominal cavity, parts of the fetus can be palpated. They are located directly under the abdominal wall. The woman takes a forced position on her back, on her side. The pain increases, the general condition worsens. Violation of the vital activity of the fetus or even the absence of a fetal heartbeat are observed during auscultation. A woman in labor complains of dizziness, tachycardia, low blood pressure, pale skin, darkening of the eyes, weakness, dry mouth (signs of increasing anemia). In cases of damage to large vessels during rupture of the uterus and the exit of the fetus into the abdominal cavity, a picture of hemorrhagic shock develops. Fatal outcome in uterine rupture (with a combination of painful, traumatic and hemorrhagic components) is 2-3 times more likely than in patients with presentation and premature detachment of a normally located placenta, hypotonic bleeding. Diagnostics uterine rupture is based on the presence of characteristic symptoms of uterine rupture and history (such as uterine scar after caesarean section, uterine perforation, complications in previous births, weakness of labor forces, bleeding, birth of a large or still fetus, vaginal delivery operations, infection in childbirth and postpartum period). In some cases, women have a burdened gynecological history (myomectomy, tubectomy in the past, cervical surgery, inflammatory disease of the female genital organs, etc.). Help Tactics. If symptoms characteristic of uterine rupture occur, the woman must be transported to an obstetric hospital on a stretcher. The woman immediately begins transfusion of any blood replacement solutions in combination with ascorbic acid (3-4 ml of a 5% solution), cocarboxylase (100-150 mg); in case of arterial hypotension, prednisolone (60 mg) or hydrocortisone (150-200 mg) is administered. . The administration of analgesics should be avoided until an accurate diagnosis has been established. In cases of severe shock, the administration of analgesics is acceptable, especially during transport. During transportation, they most often resort to mask anesthesia with nitrous oxide and oxygen in a ratio of 1: 2. However, we should not forget that narcotic analgesics cause depression of the respiratory center and that pregnant women are especially sensitive to their effects. Treatment of uterine rupture. If the uterus ruptures, a transsection operation is performed and the scope of subsequent actions is determined, regardless of the condition in which the patient is, the presence of a concomitant infection, the nature of the damage, etc. The operation can be aimed at removing the fertilized egg, suturing the rupture, performing amputation or extirpation of the uterus. At the same time, antishock therapy is carried out. Author: Ilyin A.A. << Back: placenta previa >> Forward: Toxicosis of pregnant women
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