Genital Injuries

Prepared by : Racha ElkassemPrepared to : Dr. Mageda Mourad

Outline• Definition• Classifications• Anatomy and Physiology• Causes• Signs and Symptoms• Risk factors• Diagnostic procedure • Complications• Treatment • Prevention & Risk for reoccurrance • Nursing management• References

Female genitalia

External female genitalia Vulva, clitoris, major and minor labia ,

vagina

Internal female genitaliaUterus, ovary

INJURIES TO BIRTH CANAL

• NOT SO UNCOMMON – SPONTANEOUS or ASSISTED DELIVERIES

• DEPEND UPON THE CARE PROVIDED BY THE OBSTETRICIAN

• AVOIDANCE, EARLY DETECTION & PROMPT MANAGEMENT – KEY TO REDUCE SIGNIFICANT MORBIDITY

CLASSIFIEDINJURIES TO BONY PARTS

i) Injury to Symphysis Pubisii) Injury to Sacro-coccygeal Jointiii)Injury to Sacro-iliac Joint

INJURIES TO SOFT TISSUEi) Injury to Vulvaii) Perineal Tearsiii)Laceration of Vagina & Cervixiv)Rupture of Uterus

The vagina

• It is the fibromusculo – membranous sheath communicates uterine cavity with exterior at the vulva.

• It extends from the vestibule upwards and backwards upto the vaginal part of the cervix.

• Walls – anterior (7cm), posterior (9cm) and 2 lateral walls44.

• The lower third, resembles, figure of H, middle third is like transverse slit and upper thirdis rounded in shape.

Structures:

• Mucous coat: lined by the stratified squamous epithelium without any glands.

• Sub mucous layer consists of loose areolar tissue.

• Muscular layer consists of inner circular and outer longitudinal.

• Fibrous coat from endopelvic fascia.

CERVIX

• The cervix is a constricted part of uterus separated from the body by the constriction part known as the isthamus and behind by the transverse ridge considered as torus uterinus. This contains a cervical canal, which communicates the uterine cavity with the vagina. It extends downwards and backwards from the isthamus, protrudes through the anterior wall of vagina which divides the cervix into supravaginal and vaginal parts.

Structure of the cervix:

• Serous coat: from the peritoneum which covers the posterior surface of supravaginal part.

• Muscular coat: disposed smooth muscle. Some parts produced from collagenous and elastic fibrous tissue.

• Mucous membrane: by columnar epithelium and stratified squamous epithelium.

Ligaments of cervix

• Laterally by a pair of Mackenrodt’s ligaments.• Posteriorly by a pair of uterosacral ligaments. These ligaments have unstriped muscles and

leashes of blood vessels and lymphatic’s.On each side, the lymphatic drainage into

external iliac, obturator lymph nodes, internal iliac groups and sacral groups.

PERINEAL TEAR

Anatomy and Physiology A. Pelvic floor:Pelvic floor is a muscular diaphragm that separates the pelvic

cavity above from the perineal space below.It is formed by the levator ani and coccygeus muscles, and is covered by parietal fascia. The levator animuscles on either side arise from posterior surface of pubic symphysis, the white line over fascia covering obturator internus and ischial spine.

• The levators sweep from the lateral pelvic wall downwards and medially to fuse with the opposite side in the midline and form a pubo-coccygeal raphe.

• Fibres of Levators are inserted from before backwards and fuse with muscle fibres of urethra, the vaginal walls, perineal body, anal canal, anococcygeal body and the lateral borders of coccyx.

Functions: • To support the pelvic viscera.• To maintain effective intra-abdominal pressure.• To facilitate anterior rotation and downward and

forward propulsion of the presenting part during parturition.

• Serves as a support and voluntary sphicter of urethra, vagina and anal canal.

B. Urogenital diaphragm:The urogenital diaphragm is external to pelvicdiaphragm and includes the triangular areabetween the ischial tuberosities and thesymphysis. It is madeup of deep transverse perineal muscles, sphincterurethrae and internaland external fascial coverings.

C. Perineum:Perineum is a diamond-shaped space that lies below the pelvic floor.

it is bounded by: Superiorly: pelvic floor Laterally: the pelvic outlet consisting of subpubic

angle, ischiopubic rami, ischial tuerosities, sacrotuberous ligaments and coccyx

Inferiorly: skin and fascia

• This area is divided into two triangles by transverse muscles of perineum and base of urogenital diaphragm:

– Anteriorly- Urogenital triangle.– Posteriorly- Anal triangle

• Most of the support of perineum is provided by pelvic and urogenital diaphragms.

Perineal Body:• The median raphe of levator ani between the

anus and vagina, is reinforced by the central tendon of the perineum. Bulbocavernosus, superficial transverse perineal and external anal sphincter muscles also converge on the central tendon. These muscles contribute to perineal body, which provides much support to perineum.

PERINEAL TEARGross injury is due to MISMANAGED 2ND STAGE OF

LABOURMore common in PRIMIGRAVIDA than

MULTIGRAVIDA .Due to extension of episiotomy, posteriory it

involves the anal sphincter from back & obliquely upwards into the lateral vaginal wall

ETIOLOGY: - OVER STRETCHING OF PERINIUM - RAPID STRETCHING OF PERINIUM - INELASTIC PERINIUM

Causes and Predisposing Factors:• Obstetric injuries:

Malpresentations such as breechContracted pelvic outletspontaneous labouroperative vaginal deliveries( forceps or vaccum)Macrosomic babies

• Non-obstetric injuries: rape, molestation, fall, accidental injuries like RTA, bull horn injuries etc.

First degree- limited to vaginal mucosa and skin of the introitus.

Second degree- extends to the fascia and muscles of the perineal body.

Third degree- trauma involves the anal sphincter. Fourth degree - extends into the rectal lumen, through

the rectal mucosa.

• A rare type of tear is central tear of the perineum when the head penetrates first through the posterior vaginal wall, then through the perineal body and appears through the skin of the perineum. It usually occurs in patients with contracted outlet.

Degrees of Perineal tear:

THIRD DEGREE PERINEAL TEAR

FOURTH-DEGREE PERINEAL TEAR

First & second degree tears :-Spontaneous tears originate near the midline of the

perineum, but when they are traced upwards they are invariably found to extend into one / other posteriolateral vaginal sulcus.

Sometimes the upper limit of the tear is felt better – helpful to catch the upper edge of the vaginal tear.

If a double tear is found, care must be taken to unite the lateral vaginal walls to the loose posterior tongue.

Tears of the anterior vaginal wall often involve the tissues close to the urethral meatus. Later, pt. is unable to void urine because of muscle spasm consequent on the bruising around the urethra & bladder neck.

Third degree tears:-A tear has extended into the anal sphincter or

canal.Any fecal contamination is cleared away & area

drenched with an aqueous solution of antiseptic.

The muscle wall of the rectum & anal canal is closed by interrupted or continuous catgut sutures (No.0) placed so that the suture avoids the bowel mucosa.

Disadvantage – appearance of small rectovaginal fistula at the upper end of the wound.

Symptomatology:• Immediate:

– Bleeding Traumatic PPH - hemorrhagic shock.– Perineal Pain– Perineal hematoma– Urinary retention due to painful perineum– Urinary incontinence– Anorectal dysfunctions like fecal incontinence

• Delayed:1. Infected perineum- perineal abscess2. Uterovaginal prolapse3. Urinary incontinence (stress and urinary fistula)4. Fecal incontinence ( rectovaginal fistula)5. Dyspareunia6. Feeling of slack vagina during coitus

• Bleeding• Disruption of anatomical continuity

PREVENTION

- LIBERAL USE OF EPISIOTOMY - PROPER CONDUCT OF LABOUR DURING

2ND STAGE - PERINEAL SUPPORT DURING 2ND STAGE

Repair of perineal tear : First degree:• Sometime doesn’t require suturing or can use

one or two interrupted suture.Second degree:• The vaginal mucosa is to be sutured first. The first

suture is placed at or just above the apex of the tear. Thereafter, the vaginal walls are opposed by interrupted sutures with chromic catgut no. ‘Ofrom above downwards till the fourchette is reached. The sutures should include the deeper tissues to obliterate the dead space.

• A continuous suturing may cause shortening of the posterior vaginal wall.

Complete perineal tear:

• The rectal and anal mucosa is sutured from above downwards by interrupted sutures. Muscle walls including the pararectal fascia are then sutured by interrupted sutures. The torn ends of the sphincter ani externus are sutured with figure of eight stitch by another interrupted suture.

• Perineal skin by interrupted suture

AFTER CARE: • LOW RESIDUE DIET• STOOL SOFTNER• SEITZ BATH BD• ORAL ANTIBIOTICS: ANAEROBIC• ANALGESICS

Complications if left untreated:

• Infection• Hemorrhagic Shock• Cosmetic disadvantage• 3rd and 4th degree tears if left untreated may

lead to fecal incontinence.

Episiotomy• It is an incision on the perineum & the

posterior vaginal wall during the second stage of labor

• It should be performed just before the crowning of head in second stage of labour.

• It is commonly performed for spontaneous vaginal delivery , about 2/3rd of primigravida , 1/3rd of the multiparous

Objective:• To enlarge the vaginal introitus so as to facilitate easy &

safe delivery of the fetus – spontaneous or manipulative.• To minimize over stretching & rupture of the perineal

muscles & fascia• To reduce the stress & strain on the fetal head.Indications:• In elastic or rigid perineum.• Anticipating perineal tear – big baby, face to pubis

delivery, breech delivery, shoulder dystocia.• Operative delivery: forceps delivery, ventouse delivery.• Previous perineal surgery: pelvic floor repair, perineal

reconstructive surgery.

Mid line: incision through the fourchette & perineal body.

Advantage: no large blood vessels are encountered & repair is very simple.

Disadvantage: extension of incision includes the anal sphincter or canal itself.

Lateral incision: may cause bleeding or the bartholian gland / duct may be injured & considerable difficulty may be encountered in securing an accurate realignment of the divided structures.

Types

Posterolateral incision: starting at the midpoint of the fourchette or posterior commissure.

It has the advantage to the damage to the sphincter.

J shaped incision: in which after incising the perineum in the midline until a point is reached 2-3 cm from the anterior margin of the anus.

DR ASHRAF ATIA DEWIDAR MD MRCOG

Median MediolateralMerits :-the muscles are not cut- blood loss is least.- repair is easy.- postoperative comfort is maximum.- healing is superior.- Wound disruption is rare.- Dypareunia is rare.

- relative safety from rectalinvolvement from extension.

- if necessary, the incision can be extended.

Demerits :

- Extension, if occursinvolves rectum.

- Not suitable inmanipulative delivery or in abnormal presentation or position.

-Apposition of the tissues is not so good.

-Blood loss is little more.

- Relative increased incidence of wound disruption.

- Dyspareunia is more

AdvantagesMaternal – Reduction in the duration of second

stage. Reduction of trauma to the pelvic floor

muscles.Fetal – it minimizes intracranial injuries.

The structures involved during mediolateral episiotomy are :

Posterior vaginal wall Superficial and deep transverse perineal muscle,

bulbospongiosus and part of levator ani. Fascia covering those muscles. Transverse perineal branches of pudendal vessels

and nerves. Subcutaneous tissue and skin

Timing of the repair of episiotomy The most common practice is to defer

episiotomy repair until the placenta has been delivered.

Early delivery of the placenta reduces blood loss from the implantation site because it prevents the development of extensive retroplacement bleeding.

Advantage is that episiotomy repair is not interrupted or disrupted by delivery of placenta, especially if manual removal must be performed

Post operative care:

• Clean wound with clean water after each urination and defaecation.

• Keep area dry• Apply clean pads• Analgesics if needed• Peri-care and peri-light• Suture removal on 7th -10th post op day if silk is

applied.• F/U after 6 wks if no complication

ComplicationImmediate:1. Extension of the incision: involves rectum,

mainly in median episiotomy or occipito posterior.

2. Vulval haematoma.3. Infection.4. Wound dehiscence: infection is the primary

cause of wound disruption.5. Injury to anal sphincter.6. Rectovaginal fistula.

Cont-dRemote:• Dyspareunia due to narrow introitus.• Chance of perineal lacerations.• Scar endometriosis.

Prevention of perineal tear:

• Well support of the perineum at the time of delivery of head

• Delivery by early extension is to be avoided • Spontaneously forcible delivery is to be

avoided• To deliver the head in between contraction• To perform timely epsiotomy• To take care during delivery of shoulder

Periurethral Tears Vaginal tears can also occur at the

region around the urethra - the opening through which urine comes out. These are then called ' Periurethral tears'. The problem with these type of tears is that there may be profuse bleeding from even a small tear since the region has a large blood supply.

Causes • The commonest cause for a periurethral

tear is a sudden extension of the fetal head at the time of delivery. Normally, the fetal head is in a position of flexion with the chin touching the chest. At the time of delivery, after crowning occurs, the head is born by extension. A gradual extension will not put much presure on the anterior or upper part of the vagina. But a sudden extension will cause a sudden pressure on upper vaginal area resulting in a periurethral tear.

How to prevent

• It is important for the doctor or midwife to press gently on the fetal head at the time of delivery and guide it to a slow and gradual extension at the time of birth.

Treatment• Periurethral tears need to be stitched carefully

under proper light. If not repaired well or if it is not diagnosed after the delivery, it can bleed continuously for quite some time and cause many other problems

• It is advisable for the woman to use cold packs on the site of the tear for at laeast 7-10 days to hasten healing. Using anti-inflammatory painkillers like Ibuprofen aslo helps.

• Thankfully, during the course of a pregnancy the body is primed to heal quickly. The immune system is more efficient than usual and therefore wounds will heal within a few weeks after childbirth

Complications if not treated • Continuous Bleeding• Infections in the tear• Severe pain and inflammation• Urine Retention due to inability of the

woman to pass urine through the inflamed urethra

Vaginal lacerationsIt involves middle or upper third of the vagina

but not associated with lacerations of the perineum or cervix.

Common during forceps delivery or vaccum, sometime even with spontaneous delivery.

Frequently extend deep into the underlying tissues and give rise to haemorrhage, which is controlled by appropriate suturing.

The tears are repaired by interrupted or continuous sutures using chromic catgut no. ‘0’.

TREATMENT:

MINOR TEAR: NO SUTURINGMAJOR LACERATION: REPAIR USING ABSORABL SUTURE

Cervical tear• The cervix is lacerated in over half of vaginal

deliveries.• Most of these are less than 0.5cm.• Deep cervical tears may be extended to the

upper third of vagina.• In rare instances, the cervix may be entirely or

partially avulsed from the vagina, with colporrhexis in the anterior, posterior or lateral fornices.

Cont-d• Rarely, cervical tears may extend to involve the

lower uterine segment & uterine artery & its major branches & even through the peritoneum.

• Cervical lacerations upto 2 cm must be regraded as inevitable in childbirth. Such tears heal rapidly.

• In healing, they cause a significant change in round shape of the external os before cervical effacement & dilatation to that of appreciable lateral elongation after delivery.

CAUSES:

• RAPID DELIVERY OF FETUS• ASSISTED DELIVERIES• RIGID CERVIX

Diagnosis

A deep cervical tear should always suspected in cases of profuse haemorrhage during & after third stage labour, if the uterus is firmly contracted

• Extent of the injury can be fully appreciated only after adequate exposure & visual inspection of cervix.

Treatment

• Deep cervical tears require surgical repair when the laceration is limited to the cervix or extends into the vaginal fornix, results are obtained by suturing the cervix. Either interrupted / running absorable sutures are suitable

complication INFECTION, PERSISTENT CERVISITIS EXTENSIVE SCARRING STERILITY REPEATED ABORTION PREMATURE LABOUR

Wound healing

• Healing by primary intension occurs in clean incised wounds such as surgical incision.

• It produces a clean, neat, thin scar.• Healing by secondary intension refers to a wound

which is infected, discharging pus or wound with skin loss.

Factors influencing wound healing

1. General: Age Nutrition - protein deficiency, vitamin c and

vitamin A deficiency. Hormones – corticosteroid Medical disorder – Anaemia , Jaundice, Diabetes,

Blood dyscrasis.

Cont-d

2. Local: Position of wound, faulty technique of wound

closure. Poor blood supply, Impairment of lymphatic

drainage. Tension Movement Exposure to ionizing radiation. Foreign bodies tissue reaction and inflammation,

necrosis

UTERINE RUPTURE

• spontaneous or traumatic rupture of the uterus ie., the

actual separation of the uterine myometrium/

previous uterine scar, with rupture of membranes and

extrusion of the fetus or fetal parts into the peritoneal

cavity.

• Dehiscence - partial separation of the old uterine scar;

- the fetus usually stays inside uterus and

the bleeding is minimal when dehiscence occurs

Rupture uterus

CAUSES:IATROGENIC: INJUDICIOUS USE OF OXYTOCIN,

FORCIBLE ECV/ IPV, FALL OR BLOW OVER THE ABDOMEN, , FORCEPS or BREECH EXTRACTION

TYPES:INCOMPLETE RUPTURE: PERITONIUM REMAINS

INTACTCOMPLETE RUPTURE: SCAR IN UPPER SEGMENT-

INVOLVES PERITONIUM

RISK FACTORS:• Women who have had previous surgery on the uterus (upper muscular

portion)

• Having more than five full-term pregnancies

• Having an overdistended uterus (as with twins or other multiples)

• Abnormal positions of the baby such as transverse lie.

• Use of Pitocin (oxytocin) and other labor-induced medications (prostaglandin)

• Rupture of the scar from a previous CS delivery/hysterectomy.

• Uterine/abdominal trauma

• Uterine congenital anomaly

• Obstructed labor; maneuvers within the uterus

• Interdelivery interval (time between deliveries)

Pathologic retraction ring occurs, strong uterine contractions w/o cervical dilatation

“tearing sensation”

Complete rupture Incomplete rupture

Rupturing of endometrium, myometrium and perimetrium

Rupturing of endometrium and myometrium

PATHOPHYSIOLOGY

Uterine contraction stopsLocalized tenderness and

persisting aching pain over the area of the uterine segment

Bleeding into the peritoneal cavity

Decreased venous return

Decreased BP

Heart attempts to circulate remaining blood volume

Vasoconstriction of peripheral vessels, increased heart rate

Swelling of the abdomen:• Retracted uterus• Extrauterine fetus

Hemorrhage from torn uterine arteries

Bleeding to the vagina

Decreased blood volume Decreased cardiac output

Increases gas exchange to oxygenate better the decreased

blood volume

Cold, clammy skin

Increased respiratory rate

Continued blood loss will continue to fall BP

Uterine perfusion is decreased

Fetal distress

Decreased brain perfusion

Decreased kidney perfusion

Decreased LOC (lethargy, coma) Decreased urine output

Renal failure

Death of Mother and fetus

ASSESSMENT:•evaluate maternal vital signs•note an increase in rate and depth of respirations, an increase in pulse , or a drop in BP indicating status change•assess fetal status by continuous monitoring•speak with family, and evaluate their understanding of the situation•observe for signs and symptoms of impending rupture

-lack of cervical dilatation-tetanic uterine contractions- restlessness- anxiety- severe abdominal pain- fetal bradycardia- late or variable decelerations of the FHR)

SIGNS AND SYMPTOMS

Developing Rupture•Abdominal pain and tenderness

•Uterine contractions will usually continue but will diminish in intensity and tone.

•Bleeding into the abdominal cavity and sometimes into the vagina.

•Vomiting

•Syncope; tachycardia; pallor

•Significant change in FHR characteristics – usually bradycardia (most significant sign)

•Difficulty identifying fundal height

•Vaginal bleeding

•Maternal hemorrhage and shock

•Absent fetal heart tones

Clinical Manifestations:

Violent Traumatic Rupture

•Sudden sharp abdominal pain during or between contractions.

•Abdominal tenderness

•Uterine contractions may be absent, or may continue but be diminished in intensity

and cord

•bleeding vaginally, abdominally, or both

•Fetus easily palpated in the abdominal with shoulder pain

•Tenses, acute abdominal with shoulder pain

•Signs of shock

•Chest pain from diaphragmatic irritation due to bleeding into the abdomen.

NURSING DIAGNOSIS AND INTERVENTIONS

Aspiration riskImpaired gas exchangeAltered tissue perfusionFluid volume deficitInfection riskAnxiety and fearAnticipatory grievingPain

OxygenIntravenous fluidsMaternal vital signsUterine contractionsUterine/vaginal blood lossMeasure and record fundal height every 30 minutes

Planning and Implementation

Start or maintain an IV fluid as prescribed. Use

a large gauge catheter when starting the IV for

blood and large quantities of fluid replacemnt.

Maintain CVP and arterial lines, as indicated for

hemodynamic monitoring.

Maintain bed rest to decrease metabolic

demands.

Insert Foley catheter, and moniter urine output

hourly or as indicated.

Obtain and administer blood products as

indicated.

Deficient Fluid Volume

FearGive brief explanation to the woman and her support

person before beginning a procedure.

Answer questions that the family or woman may have.

Maintain a quiet and calm atmosphere to enhance

relaxation.

Remain with the woman until anesthesia has been

administered; offer support as needed.

Keep the family members aware of the situation while the

woman is in surgery and allow time for them to express

feelings.

Decreased cardiac output

•Administer supplemental oxygen, blood/fluid replacement, antibiotics, diuretics, inotropic drugs, antidysrhythmics, steroids, vassopressors, and/or dilators as ordered.•Position HOB flat or keep trunk horizontal while raising legs 20 to 30 degrees in shock situation•Activities such as isometric exercises, rectal stimulation, vomiting, spasmodic coughing which may stimulate Valsalva response should be avoided; administer stool softener as indicated.

Administer O2 using a face mask at 8-12 L/min or

as ordered to provide high oxygen concentration.

Apply pulse oximeter, and monitor oxygen

saturation as indicated.

Monitor ABG levels and serum electrolytes as

indicated to assess respiratory status, observing for

hyperventilation and electrolyte imbalance.

Continually monitor maternal and fetal vital signs

to assess pattern because progressive changes may

indicate profound shock.

Ineffective Tissue Perfusion

Risk for Infection

• Observe for localized signs of infection.

•Cleanse incision or insertion sites daily

and PRN with povidone iodine or other

appropriate solutions.

•Change dressings as needed or indicated.

•Encourage early ambulation, deep

breathing, coughing and position changes.

•Maintain adequate hydration and

provide.

•Provide perineal care.

MEDICAL MANAGEMENT• Immediate stabilization of maternal

hemodynamics and immediate

caesarean delivery

• Oxytocin is given to contract the uterus

and the replacement .

• After surgery, additional blood, and fluid

replacement is continued along with

antibiotic theory.

SURGICAL MANAGEMENT

•Caesarean Section

•Laparotomy

•Hysterectomy

NURSING MANAGEMENT•Continually evaluate maternal vital signs; especially note an increase in rate and depth of respirations, an increase in pulse , or a drop in BP indicating status change.•Assess fetal status by continuous monitoring.•Speak with family, and evaluate their understanding of the situation. •Anticipate the need for an immediate caesarean birth to prevent rupture when symptoms are present.•Provide information to the support person and inform him or her about fetal outcome, the extent of the surgery and the woman’s safety.•Let the pt express her emotion without feeing threatened.

• Female Genital Mutilation compromises all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non medical reasons (WHO, UNICEF, UNFPA, 1997)..

FGM

ProceduresNO ANESTHESIA*Type III- Also known as

Infibulation.*Type IV- All other

harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization.

Health Risks• ZERO health benefits. • Obvious: damages healthy genital tissue and

interferes with a woman’s natural bodily functions.

Health Risks • Immediate Complications• Severe pain• Shock• Hemorrhage• Tetanus• Sepsis (bacterial infection) • Urine retention• Open sores

Cont-d• Long Term Consequences• Bladder and urinary tract infections• Cysts• Infertility • Need for later surgeries• Childbirth complications • Newborn deaths • Decreased sexual pleasure

International Organizations