1. Anatomy of Vagina2. Episiotomy and its repair3. Cervical tear

Presented by:

Ashok Kumar Yadav

Choodamani Nepal

Tapendra Koirala

1. Anatomy of Vagina

Vagina is fibromusculomembranous tube of 7-9cmCommunicates uterine cavity with exterior at vulva

Vagina

Uterus

Bladder

Rectum

Fornices

- Cleft formed at the top of vagina

- Projection of uterine cervix

Four fornices are:

1. One anterior fornix

2. One posterior fornix

3. Two lateral fornix

- Posterior deeper, - anterior shallow

Relations

Anterior: upper 1/3rd - base of bladder

lower 2/3rd - urethra

Posterior: upper – pouch of Douglas

middle – anterior rectal wall

lower – perineal body

Lateral: upper – ureter and uterine artery

middle – levator ani muscle

lower – bulbocavernosus muscle, vestibular bulbs & Bartholin’s glands

Layers:

From within outward:

1. Mucous coat: lined by stratified squamous epithelium

2. Sub-mucous layer: of loose areolar connective tissue

3. Muscular layer: inner circular & outer longitudinal layer

4. Fibrous coat: endopelvic fascia

Function:

- Canal for menstrual fluid- Forms the inferior part of the birth canal- Receives penis and ejaculate during sexual intercourse

Blood Supply

Arterial system- Vaginal artery: division of internal iliac artery- Cervicovaginal: branch of uterine artery- Middle rectal artery- Internal pudendal artery

Venous system- Corresponds with arteries

Lymphatic system

Above hymen: internal iliac group of lymph nodes

Below hymen: superficial inguinal group of lymph nodes

Nerve supplyautonomic nervous supply by pelvic plexus

Lower part: by pudendal nerve

2. Episiotomy and it’s repair

Episiotomy

- Definition

A surgically planned incision on the perineum and posterior vaginal wall during the second stage of labor

- Objectives- To enlarge the vaginal introitus so as to facilitate the

easy and safe delivery- To minimize the overstretching and rupture of perineal

muscles and fascia- To reduce the stress and strain on the fetal head

Advantages

- Maternal: - Reduction of trauma to pelvic floor muscle and fascia –

reduces incidence of prolapse and perhaps urinary incontinence

- Reduction in second stage of labor- Clear and controlled incision is easy to repair and heals

better than a lacerated wound

- Fetal:- Minimizes the intracranial injuries

Indication

- In-elastic perineum e.g. elderly primigravidae - Anticipated perineal tear e.g. big baby, face to pubis

delivery, breech delivery, shoulder dystocia- Operative delivery e.g. forceps delivery, ventouse

delivery- Previous perineal surgery e.g. pelvic floor repair,

perineal reconstructive surgery

Timing of the episiotomy

- If done early:- To much bleeding

- If done late:- Fails to protect micro lacerations and tear

- Bulging thinned perineum during the contraction just prior to crowning (when 3-4 cm of head is visible) is the ideal time

Types of episiotomy

1. Mediolateral

2. Median

3. Lateral

4. ‘J’ shaped

Commonest type is mediolateral

Cervical Tear

- Most common cause of traumatic postpartum haemorrhage

- Causes: Iatrogenic: forceps delivery, breech extraction through

incompletely dilated cervix

Rigid cervix: congenital, previous operation, carcinoma

Strong uterine contraction

Detachment of cervix

Diagnosis- Excessive vaginal bleeding immediately following delivery

DangersEarly: Deep cervical tear with major vessels lead to severe

- postpartum haemorrhage

- broad ligament hematoma

- pelvic cellulitis,

- Thrombophlebitis

Late: Ectropion- Cervical incompetence with mid-trimester- Abortion

Treatment

- Minor degree of cervical tear requires no treatment- Deep cervical tear should be repaired soon after

delivery of placenta- Suturing

Pre-requisites:- Sim’s posterior vaginal speculum- Vaginal wall retractors- At least two forceps- Assistant

Thank you!