Patrimonial trauma – the collective concept including various damages of fabrics and bodies of the woman in labor or newborn caused by action of patrimonial forces. Hematomas, ruptures of a vulva, crotch and vagina, injury of a uterus, formation of urinogenital and enterosexual fistulas, deformations of pelvic bones occur among patrimonial injuries of mother. Many of patrimonial injuries can have the character menacing for life. Diagnosis of patrimonial injuries is made on the basis of external examination, a gynecologic research, tool methods. Treatment of patrimonial injuries of mother, as a rule, demands the emergency operational grant and involvement of narrow experts (urologists, proctologists, traumatologists).
Childbirth is difficult test for the born fruit and mother. Therefore after appearance of the child experts quite often state presence of various patrimonial injuries and postnatal violations at the woman in labor and the newborn. In obstetrics and gynecology distinguish maternal and children's patrimonial traumatism. Treat patrimonial injuries of the newborn various on character and expressiveness of damage peripheral and the central nervous system, an injury of bones and soft fabrics, internals. Within this review the main patrimonial injuries which are found at women will be considered.
Considerable stretching of patrimonial ways of mother in the course of the patrimonial act quite often leads to their damage. These damages – patrimonial injuries, can have superficial, not rough character (for example, grazes, cracks) and to heal independently in the early postnatal period, and remaining not distinguished. In certain cases patrimonial injuries happen so considerable that can lead to serious postnatal complications, disability and even death of the woman. Hematomas occur among patrimonial injuries of mother; ruptures of a vulva, crotch, vagina, body and neck of a uterus; uterus eversion; stretchings and ruptures of joints of a basin; urogenital and enterogenital fistulas.
General reasons of patrimonial injuries of mother
The variety of options of patrimonial injuries of mother can be caused by various mechanical and gistopatichesky reasons. The rough or dicoordinated patrimonial activity, rendering operational grants in labor (imposing of nippers, carrying out vacuum extraction of a fruit, manual office of an afterbirth, plodorazrushayushchy operations), an excessive rodostimulyation, irrational maintaining the potuzhny period, an inadequate zashchiyota of a crotch etc. belong to mechanical factors of developing of patrimonial injuries. Perenoshenny pregnancy, the cross provision of a fruit, pelvic prelying of a fruit, premature birth, a narrow basin, abundance of water, mnogoplody, prelying of a placenta can promote patrimonial injuries.
The Gistopatichesky reasons of patrimonial injuries are caused by the burdened obstetric and gynecologic anamnesis of the woman in labor. So, as the reasons of patrimonial injuries of a uterus surgeries can serve in the past (Cesarean section, metroplasticity, a conservative miomektomiya, full or partial perforation of a uterus at abortion, etc.) which lead to formation of a hem on a uterus and, as a result, defective sokratitelny ability a miometriya in labor.
The probability of developing of injuries of patrimonial ways increases with anatomic defects of genitals (an intrauterine partition, a hypoplasia of a uterus, a two-horned uterus), a uterus neck rigidnost at late primipara, uterus giperantefleksiya. Also patrimonial injuries can be caused by tservitsita, adenomiozy, endometritises, colpitises, a puzyrny drift and horionepiteliomy. At an etiopatogeneza of a patrimonial trauma there are several burdening factors more often.
Patrimonial injuries of a vulva and vagina
Hematomas of a vulva and vagina
Hematomas of a vulva and vagina are caused by stretching and a rupture of vessels in the thickness of soft fabrics at the intact covers. At the same time the blood streaming from the damaged vessel accumulates in cellulose and under mucous, forming a hematoma.
At patrimonial injuries of soft fabrics in a vulva and a vagina there is a tumor of blue-crimson color which size can reach the newborn's head. Hematomas cause feeling of discomfort (a raspiraniye, pressure), morbidity. The big progressing hematomas extend to cellulose of a small pelvis and can be followed by development of hemorrhagic shock. Small hemorrhages usually independently resolve; at large hematomas their suppuration is possible. Recognition of patrimonial injuries of soft fabrics happens at external examination and a gynecologic research.
Surgical tactics is shown concerning large (diameter more than 4-5 cm) and the progressing hematomas. At the same time fabrics over a hematoma open, delete the accumulated blood, allocate and tie up the bleeding vessel, sew up a wound tightly. At the infected hematoma the ushivaniye of a wound is not made. At the progressing hematoma the chrevosecheniye sometimes is required.
Ruptures of a vulva and vagina
Patrimonial injuries of a vulva and vagina most often occur at primipara. Easy cracks and anguishes usually proceed asymptomatically and do not demand intervention. Gaps in a clitoris, an urethra, a vagina are followed by formation of hematomas, massive bleeding, hemorrhagic shock.
Patrimonial injuries of a vagina can have spontaneous and violent character. In the latter case as the reasons of patrimonial injuries serve various obstetric operations. Ruptures of a vagina can happen in its top, average or lower departments; to have superficial or deep character, reaching cellulose of a small pelvis and an abdominal cavity.
Patrimonial injuries of tissues of vulva come to light at survey. Survey of walls of a vagina by means of mirrors is necessary for an exception of internal gaps.
Treatment of patrimonial injuries of vulva and vagina exclusively surgical. After a bladder kateterization a metal catheter make an ushivaniye of gaps ketgutovy seams. In the post-operational period antimicrobic therapy and vaginal trays with antiseptics is appointed. Not recognizable ruptures of a vagina can heal neoslozhnenno or be infected. Deep gaps can lead to a secondary atresia of a vagina subsequently, dictating need of performance of vaginoplasty.
Patrimonial injuries of a crotch
Violent or spontaneous ruptures of skin, cellulose and musculo fabrics of a pelvic bottom belong to patrimonial injuries of a crotch. Patrimonial injuries of a crotch occur at 7-15% of women in labor, and is much more often at primipara. Ruptures of a crotch are often combined with patrimonial injuries of a vagina.
The threat of a patrimonial injury of crotch is demonstrated by protrusion and cyanosis of fabrics of a pelvic bottom, puffiness and gloss of fabrics, cracks. In the presence of threat of a patrimonial injury of crotch resort to a median section of fabrics – to a perineotomiya or a side section – an epiziotomiya with the subsequent ushivaniye.
Symptoms of a rupture of a crotch
Depending on depth of a patrimonial trauma allocate 3 degrees of ruptures of a crotch.
At a rupture of a crotch of the I degree integrity of skin and hypodermic cellulose in the field of back soldering is broken. The II degree of a rupture of a crotch is characterized by additional injuries of muscles of a pelvic bottom (including, the muscle lifting back pass), back or sidewalls of a vagina. At a patrimonial injury of a crotch of the III degree the rupture of an external sphincter, and sometimes and rectum walls joins above-mentioned damages.
Patrimonial injuries of a crotch are shown by violation of integrity of fabrics and bleeding.
Diagnostics and treatment of ruptures of a crotch
Patrimonial injuries of a crotch are distinguished after the placenta birth. For this purpose the obstetrician-gynecologist parts a sexual crack, examines walls of a vagina and a neck of a uterus. More often injury of a crotch to childbirth happens not on the median line, and ekstramedialno, however also the central gap between the back soldering and a muscle lifting back pass meets.
Restoration of integrity of tissues of crotch is made by an ushivaniye under local infiltration or general anesthesia. Separate ketgutovy seams are imposed on the damaged walls of a vagina and a rectum, a muscle of a pelvic bottom, hypodermic cellulose and skin of a crotch. In the postnatal period processing of seams, a careful toilet of a wound after each defecation and an urination, prevention of locks is made.
Patrimonial injuries of a uterus
Ruptures of a uterus
The rupture of a uterus belongs to the hardest patrimonial injuries and meets in 0,015%-0,1% of total of childbirth. At a rupture of a uterus there is a violation of integrity of walls of her body. The lethality of women at a patrimonial injury of a uterus from shock, anemia and septic complications reaches 3-4%. At many women who transferred a rupture of a uterus hypoxemic encephalopathy develops further. Death of a fruit at ruptures of a uterus is close to 100%.
Classification of ruptures of a uterus
Distinguish the ruptures of a uterus which occurred in the course of pregnancy and during childbirth. On pathogenetic symptoms of a patrimonial trauma allocate spontaneous (mechanical, gistopatichesky and mechanical ) and violent (traumatic, mixed) ruptures of a uterus. On clinic of a patrimonial trauma ruptures of a uterus can have the menacing, begun, made character.
On a damage rate of walls of a uterus the patrimonial trauma can have the form of a crack, the incomplete gap and a complete separation getting into an abdominal cavity. On localization distinguish a rupture of a bottom of a uterus, her body, the lower segment, and also a full separation of a uterus from the vaginal arches () at the cross provision of a fruit.
Symptoms of a rupture of a uterus
The clinic of a patrimonial injury of uterus depends on the reasons, a stage, degree, localization of a gap. Weight of manifestations and a consequence are in many respects caused by the accompanying background – in the presence of somatic diseases of the woman in labor, gestoz, physical and mental exhaustion, an infection and so forth in an organism irreversible changes quickly develop.
Excessive patrimonial activity with painful strong contractions, deformation of a uterus in the form of hourglasses, development of hypostasis of a neck of a uterus, vagina and vulva, difficulty of an urination, concern of the woman in labor is typical for the menacing rupture of a uterus. At the begun rupture of a uterus in the listed symptoms gematuriya are supplemented with convulsive fights, emergence of sanious or blood allocations from a vagina.
At the come true rupture of a uterus after sharp pain and burning in a stomach patrimonial activity stops, the woman in labor calms down, becomes oppressed, apathetic. Owing to development of hemorrhagic and painful shock pallor of skin, hypotonia, tachycardia quickly increase, cold sweat, nausea and vomiting appears. After a rupture of a uterus of a part of a fruit are partially or completely palpated in an abdominal cavity, heartbeat of a fruit is absent. External bleeding at this patrimonial trauma can be considerable or poor depending on the sizes and localization of a rupture of a uterus.
Emergency aid at ruptures of a uterus
At threat of a rupture of a uterus the immediate termination of patrimonial activity and completion of childbirth – Caesarian the section or plodorazrushayushchy operation is necessary in the operational way. At the begun or come true rupture of a uterus the chrevosecheniye, extraction of a fruit and afterbirth, removal of amniotic waters and blood is carried out, the hemostasis is made. Intervention volume at these patrimonial injuries – from nadvlagalishchny amputation to a hysterectomy. The Ushivany uterus perhaps at young patients at recent and small ruptures of linear character, absence of an infection.
Carrying out adequate completion of blood loss, antishock infusion-transfusion therapy, haemo coagulation correction is at the same time necessary. If patrimonial injuries of a uterus were not distinguished, bleeding or peritonitis can develop, and also to come death of the woman in childbirth. At infectious complications the laparotomy, removal of a uterus with appendages is undertaken (pan-hysterectomy), drainage of an abdominal cavity, massive antibacterial therapy.
Ruptures of a neck of a uterus
This type of a patrimonial trauma occurs according to various authors at 3-60% of women in labor. Ruptures of a neck of a uterus (violent or spontaneous) on depth of damage are divided into 3 degrees: I – defect no more than 2 cm; II - defect more than 2 cm, but not reaching the vaginal arches; III – the defect reaching the arches and passing to them. Ruptures of a neck of a uterus are usually localized in side departments, a thicket at the left.
Symptoms of ruptures of a neck of a uterus
Patrimonial injuries of a neck of a uterus are shown by postnatal bleeding from a vagina after the birth of an afterbirth and reduction of a uterus. The blood following from a genital tract has scarlet color, is emitted with a continuous stream or in the form of a large number of clots in the absence of external damages of patrimonial ways. Sometimes bleeding happens insignificant or absolutely is absent. At damage of branches of uterine arteries izlity blood or formation of hematomas in paratservikalny cellulose, the clinic of hemorrhagic shock is observed massive.
Diagnostics and treatment of ruptures of a neck of a uterus
For recognition of patrimonial injuries of neck of a uterus all women in childbirth need carrying out survey by means of mirrors right after completion of childbirth, and also in 6-48 hours after reduction of hypostasis and stretching of fabrics.
The found ruptures of a neck of a uterus are subject to an ushivaniye at once or is delayed, no later than 2 days after the delivery. Seams on ruptures of a neck impose through all layers of fabrics, beginning from the top corner of defect in the direction of an external pharynx. In view of adverse conditions (existence of lokhiya, hypostasis, a razmozzheniye of fabrics) patrimonial injuries of a neck of a uterus quite often heal a secondary tension.
Other patrimonial injuries
Development of a sharp eversion of a uterus is caused by the wrong maintaining the posledovy period, weakness of uterine sheaves, an atoniy uterus. Distinguish a partial and full eversion of a uterus. This patrimonial trauma proceeds with the phenomena of painful shock.
Treatment of an eversion of a uterus consists in holding antishock actions and reposition of a uterus on its anatomic place in the conditions of the general anesthesia.
Stretching and ruptures of pelvic joints
These patrimonial injuries develop at an excessive softening of joints of a basin (a simfiziopatiya, a simfizita), childbirth by a perenoshenny or large fruit, obstetric grants. At the same time there is stretching and a divergence of lonny bones on distance more than 0,5 cm from each other. The rupture of a lonny joint often is followed by the shift of bones, injury of a bladder, urethra, clitoris. Stretching sacral joints leads to hemorrhages and the subsequent inflammations of joints.
The clinic of patrimonial injuries of pelvic joints is shown by the pains in the field of a bosom, a tailbone, a sacrum amplifying at assignment of legs, walking; gait violation, hyperaemia of skin and hypostasis of surrounding fabrics.
Patrimonial injuries of pelvic area come to light during consultation of the traumatologist at survey, a palpation, a X-ray analysis lonny, sacral joints, a basin. Treatment of stretchings of pelvic joints demands rest, hard bandaging, carrying special corsets. The rupture of a lonny joint or a considerable divergence of bones of a basin demands surgical intervention.
Urogenital and vaginal fistulas
Patrimonial injuries with formation of fistulas are caused long (more than 2 hours) by standing of a head of the child in one plane owing to what blood circulation violation fabrics with their subsequent necrosis develops. Sometimes urinogenital and vaginal fistulas are formed as a result of intraoperative damage of walls of a bladder or a rectum.
Fistulas are shown by release of urine or gases and a calla through vaginas out of acts of an urination and defecation. Such violations are always followed by development of local inflammatory reaction in a vagina (colpitis).
Diagnosis of urogenital fistulas is made during gynecologic survey, a tsistoskopiya; vaginal fistulas are distinguished at a manual rectal research, an irrigoskopiya, a fistulografiya, a rektoskopiya. At identification urinogenital and vaginal fistulas their surgical closing (fistuloplastika) usually is required.
Prevention of patrimonial injuries
Prevention of patrimonial injuries of uterus demands studying of the gynecologic anamnesis of the pregnant woman on early terms, carrying out ultrasonography control of a condition of hems on a uterus during conducting pregnancy, hospitalization of pregnant women with threat of traumatism in labor.
The prevention of patrimonial injuries demands refusal of the forced rodorazresheniye, application of obstetric grants strictly according to indications.