Posterior commissure after childbirth. Stitches after childbirth

Stitches after childbirth are a common and very unpleasant occurrence. Every third woman is faced with this problem and, having heard from experienced friends about the danger of seams coming apart, in a panic she searches for information on how to protect herself from such a situation.

There are several mandatory rules in caring for postpartum scars, but first you need to understand what kind of stitches there are and in what cases they are applied to a woman in labor.

Stitches after caesarean section. Everything here is self-explanatory. Stitches are required. The size of the surgical incision is about 12 cm, and it is made in the area of the lower segment of the uterus.
Sutures on the cervix. Apply when uterine tissue ruptures natural childbirth cervix and premature expulsion, in which the head puts pressure on the cervix, causing it to rupture.
Stitches in the vagina. The walls of the vagina are torn in the same cases as the cervix.
Stitches on the crotch. Perineal ruptures are the most common, there are several types and occur in different situations: quick birth, and so on. The posterior commissure of the vagina (grade 1 rupture), skin and muscles can rupture pelvic floor(2nd degree) and skin, muscles and walls of the rectum (3rd degree). Perineal ruptures can also be artificial: the perineum is cut with a special instrument along the midline from the posterior commissure of the vagina to the anus.

There are several suture techniques. IN lately stitches are increasingly used, borrowed from cosmetology. After healing they are completely invisible. However, regardless of the application technique, sutures require the same quality care. The only difference between seams is the material with which they are made. If sutures are applied with non-absorbable threads, they should be removed after 2-5 days. But self-resorbable material does not require such a procedure. The most commonly used are cadgut, vicryl and maxon. These threads completely dissolve without repeated medical intervention, that is, such sutures are not removed.

How to treat stitches after childbirth?

Sutures in the vagina and cervix, as a rule, practically do not bother a woman and do not require special care. You just need to follow the rules of personal hygiene and not lift heavy objects. Such sutures are applied with threads, which dissolve on their own within a few weeks. Scars heal painlessly and quite quickly.

Sutures after cesarean section require special attention. In the first days after surgery, they are cared for by a nurse. Postoperative suture treated daily with antiseptic solutions and applied sterile bandage. After a week, the non-absorbable threads are removed, but the treatment procedures continue.

Women often complain that the pain from stitches in the perineum does not go away for a long time, and the stitches heal poorly. This requires some patience, but processing is extremely important. To different women suitable for this different drugs. Obstetricians in maternity hospitals treat stitches on the perineum, usually with brilliant green. At home, it is recommended to try Levomekol ointment, Bepanten, Malavit gel, Solcoseryl, Chlorhexidine, sea buckthorn oil, Chlorophyllipt. It should be taken into account that not all remedies are equally good: many women, for example, note increased pain when using Levomekol, and therefore you need to try, select and endure - time also heals in this case. Meanwhile, don’t forget about hygiene.

First shower with postoperative scar can be taken no earlier than a week after the operation, and the seam itself is washed with special care (it should not be rubbed with a washcloth).

How long does it take for stitches to heal after childbirth?

In the area of surgical intervention, the woman in labor will be tormented by pain for a long time, which painkillers will help to cope with first, and then special medications will help reduce the pain; the stomach can also be tied up with a diaper. For 2 months, a woman should not lift weights to avoid possible rupture seam

Careful care is necessary, as we have already said, for the external seams of the perineum. Plus, these wounds are the most difficult to care for. Artificial incisions heal faster and easier, because such an incision has smooth edges, which promotes rapid healing and the formation of an aesthetic scar.

The main condition for the rapid healing of any wound is maximum protection from all kinds of bacteria and peace. It is most difficult to ensure aseptic conditions in the perineal area. There is no bandage to put here, no postpartum discharge don't get rid of it. It remains to observe personal hygiene with special care:

change pads every 2 hours;
wear loose cotton underwear;
refuse shapewear;
After each visit to the toilet, wash with clean water;
Wash the seams with soap every morning and evening;
after washing, dry the perineum with a towel;
treat seams with antiseptic agents daily.

Perineal sutures bother a woman for at least several weeks after childbirth, and sometimes for months. Sometimes they are accompanied by pain and particular discomfort. The main difficulty of a “tailored” woman is the prohibition on sitting. The woman in labor will have to do everything half-sitting for at least a week due to the risk of tearing the stitches. After a few days, you can sit on a hard chair with only one buttock, and then the whole one. Constipation should be avoided so as not to put unnecessary pressure on the perineum.

Scars on the perineum cause pain and discomfort during sex for several months after they have completely healed, because the resulting scar narrows the entrance to the vagina. In this case, a comfortable position and special ointments for scars can help.

Complications

The most unpleasant and dangerous complication is the divergence of postpartum sutures. The reasons may be the following: suppuration of the sutures, sudden movements, early sitting down.

Symptoms of possible complications:

bleeding of sutures;
incessant pain in the area of the sutures;
a feeling of heaviness in the perineum (most often indicating the accumulation of blood in the area of injury);
painful swelling of wounds;
high body temperature.

In all these cases, you need to see a doctor who will examine your stitches and prescribe appropriate treatment. For purulent-inflammatory complications, Vishnevsky ointment or Syntomycin emulsion are usually prescribed, which are used for several days.

You can speed up the healing process of sutures using simple special exercises. To increase blood flow, you should tense and relax your pelvic floor muscles. The most effective exercise is “hold the stream of urine,” during which the vaginal muscles contract. The tension should be held for 6 seconds, then relax. You can repeat the exercises several times a day, alternating tension and relaxation 5-8 times

Especially for- Tanya Kivezhdiy

Overstretching and rupture of the pelvic floor muscles and branches of the pudendal nerve can lead to delayed uterovaginal prolapse and associated urinary and fecal incontinence. Thus, measures to reduce the incidence of injuries to the lower genital tract, knowledge of the anatomy of the pelvic floor and perineum, and techniques for treating injury are integral components of obstetric care.

Anatomy

The tendon center of the perineum is formed by dense connective tissue, to which the bulbocavernosus muscle is attached in front, the superficial transverse perineal muscles are attached to the side, and the anal sphincter muscle complex is attached to the back. The rectovaginal septum and fascia are also attached to the tendon center. The puborectal component of the levator ani muscle forms a loop around the entire anal sphincter muscle complex. The internal sphincter of the anus is a direct continuation of the muscular layer of the rectum.

Principles of surgical reconstruction

The tissues of the lower genital tract are well vascularized and heal quickly. The principles of repair are to ensure hemostasis and juxtapose the tissues tightly and without tension, otherwise subsequent swelling may cause severe
pressure on them with development pain syndrome and necrosis.
The tissue reaction depends on the thickness and type of suture material, as well as on the size of the nodes. Three nodes are enough. A continuous suture technique should be used where possible and the number of stitches should be limited to reduce the number of knots to reduce tissue reaction to the foreign body.
The use of absorbable synthetic suture materials - polyglycolic acid (Dexon) and polyglactin 910 (Vicryl) - provides less pain in the perineal area and a lower percentage of suture divergence compared to catgut. The only drawback of these materials is their slow absorption and the need to remove remaining sutures. This drawback was completely eliminated with the introduction of rapidly absorbable polyglactin 910 (vicrylrapid). Since 2002, catgut has been suture material not used in Europe and the UK.
In general, joining large sections of fabric together in a tight but neat juxtaposition is more acceptable than laying down individual stitches.
If there are local areas of bleeding, they must be clamped and ligated separately. General tissue bleeding can be successfully treated by applying a continuous suture. Firmly pressing this area with a tampon for 1-2 minutes before applying a suture often significantly reduces bleeding and allows you to apply a suture with greater care and accuracy.
To ensure a clean field for work, you can place a swab in top part vagina (this should be noted in the protocol). After closure of an episiotomy or other injury to the lower genital tract is completed, all napkins and needles should be counted to exclude potential clinical complications and lawsuits.

Perineotomy and episiotomy

The traditional belief that perineo/episiotomy prevents more serious perineal tears has not been confirmed. Thus, free conduct“prophylactic” perineo/episiotomy is no longer recommended. However, there are clear indications for this benefit:

shortening the second stage of labor in case of fetal distress;
application of obstetric forceps or, less commonly, a vacuum extractor (in some cases);
shoulder dystocia, breech presentation or the birth of a second fetus from twins (in order to provide more space for obstetric manipulations).

“It sometimes happens... that the baby's head... cannot be born due to excessive constriction of the vaginal opening... so it is necessary to expand it with your fingers, if possible... if not, you need to make an incision towards the anus with curved scissors. by passing one blade between the head and the wall of the vagina as far as is necessary in this case, and making this cut in one movement, with the result that the whole body of the child will be easily delivered.”

There are two types of perineal dissection.

Perineotomy (median episiotomy). Two fingers are inserted into the vagina between the head of the fetus and the tissues of the perineum and, using straight scissors, an incision is made from the commissure of the labia through the tissues of the perineum towards the external sphincter of the anus, but without touching it. The advantages of perineotomy are that the belly of the muscle is not cut, the edges of the cut area are anatomically consistent with each other, which makes suturing the incision easier, and blood loss is less than with an episiotomy. The main negative feature is the tendency to extend the incision into the area of the external anal sphincter and the rectum. Based on these considerations, many practitioners avoid the use of perineotomy.

Mid-lateral episiotomy. The incision starts from the middle of the posterior commissure of the labia and moves towards the ischial tuberosity to avoid damage to the anal sphincter. The length of the incision is usually about 4 cm. In addition to the skin and subcutaneous fat, the incision includes the bulbospongiosus muscle, the transverse muscles of the perineum, and the puborectalis muscle. The direction of the incision to the right or left depends on the preference of the surgeon.

Perineorrhaphy and episiorrhaphy

The principles of perineal reconstruction are similar when using a midline and midlateral incision. First of all, it is necessary to assess the extent of damage. If such evaluation is not carefully performed, partial or complete anal sphincter tears may be missed. The examination should include a rectal examination.

The vaginal tissue and underlying fascia are closed with a single continuous suture using 2/0 or 3/0 rapidly absorbable polyglactin 910 (vicrylrapid) 1 cm from the superior edge of the incision to ensure proper hemostasis. If the tissue bleeds heavily, a double crochet stitch is placed. The suture is continued to the posterior commissure of the labia majora. A separate “crown suture” can be placed under the lower end of this suture to approximate the bulbospongiosus muscle. The deep perineal muscle and the puborectalis muscle are connected with separate sutures. It is necessary to insert a finger into the incision to assess the depth of the injury by touch, especially with a mid-lateral episiotomy. It is also important to ensure that the deep muscle layers are carefully mapped. Sometimes it may be necessary to place two layers of separate sutures to approximate these muscles, but in most cases one continuous suture is sufficient.

The end of the continuous vaginal suture is then directed through the vaginal wall to the deep tissues and also continuously continued at a distance of approximately 1 cm from the edges of the perineal skin to the top of the incision. The same needle is used to extend the suture into a continuous subcutaneous suture back to the posterior commissure of the labia majora where it is tied. In some cases, the depth of the tissue incision is small (usually with perineotomy), and it is enough to apply a single subcutaneous suture from the commissure of the labia to the tip of the incision. It is necessary to use the technique of applying subcutaneous sutures, because through skin sutures more painful and need to be removed.

Suturing of incision dehiscence after episiorrhaphy

Dehiscence of the edges of the incision after episiorrhaphy occurs as a result of incorrect application of the suturing technique or infection. Small areas of dehiscence can be treated with antibiotics and sitz baths if adequate drainage is provided. These small discrepancies are then filled with granulation tissue and heal well within a few days or weeks. Longer suture dehiscences can be treated initially with antibiotics and sitz baths and then re-sutured when signs of active infection have subsided. This will require regional anesthesia and careful surgical debridement of the incision area. If the anal sphincter is damaged, the intestines must be cleaned before re-suturing. The principle of the least number of seams and knots should be adhered to. Subcutaneous or external skin sutures are not recommended. When juxtaposing the underlying tissues, it is necessary to slightly open the edges of the incision to ensure proper drainage.

Perineal lacerations

Anatomically, the perineum is the space between the tip of the coccyx and the lower edge of the pubic symphysis. The anterior perineal region includes the clitoris, urethra, labia, and anterior vaginal wall. The posterior perineal region includes the posterior vaginal wall, the transverse perineal muscles, the levator ani muscle, and the anal sphincter complex. For development standard definitions perineal ruptures, which can be correlated with subsequent diseases of the pelvic floor organs, the following classification has been proposed:

first degree - vagina and perineal skin;
second degree - skin and muscles of the perineum;
third degree - anal sphincter complex:

For -< 50% наружного сфинктера заднего прохода;
3b - > 50% of the external anal sphincter;
3c - external and internal sphincters of the anus;

fourth degree - external and internal sphincters of the anus and rectal mucosa.

Perineal lacerations

“But sometimes, in an unfortunate and deplorable development of events, ruptures occur in the perineum, including both the external genitalia and the anus... They need to be firmly sewn together with three, four stitches or more along the entire length of the rupture, capturing a sufficient fragment of tissue on each side so that the seam didn't break up..."

The incidence of third and fourth degree ruptures usually ranges from 0.5-5.0%. Follow-up ultrasound with a rectal probe shows that more than 30% of women after their first vaginal birth may experience hidden damage sphincter. Thus, damage to the anal sphincter during childbirth may remain unrecognized until an experienced physician performs a thorough ultrasound examination for obvious second-degree tears.

The principles of suturing and repairing first and second degree tears are similar to the principles of episiorrhaphy. Correct primary repair of third and fourth degree tears gives the patient best chance for good long-term results and restoration of anal sphincter function. The following principles must be adhered to.

Recovery should be carried out in the delivery room or operating room with appropriate assistance, lighting, equipment and correct position patients.
Regional anesthesia, spinal or epidural, is optimal because... provides sphincter relaxation and better identification and comparison of separated muscle ends.
The anorectal epithelial rupture is repaired with a running 3/0 Dexon/Vicryl suture.
The internal sphincter tends to retract to such an extent that it is necessary to find the edge of the epithelial layer of the suture from the lateral side. It should be sutured with separate 3/0 polydioxanone (PDS/Maxon) sutures. This suture has a longer tensile strength loss period of 50% and greater tensile strength than Dexon and Vicryl.
Allis clamps secure the ends of the external sphincter. The sphincter is more likely to tear on the side than in the middle, so one end of the sphincter muscle may be pulled into a socket on one side. Having grasped each end of the torn muscle with an Allis forceps, it is necessary to mobilize the ends of the muscle, carefully separating the connective tissue with Metzembaum scissors.
There are two recognized techniques for repairing a torn external sphincter muscle:

“end to end” suturing technique - connecting the ends of the muscle with two or three 8-shaped sutures;
overlapping technique - the ends of the muscle are mobilized so that they overlap each other by 1-1.5 cm. Two or, if possible, three sutures are placed using the PDS/Maxon 3/0 technique. Then the distal end of the upper edge of the muscle is sutured to the lower, underlying edge with two sutures. When using the overlap suturing technique, each suture after placement is held with vascular forceps until the remaining sutures are placed, then all sutures are pulled together and tied at the same time. This ensures that all sutures are placed correctly.

After using any of the described techniques for repairing the external sphincter, the remaining tear is sutured according to the principles of episiorrhaphy using the mentioned suture materials.

It is necessary to prescribe broad-spectrum antibiotics for 5-7 days, as well as laxatives for 2 weeks. postpartum period. There is no evidence that one of these techniques is preferable to the other. Careful identification of third and fourth degree tears and careful adherence to the principles of any chosen suturing technique are key to obtaining good results.

Other types of ruptures

In addition to perineal ruptures, injuries to the vulva and vagina are common.

Damage to the urethra and clitoris area

Minor injuries to the urethral and clitoral area occur quite often, usually during the first birth, when an episiotomy is not performed and the pressure of the nascent head is transferred from the intact posterior perineal area to the anterior one. However, such damage is usually small, and the edges are compared when the woman’s legs are returned to their normal position after the birth of the fetus. If the tear bleeds, pressing with a tampon for 1-2 minutes usually provides hemostasis. If there is significant bleeding, these tears should be closed with a thin continuous suture. It may also be necessary to install urinary catheter to control the placement of sutures.

Tears in the vaginal walls

Injuries to the vagina are common, usually affecting the lower 2/3 of the posterolateral section, and can be a continuation of the episiotomy incision. Injuries to the anterior vaginal wall are less common, but may be associated with a narrow subpubic arch and upward movement of the forceps before the head has completely descended beyond the pubic symphysis. Damage upper third vaginal lesions are rare and, as a rule, are caused by rotation of obstetric forceps during childbirth, which can lead to damage ascending to the fornix, which is then difficult to identify.

The principles for repairing vaginal ruptures are the same as for perineal ruptures. The main difficulty lies in identifying these lesions and their accessibility for suturing. Regional or general anesthesia may be required. The help of assistants, the presence of retractors and good lighting are required. If the top edge of the tear cannot be seen, the suture is placed as high as possible and used to pull the tissue down to bring the top edge of the tear into view. Apply a continuous or (in case of bleeding) continuous double crochet suture. With large and highly located ruptures, it may be necessary to tightly tamponade the vagina along the suture to ensure hemostasis and avoid hematoma formation. In this case, a Foley catheter is installed in the bladder, which can be removed after 12-24 hours along with a tampon. In such situations, it is recommended to prescribe broad-spectrum antibiotics.

Cervical ruptures

Cervical ruptures are quite rare, in most cases they do not bleed and do not require treatment. The cervix is usually inspected using fenestrated forceps, which are applied sequentially to the anterior and posterior lips. If the posterior lip of the cervix is inaccessible for inspection, one clamp should be placed on the anterior lip, and the second on the side, on the 2 o'clock area of the conventional dial. The front clamp is then removed and applied, jumping over the second clamp, to the 4 o'clock area. In this way, you can carefully examine the entire cervix. The rupture usually occurs along the side wall. If its size is less than 2 cm and the wound does not bleed, there is no need for suturing. If the rupture bleeds or the damage is extensive, window clamps are applied on both sides of the rupture and suturing is performed with a continuous double crochet suture. The cervix is well vascularized, and even after applying such a suture, bleeding may persist, and additional sutures only increase the number of bleeding areas. In such cases, window clamps are applied to this area and left for 4 hours, after which they can be removed. Surprisingly, such suturing can be performed with minimal discomfort for a woman in the early postpartum period.

Detachment of a circular fragment of the cervix

Severance of a circular fragment of the cervix is an extremely rare situation associated with cervical dystocia due to its rigidity or scar changes, which leads to the separation of a ring-shaped fragment of the cervix and its birth along with the fetal head. In an early edition of this manual, Chasser Moir vividly described a similar case:

“I remember the family doctor running out the front door to meet the midwife. In his outstretched hands he held a separated fragment of the cervix and explained in a frightened voice: “I just wanted to apply forceps when it ended up in my hands.” Interestingly, this patient later came to me for observation before next births. I carefully examined her neck, but did not find any visible damage ».

In modern obstetrics, avulsion of a circular fragment of the cervix practically does not occur, but “stalk-like” ruptures and small areas of avulsion of the anterior lip can occur during a long first or second stage of labor. If there is no bleeding, such lesions do not require treatment and, as described by Chasser Moir, the cervix remains normal after delivery.

Hematomas

Postpartum hematomas are divided into hematomas of the vulva, vagina, broad ligament of the uterus and retroperitoneal hematomas. Predisposing factors include a long second stage of labor, instrumental obstetric aid, pudendal block and varicose veins of the vulva. Hematomas may be caused by incomplete suturing of vaginal tears or episiotomy. Often there is no obvious trauma, childbirth occurs spontaneously, and the vaginal epithelium covering the damaged vessel remains intact.

Symptoms and signs

Hematomas of the vulva area are clinically clearly manifested by acute pain, hypersensitivity, the formation of purple swelling in the area of the labia majora and can extend to lower section vagina and ischiorectal fossa.
Paravaginal hematomas are not visible upon external examination and usually appear in combination with some or all of the following factors: pain, anxiety of the patient, inability to urinate independently, tenesmus. With careful vaginal examination One finger reveals a painful protrusion into the vagina.
Hematomas of the broad ligament of the uterus and retroperitoneal hematomas are formed when a vessel located above the urogenital diaphragm ruptures. Blood penetrates into the supravaginal space between the leaves of the broad ligament of the uterus and can accumulate retroperitoneally even to the level of the kidneys. Such hematomas often occur against the background of deep injuries reaching the lower uterine segment, or unrecognized lateral ruptures of the lower uterine segment. Hematomas of the broad ligament of the uterus can be detected during a bimanual examination when the uterus is displaced to the side. The formation of extensive hematomas of the broad ligament of the uterus and retroperitoneal hematomas in most cases leads to the development of deep hypovolemic shock and their breakthrough into the abdominal cavity. An ultrasound or MRI will help make the diagnosis.

Treatment

Small hematomas of the vulva area (< 5 см) можно лечить консервативно, используя обезболивание, тщательное наблюдение и прикладывание льда на эту область. Однако при сохранении болевого синдрома или продолжающемся увеличении гематомы ее необходимо вскрыть и опорожнить. Гематомы области влагалища также требуют иссечения и опорожнения. Для этого необходима регионарная или general anesthesia. The incision is made over the area of greatest tension, blood clot deleted. It is necessary to find and ligate bleeding vessels, but this is often not possible. Bleeding areas can be sutured over the edge with 8-shaped sutures. Pressing with a swab for 2-3 minutes helps locate areas of bleeding or areas of ongoing bleeding that require suturing. Then a tight vaginal tamponade is performed gauze swab moistened with lubricant or antiseptic cream. A Foley catheter is inserted into the bladder and removed after 12-24 hours along with a tampon.

Broad ligament hematomas and retroperitoneal hematomas may self-limit and undergo absorption within a few weeks. If the patient is stable, initial management may be conservative with intravenous crystalloids, blood transfusions, analgesia, and observation. If possible, it is advisable to prepare equipment and personnel for embolization of branches of the internal iliac artery. Embolization should be performed if there is evidence of ongoing bleeding. In this case, the procedure can be very effective. In the absence necessary equipment embolization requires laparotomy: the hematoma is removed and the bleeding vessels are ligated. A careful examination should be performed to ensure the presence or absence of uterine rupture as a source of bleeding. The presence of such damage requires suturing the rupture or further hysterectomy.

Manifestations of maternal trauma include injuries birth canal and uterus. Ruptures after childbirth occur in 5-20% of women. Damage to the uterus develops much less frequently - in one case out of 3000. The frequency of injuries to the ligaments and joints of the pelvic bones is even lower.

What kind of gaps are there?

Mostly soft tissues (perineum, vagina, cervix) are affected. Their injuries are usually observed in primiparous patients. If there is an abnormal course of the birth process and incorrect or untimely implementation of obstetric care, both during the first and repeated births, a serious complication may occur - uterine rupture. Stretching or damage to the pubic and iliosacral joints occurs when congenital feature– weaknesses connective tissue.

Injuries to the perineum and vagina

These are the so-called external breaks, the causes of which are:

large fruit;
rapid course of the birth process;
weak labor activity, developed secondarily;
prolonged labor;
extension insertion of the child's head into pelvic ring, for example, facial, when the child’s head enters the birth canal not at its smallest size;
inappropriate sizes of the pelvis and fetus;
deformation of soft tissues by scars after previous births;
, at the end of pregnancy;
post-term pregnancy (more than 42 weeks);
improper breathing during the 2nd period or premature attempts;
use of obstetric forceps.

Damage to the vagina and vulva

Injuries to the vulva are accompanied by superficial tears of the clitoris and labia minora. Injuries to the lower vaginal region are often combined with perineal involvement. If the vaginal rupture occurs in the upper third, it can extend to the cervix. There are situations when the mucous membrane is not damaged, but the soft tissues underneath are crushed by the head passing through the birth canal. As a result, a hematoma, or hemorrhage, occurs in the deep layer of the vaginal wall.

The external genitalia are well supplied with blood, so even with minor damage it is likely heavy bleeding. The resulting defects are sutured, taking care not to damage the corpora cavernosa of the clitoris. For such an intervention, intravenous anesthesia is used if the woman has not previously had epidural anesthesia.

The submucosal hematoma is opened if its size is more than 3 cm. It is cleaned, and the damaged vessels are sutured. If the hemorrhage is very large, drainage strips are left in its cavity for several days, and sutures are placed on the tissue. Absorbable suture material is used, which does not need to be removed later.

If there is an injury to the upper part of the vagina, the doctor must carefully examine the cervix and examine the uterus to prevent the damage from spreading to these organs.

Perineal rupture

Usually develops during the 2nd stage of labor. It can be natural or occur as a result of perineotomy (artificial incision of the perineum to facilitate delivery).

There are 3 degrees of severity of pathology:

I – only the skin of the perineum and the vaginal wall in its lower part are damaged;
II – damage to the muscular structures of the pelvic floor and rupture of the posterior commissure occurs;
III – deeper tissues are affected, in particular the sphincter or rectal wall.

A third degree tear is a serious injury. At improper treatment in the future it becomes the cause of fecal incontinence.

A rare but serious condition is a central rupture. The child is not born through the vagina, but is born through a hole formed in the middle of the perineum. The rectal sphincter and posterior commissure are not injured, but extensive muscle damage occurs.

There are three stages of the pathological process:

Excessive stretching of soft tissues, compression of them by the child’s head or pelvis and difficulty in the outflow of blood through the veins (externally this is accompanied by cyanosis of the skin).
Tissue swelling, characterized by the appearance of a peculiar skin sheen.
Compression of the arteries, pale skin color, malnutrition of soft tissues and their rupture.

To diagnose such injuries, the birth canal is examined immediately after the baby is born. Treatment of injuries is carried out in the first half hour. If regional anesthesia was not used during childbirth, the patient is given an anesthetic intravenously. The operation should be performed by an experienced gynecologist, because if the suturing is improper, prolapse of the muscles of the perineum, vagina, and uterus may occur. scar deformity this anatomical area and even fecal incontinence. In case of muscle injury, they are sutured using absorbable sutures, and non-absorbable sutures are placed on the skin. They are removed after a few days.

Childbirth without perineal rupture takes place under the following conditions:

proper management of the process by the midwife and doctor;
teaching a woman how to behave during the birth of a child during pregnancy;
timely episiotomy (incision) if there is a threat of tissue damage.

Cervical injuries

Its rupture occurs during pushing, mainly in primiparous patients. His reasons:

scars after electrocoagulation, conization, laser exposure or cryosurgery of the cervix before pregnancy;
consequences of cervical rupture during previous births;
heavy weight child;
extensor or occipital presentation(his rear view);
rapid progress or incoordination of labor activity;
vacuum extraction to extract the fetus, use of obstetric forceps.

There are three degrees of injury severity:

I degree - accompanied by one- or two-sided damage up to 2 cm in length. Symptoms are often absent.
II degree - tissue divergence does not reach the edges of the cervix, but exceeds 2 cm in length. Damage to the blood vessels causes moderate bleeding, which does not stop after the release of the placenta and contraction of the myometrium.
III degree – severe damage, involving upper section vagina, often the adjacent uterine segment.

If a cervical injury is not accompanied by bleeding, it can be recognized by careful examination using mirrors. This manipulation is performed on all women in labor in the first 2 hours after the end of labor. If there is bleeding, examination and treatment begin immediately when the placenta comes out and its integrity is confirmed.

If a third degree rupture is suspected, the uterine cavity is examined manually.

Cervical injuries are sutured with catgut.

Damage to the symphysis pubis

Previously, this complication developed when using high forceps or using the Kristeller method for the birth of a large fetus. Nowadays, rupture of the symphysis pubis is observed extremely rarely, mainly against the background of symphysitis - softening of the connective tissue that forms the ligaments in this area. During the birth of a child, the pubic bones diverge by 5 mm or more, without returning to their original position. Damage to the articulation of the bones of the sacrum and pelvis is possible.

This complication is characterized by pain in the pubic area that occurs shortly after childbirth. It gets stronger as you open your hips and walk. The gait changes, redness and swelling appear in the affected area.

Conservative treatment is used, in which a wide bandage is placed around the patient’s pelvis, which crosses in front, and a weight is suspended from its ends. This is how the pubic bones are mechanically pressed against each other. The disadvantage of this method is bed rest within a few weeks. Therefore, a surgical operation is also possible, during which the bones on both sides of the womb are attracted to each other, for example, using a wire.

Birth trauma to the uterus

Internal ruptures during childbirth involving the uterine pharynx and the muscular wall itself in half of the cases are accompanied by the death of the child and can cause fatal outcome for the woman herself. In modern obstetrics, such a pathology rarely occurs, since predisposing factors of damage are recognized in time, and the patient is referred to.

The causes of this serious condition are an obstacle to the child in the natural birth canal and pathology of the uterine wall that arose even before pregnancy. Uterine rupture can be incomplete or complete. Incomplete occurs in the lower part of the organ, not covered by the peritoneum, and does not penetrate into the abdominal cavity, unlike complete. Pathology can be observed in any part, and most often occurs at the site of a scar after a cesarean section or myomectomy.

Mechanical damage caused by an obstacle to the birth of a child is now rarely diagnosed. Risk factors:

narrow pelvis;
neoplasms of the pelvic organs;
large fruit size;
scars on the cervix or vaginal wall;
incorrect presentation or position of the baby.

Much more often, injury develops in the area of pathologically changed tissues. Disturbance of the normal structure of the myometrium occurs:

after surgery;
at large quantities childbirth (4 or more);
with numerous abortions or curettages;
after .

Obstetricians are increasingly using caesarean section surgery, which leaves a scar after healing. At repeat pregnancy the tissues gradually weaken and “spread,” which intensifies during childbirth. Damage to the myometrial vessels leads to hemorrhage into the uterine wall, and only then does the organ rupture.

The obstetrician must be aware of the danger of violent injury to the uterus. Its threat is real in a situation where labor is stimulated using oxytocin in a multiparous woman with a large fetus and a pathologically altered uterine wall. In this case, the myometrium begins to contract intensively, and even the slightest difference in the size of the pelvis and the fetus leads to rapid rupture of the muscle wall.

Signs threatening break:

after the release of amniotic fluid, frequent, gradually intensifying, very painful contractions occur;
a woman worries not only during contractions, but also in the rest periods between them;
heart rate increases, shortness of breath appears;
the bladder is located above the pubis, urination is impaired, blood can be detected in the urine;
the stomach takes shape " hourglass» due to upward displacement of the contraction ring of the uterus;
the genitals become swollen.

Symptoms of incipient uterine damage:

signs of painful shock - screaming, agitation, redness of the face;
convulsive nature of contractions, attempts appear when the head is located high;
bloody discharge from the birth canal;
and the death of a child.

At complete break suddenly, during a contraction, acute pain appears. Labor activity stops completely. Internal bleeding accompanied by pallor, sweating, weakened pulse, dizziness and loss of consciousness. The fetus dies and may move into the abdominal cavity. Blood continues to flow from the birth canal.

The entire process from start to completion of the rip takes just a few minutes.

Sometimes damage develops during the last push. Is born healthy child, then the afterbirth comes out. Signs of blood loss gradually begin to appear. The diagnosis is made after manual examination of the uterine cavity or during emergency laparoscopic surgery.

An incomplete rupture is characterized by the following symptoms:

pallor, palpitations, decreased blood pressure;
pain in the lower abdominal segment, which often radiates (“gives”) to the leg;
bloating and soreness of the abdomen, which gradually becomes diffuse.

In case of threatening or incipient damage, immediate caesarean section is indicated, intensive infusion therapy(intravenous infusion of solutions, if necessary, blood products). If possible, the uterus is preserved by suturing the defect. If the injury is significant, amputation is performed.

Prevention of uterine ruptures consists of careful management of pregnancy and childbirth in patients at risk.

Possible complications

Tissue trauma during childbirth may have serious consequences:

hemorrhage with the formation of a hematoma;
suppuration of the resulting accumulation of blood with the formation of an abscess;
suture infection;
swelling that makes it difficult to urinate.

Subsequently, a scar is formed, which causes deformation of the cervix. In some cases, this leads to miscarriage of subsequent pregnancies and often serves as an indication for cesarean section. In severe cases, cervical plastic surgery or removal of scar tissue using laser techniques is necessary. Another complication is, or “eversion” of the cervical canal.

Damage to the vagina and labia usually does not have serious consequences. If the clitoris is injured, its sensitivity may temporarily decrease. If the skin is damaged, a small scar will form.

Recovery period

It is much easier to prevent soft tissue tears than to treat them. If an injury does occur, it is necessary to follow doctors’ instructions for speedy recovery health.

How long does it take for tears to heal after childbirth?

The most common of them (perineal injuries) disappear after 4-5 weeks. For favorable healing in the first days, the sutures are treated with antiseptics, for example, a solution of brilliant green or hydrogen peroxide. The patient is then given the following recommendations:

wash with water after each urination or defecation from front to back;
dry the seam area well with a towel or paper napkin;
change sanitary pads as often as possible, ideally every 2 hours;
provide air access to the perineal area;
walk more, but without discomfort or pain;
avoid constipation, use laxatives if necessary, preferably glycerin suppositories;
when pain increases, discharge appears unusual color or smell, fever, you should immediately contact a gynecologist.

Both after an episiotomy and after perineal tears, it is not recommended to sit for at least a week. Then it is better to sit on an inflatable rubber ring to avoid fabric tension and seams coming apart.

Recovery after childbirth complicated by ruptures depends on their location and severity. However, with early detection and suturing severe complications are uncharacteristic, and in the future the woman can give birth naturally.

Prevention

To prevent injury, the mother must properly prepare for childbirth, and during the process itself, calmly follow all instructions from the medical staff.

Preparing during pregnancy

To learn how to give birth correctly without ruptures, you should visit the “School for Pregnant Women”, which operates in almost every antenatal clinic. If this is not possible, you can ask all your questions from the doctor leading the pregnancy.

rhythmic contraction of the muscles of the perineum, anus and vagina ();
imaginary grasping of the handles of a large bag with the crotch in a half-squat position and lifting it with straightening the legs;
imaginary movement of an elevator up and down the vagina with tension in the corresponding muscles.

Such gymnastics improves blood circulation in the tissues of the pelvic floor, helps to strengthen them and increase elasticity.

It is very important to become familiar with the periods of labor, breathing patterns and behavior during contractions and pushing.

About a month before the expected birth of the baby, to moisturize and nourish the tissues of the perineum, you can regularly apply almond or other vegetable oil to this area, to which, if desired, add a few drops of essential oil of eucalyptus, lemon, coniferous trees. It is undesirable to introduce any substances into the vagina, as this can provoke an increase in the tone of the uterus and.

How to avoid ruptures during childbirth?

Everything depends not only on the woman’s efforts, but also on the speed at which the child passes through the birth canal, its weight, position and many other factors. If there is a threat of soft tissue rupture, doctors make an incision, which heals much faster.

An episiotomy operation is performed when there is a threatening rupture of soft tissues in the 2nd stage of labor. The doctor makes a small incision in the skin of the perineum from the center to the side. No anesthesia is required. If epidural anesthesia is used, such an intervention is completely painless for the patient. Immediately after labor is completed, the incision is carefully sutured.

How to push correctly?

Start only at the command of the midwife, when the cervix is dilated enough for the head to come out.
Do not push as the head passes through the cervix, as the physician delivering the baby will also warn you about.
Before pushing, inhale smoothly and quickly, and then exhale forcefully for 15 seconds, while simultaneously straining your abdominal muscles. During one attempt, repeat this exhalation three times.
In the interval between attempts, relax as much as possible.
If you can’t push, start breathing “like a dog” - fast and shallow.

Application of obstetric gel

Obstetric gel for ruptures Dianatal will help facilitate the birth of a child and prevent tissue damage. It forms a lubricating film on the surface of the vagina, reducing friction on the baby's head. Studies have shown that the use of such a gel not only speeds up labor, but also protects the perineal tissue.

The drug is available in two forms, the first of which is intended for treating the birth canal during cervical dilatation, and the second - during the pushing period. The gel is inserted by the doctor into the vagina using an applicator. It is sterile and does not contain harmful substances and is the only currently licensed product to facilitate labor and protect maternal tissue.

Dianatal obstetric gel was developed in Switzerland, produced in Germany, and its only drawback is its high cost. This drug is not included in the list of medications that maternity hospitals provide as part of state guarantees free medical care, in other words, according to the policy. If a woman is going to give birth in a paid clinic, she should clarify whether such a gel will be used. You can purchase it yourself by giving it to your doctor before giving birth.

A woman's birth canal is subjected to serious stress during the expulsion of the fetus. One of the most common maternal injuries is a perineal rupture, the features of which we will now consider.

Symptoms of the development of perineal rupture during childbirth

Perineal ruptures are associated with the anatomical and functional state of the birth canal and largely depend on the correct management of labor. First of all, the high, low-yield, poorly extensible perineum of first-time labor is subject to rupture. Of great importance as the cause of rupture are rapid and rapid labor, extension insertion of the head, breech presentation, large fetus, incorrect execution techniques for protecting the perineum, difficulties in removing the shoulder girdle, surgical interventions(application of forceps), etc.

Symptoms of the pathology are observed at the end of the period of expulsion of the fetus, while the advancing fetal head, exerting pressure on the soft tissues of the birth canal, compresses venous plexuses, as a result of which the outflow of blood is disrupted, venous stagnation occurs, which is manifested by a bluish discoloration of the skin. Venous stagnation leads to the sweating of the liquid part of the blood from the vessels into the tissues, causing their swelling, and the skin acquires a peculiar shine.

With further compression of the tissues by the head, more symptoms are added severe violations blood supply is disrupted not only venous drainage, but also the blood supply with arterial blood. All this leads to disruption of metabolic processes and significantly reduces the strength of tissues, against this background a rupture of the perineum occurs. In this situation, it is better to prevent rupture of the perineum by prophylactically dissecting it. This reduces the risk of developing heavy bleeding in the future; moreover, it is better to match the smooth edges of the cut wound when suturing, and in the future the wound heals faster and without complications (suppuration).

Degrees of perineal rupture and their signs

Depending on the extent of damage, three degrees of pathology are distinguished.

I degree rupture - the posterior commissure is injured, part back wall vagina and perineal skin.

II degree – the skin of the perineum, the vaginal wall and the muscles of the perineum are damaged.

Gap III degree– except for the specified tissues, is damaged external sphincter rectum, sometimes even the anterior wall of the rectum is affected. III degree is one of the most adverse complications childbirth and in most cases is the result of untimely provision of obstetric care in a hospital.

A rare situation occurs when the posterior wall of the vagina, pelvic floor muscles and perineal skin are injured, while the posterior commissure and anal sphincter remain intact. In this case, childbirth occurs through an artificially formed canal.

Complications of perineal ruptures

If a perineal rupture occurs, a woman is at risk of bleeding varying degrees severity, besides the wound is entrance gate for an ascending infection, which can subsequently lead to the development of endometritis and more severe inflammation (pelvioperitonitis, peritonitis). In addition to all of the above, the torn wound heals secondary intention(cut surgically the wound heals by primary intention), which contributes to the gaping of the genital fissure after healing, disruption normal microflora and vaginal environment and, as a consequence, sexual dysfunction.

More severe injuries to the birth canal during childbirth with damage to the pelvic floor muscles lead to their inability to subsequently perform their initial function of supporting the uterus, as a result of which prolapse gradually develops, and the uterus may fall out of the vagina. With even more severe perineal ruptures during childbirth, for example, third degree ruptures, incontinence of gases and feces occurs, and the woman becomes unable to work.

Features of the treatment of perineal ruptures

After childbirth, the doctor and midwife must examine the cervix, vaginal vaults and external genitalia to detect ruptures. The examination is carried out using special vaginal speculums. If a third-degree perineal rupture is suspected, a finger is inserted into the rectum and, pressing it on its anterior wall, it is determined whether there is damage to the intestine and anal sphincter.

After a thorough examination, the integrity of the perineum is restored. Restoration of integrity is carried out under local anesthesia.

Catgut sutures are applied with careful comparison of the wound edges. The type of seam depends on the degree of tear. In case of a 1st degree rupture, the sutures applied will be located on one floor, in case of a 2nd degree - in two floors.

In turn, when treating a third-degree rupture, the damaged rectal wall is first restored, then, having found the ends of the torn rectal sphincter, the edges are compared, after which sutures are applied in the same order as in the case of a second-degree pathology. Silk sutures (lavsan) can be placed on the skin, which are removed on the fifth day.

Preventive repair of perineal rupture during childbirth

The main method of preventing pathology is dissection of the perineum - perineotomy or episiotomy. In our country, these operations were introduced into widespread obstetric practice at the end of the last century. With the help of their implementation, it is possible to increase the size of the exit to several centimeters; in particular, perineotomy gives a noticeable increase in the vulvar ring - up to 5-6 cm.

Surgical dissection currently provides undeniable advantages, namely:

this results in a linear wound with smooth edges,

no tissue crushing,

suturing the wound makes it possible to compare the tissues of the perineum anatomically, layer by layer,

healing after suturing the incision usually occurs by primary intention.

A special and major role in the prevention of perineal ruptures is played by the correct delivery technique during the removal of the head and shoulder girdle, the birth of the anterior and posterior arms.

Episiotomy and perineotomy involve dissection of the perineum to prevent obstetric trauma, shorten the second stage of labor, or to protect the fetus from trauma. Timely dissection of the perineum prevents the occurrence of its rupture.

Indications for surgical dissection of the perineum

You can determine the indications during childbirth for this type of operation:

threat of rupture due to a large fetus, incorrect insertion of the fetal head, narrow pelvis, high perineum, rigidity of perineal tissue, breech presentation of the fetus, etc.;

symptoms of an incipient rupture also require its dissection, however, the optimal conditions for this were at the stage of a threatening perineal rupture;

the need to shorten the second stage of labor due to obstetric or extragenital pathology (bleeding, weakness labor activity, late gestosis, hypertension, diseases cardiovascular system, respiratory diseases, myopia, etc.).

Dissection is often performed according to fetal indications. Such conditions include fetal hypoxia, which requires a shortening of the second stage of labor; premature birth, in which dissection of the perineum prevents compression of the head of the premature fetus by the pelvic floor muscles. In many cases, there are combined indications for preventive surgical treatment of perineal rupture in the interests of both the mother and the fetus. For example, with a large fruit, breech fetus, incorrect insertion of the head, weakness of labor, dissection of the perineum is performed according to combined indications.

Before performing the dissection, the external genitalia are treated with an alcohol solution of iodine. The dissection of the perineum is performed with special scissors. Dissection of the perineum is performed when the effort reaches its maximum severity and the perineum is most stretched. At this moment, the woman is as tense as possible, and the pain is practically not felt, but, on the contrary, relief is noted due to the further passage of the head. The length and depth of the incision must be at least 2 cm. After the birth of the placenta in the early postpartum period, the perineal tear is sutured.

Types of surgical treatment of perineal rupture

Episiotomy. The incision is made 2–3 cm above the posterior commissure of the vagina towards the ischial tuberosity. With this incision, the skin, subcutaneous fat, vaginal wall, fascia, several muscle layers crotch. There is a danger of dissection of the neurovascular bundle, which can lead to disruption of the innervation and blood circulation of the perineum and the formation of a hematoma. This incision is often accompanied by bleeding, so quickly restoring tissue integrity is important. In addition, during episiotomy there is a danger of injury to the large gland of the vestibule of the vagina and its ducts, which requires caution and skill on the part of the performer. medical personnel. However, at present, the qualifications of medical personnel in obstetric hospitals are quite high, and such complications do not occur so often.

Perineotomy. Dissection in the direction from the posterior commissure to the anus. With this dissection of the perineum, the skin, subcutaneous fat, posterior commissure of the vagina, fascia, and perineal muscles are dissected. The length of the incision should not exceed 3–3.5 cm from the posterior commissure, since a longer incision disrupts the integrity of the central fascial node of the perineum; in addition, the incision can extend to the rectum and lead to a third-degree rupture. Therefore, episiotomy is currently preferred for preventive treatment, since even with a normal incision length it can extend spontaneously during delivery of the fetus to the rectum. In this regard, in modern obstetrics, a modification of perineotomy is used, in which the incision is made at an angle of 30–40° from the posterior commissure towards the ischial tuberosity or slightly below it.

Ultimately, the choice of preventive treatment for a rupture is determined by topographical features, the condition of the perineum, and the obstetric situation. For example, perineotomy is preferable when a woman has a high perineum. Episiotomy is performed infrequently due to large possible complications. In most cases, a modified perineotomy is still performed, in which the nerve formations and fascial nodes.

Prevention of perineal ruptures before childbirth

Childbirth is a very important and responsible event in a woman’s life. And every woman wants the risk of pathologies and complications not only for the baby, but also for herself to be minimized. And often, in preparation for upcoming birth, women forget about themselves and think only about pregnancy.

One of the consequences of childbirth can be scars after a perineal rupture. To avoid these accidents, it is necessary to massage the perineum during pregnancy. Massage works well for everything internal organs, improves blood circulation and normalizes the condition nervous system. And perineal massage is the most important component in preparing for childbirth.

The perineum is the circular muscles of the pelvic floor. Its area is located between the vagina and anus. During childbirth, during pushing, the baby's head drops to the bottom of the pelvis and stretches the muscles of the perineum. The woman begins to push and helps push the baby out with these muscles. Therefore, the perineum receives a huge load during childbirth, and careless movements on the part of the laboring woman, or incorrectly provided obstetric care can lead to severe ruptures. The volume and frequency of ruptures are affected by hereditary factors, features of body constitution, weight of the expectant mother, fetal presentation, tissue elasticity. By massaging the perineum during pregnancy, a woman significantly reduces the likelihood of ruptures.

Rules of massage in the prevention of perineal ruptures

In order to achieve excellent elasticity of the perineum, you need to follow some rules:

Massage should be performed regularly.

Before a massage session, you must empty your bowels and bladder.

It is also useful to take a warm bath before the massage, which softens and relaxes the tissues.

The massage therapist's hands must be washed clean and his nails must be trimmed short;

There are a number of restrictions when perineal massage is categorically incompatible with pregnancy.

Firstly, these are all infectious and inflammatory diseases of the vagina, such as bacterial vaginosis or thrush. First you need to treat the inflammation, and only then do massage. Otherwise, in such a situation, massage will only bring harm; the infection spreads deep into the vagina, and then to the cervix and directly into the vagina. amniotic fluid.

Secondly, the possibility of threatening miscarriage.

And thirdly, if there are some skin diseases, involving the perineal area in the process, and with increasing temperature.

Exercise for the muscles of the perineum

The exercise is performed at a slow pace. Exercise for the perineal muscles:

Starting position: standing, legs straight, back straight. The feet are at a short distance, parallel to each other. Hands on the belt.

Put right leg on your heel, and bend your left knee and place it on your toes (or on your toes, as the professionals say).

Without lifting your feet from the floor, slowly exhale and draw in your stomach. The back is straight.

Then change position: the right foot smoothly rolls from heel to toe, the knee bends, and the left foot simultaneously rolls from toe to heel, slightly bending back, while the knee seems to retract. At the same time, inhale, repeating the abdominal movements as in the first exercise.

At first it will be difficult for you to do everything at the same time and slowly enough. If you don’t succeed right away, try performing each element of the movement separately. Stand on your heels first, and then move the weight to your toes. Watch your balance so that when moving you do not sway from side to side, sit back or lean forward. Avoid excessive load, don't get overtired. Maybe not right away, but you will be able to do these movements beautifully and correctly.

Use your imagination, imagine yourself as an oriental beauty dancing to rhythmic music or crushing ripe juicy grapes with your feet.

Features of perineal care during pregnancy

Often pregnant women complain of pain in the perineal area. The perineum during pregnancy from 35 to 37 weeks is very often subject to pain and this is a harbinger of childbirth. This is an indicator that the baby is already moving forward and at the same time puts pressure on the muscles, as well as nerves and ligaments. Sami hip joints They diverge even more, but the ligaments cannot keep up with them, and at the same time sharp pain sensations appear, and stretching begins in the perineum and in the legs.

But these pains can also occur at shorter periods; for this reason, then you will need to inform the doctor so that premature labor does not begin. And if they appear very often, this may indicate a threat of miscarriage. But such pain in the perineum during pregnancy may indicate other reasons. But most often it happens that when the fetus moves, it presses on the nerve, which causes pain. If this happens, it will be very difficult not only to get up, but also to lie down. There is only one way out - you have to endure it all. When the fetus takes a different position and releases the affected nerve, the pain will stop.

Also, another cause of pain in the perineum may be loosening of the ligaments, this will contribute to varicose veins veins of the perineum. The doctor determines the cause of the pain, and if it has already occurred, then appropriate treatment is needed.

In most cases, pain in the perineum goes away on its own after childbirth. After all, the perineum itself is always under pressure during pregnancy. Because with each passing month the approach of labor, the fetus puts more and more pressure on her. And that’s why pain occurs. Sometimes they can be false, when the uterus is in good shape and this indicates that there may be a threat of miscarriage. Therefore, during pregnancy you need to do gymnastics for the perineum. And then during childbirth there will be minimal risk perineal rupture.

Ruptures of the uterus, cervix and perineum are one of the most common complications during childbirth.

It can be either spontaneous or due to medical intervention.

In those who give birth for the first time, ruptures occur 3 times more often than in multiparous women.

This is primarily due to the inexperience of the woman in labor.

Why do ruptures occur, can they be avoided and how to do it?

Tears during childbirth - causes and types

No doctor can say 100% whether there will be ruptures or not. In most cases, the woman’s inexperience and unpreparedness are to blame. At peak moments, she loses her composure, succumbs to panic and stops obeying the doctor. However, there are also cases when even experienced and well-prepared women for childbirth experience ruptures. There are many reasons for this. Before we talk about them, let's figure out what kind of gaps there are.

Conventionally, they can be divided into three types:

● uterine rupture;

● cervical rupture;

● perineal rupture (damage resulting from severe stretching of the birth canal).

There are many factors predisposing to rupture during childbirth. Among the common ones:

● inflammatory processes (chronic or in the acute stage);

● genital infections (for example, thrush);

● inexperience of the woman in labor (in most cases, the woman simply does not listen to the doctor and gives in to panic);

● too fast delivery (with rapid movement of the fetus along the birth canal);

● sluggish labor (the perineum swells, and when exposed to hormones, the cervix ruptures);

● mature age women in labor;

● repeated births after caesarean section;

● negligence of medical workers (for example, when pulling a child);

● tone of the uterus and pelvic muscles;

● physiological feature(when the distance from the vagina to the anus is more than 7 cm).

Uterine rupture during childbirth: treatment, consequences

Uterine rupture during childbirth does not occur often. This type of rupture is the most severe. It can occur for the following reasons:

● functional obstacles that interfere with normal movement fetus along the birth canal (narrow pelvis, cervical dystocia);

● mechanical obstacles (large fetus, uterine abnormalities);

● repeated births after a caesarean section, abortion or several previous births in history;

● obstetric factor (stretching the fetus, applying forceps);

● abdominal injuries;

● slow delivery;

● induction of labor in cases where this is not necessary.

Uterine ruptures are divided into several types, depending on the location, course and nature of the damage.

The localization of the gap can be in:

● Mother's Day;

● body of the uterus;

● lower segment;

● also rare, but complete separation of the uterus from the fornix occurs.

Uterine rupture can be:

● in the form of a crack;

● incomplete, that is, not penetrating into the abdominal cavity;

● full.

Clinical picture begins with the threat of uterine rupture, then moves into the process that has begun, after which (if measures were not taken or were unsuccessful) the rupture is considered complete.

How to treat

If a uterine rupture occurs during delivery, doctors are faced with the task of doing everything possible for the speediest outcome of the birth, to save the baby and stop the mother’s bleeding.

If the uterus is completely ruptured, the woman in labor undergoes an emergency caesarean section. After the baby is removed, the uterus is stitched and the bleeding stops.

What is the danger

Uterine rupture can have a negative impact on both the fetus and the mother. If it is not detected in time, the fetus may die in the womb due to acute oxygen starvation(hypoxia). The mother, in turn, may experience hemorrhagic shock caused by large blood loss. The functioning of the nervous system and blood circulation may be disrupted.

How to avoid

Preventive measures to take to avoid uterine rupture during childbirth:

● regular visits to an obstetrician-gynecologist;

● undergoing all routine ultrasounds for early identification of factors that may affect the rupture;

● correct and timely choice of delivery;

● monitoring the condition of the fetus, especially if it is heavy;

● diagnosis and monitoring of threatening or incipient uterine rupture.

Cervical rupture during childbirth: treatment, consequences

Cervical rupture is a phenomenon that often accompanies childbirth. Rupture can be spontaneous (for example, if the fetus is large, the mother has a narrow pelvis, or rapid delivery) and forced (operations aimed at speeding up labor).

Doctors divide cervical rupture into several degrees:

1. a gap, the size of which is no more than 2 cm, is located on one or both sides;

2. the size of the tear is more than 2 cm, but does not reach the vaginal vault;

3. a tear that reaches and extends to the vaginal vault.

The first two degrees are considered uncomplicated cervical ruptures. In the latter case, the damage will be considered complicated. It will affect the internal uterine os, abdominal and pelvic cavity. Also, a third degree tear can affect the fat layer around the uterus.

How to treat

Cervical rupture is treated with surgery:

● defects are sutured (in rare cases this may not be necessary - in non-bleeding and superficial wounds);

● surgery with opening of the abdominal cavity (used for third-degree rupture, the defect is sutured directly in the uterus).

What is the danger

Such ruptures during childbirth can have serious consequences:

● inflammation of the cervix;

● inflammation of the uterine mucosa (postpartum endometritis);

● hematoma in the fatty layer of the uterus;

● hemorrhagic shock (impaired functioning of the nervous system and blood circulation).

How to avoid

To avoid cervical rupture, you must follow some rules:

● exclude excessive physical and emotional stress;

● register on time and visit a gynecologist regularly;

● go through everything necessary tests and examinations to detect possible violations in time;

● plan a pregnancy no earlier than two years after uterine surgery (if any);

● taking vitamins and sedatives (only as prescribed by the supervising doctor);

● timely assessment of indications for natural or artificial childbirth;

● moderate pain relief during childbirth.

Perineal rupture during childbirth: treatment, consequences

Rarely does childbirth go smoothly and without ruptures. The perineum is most often affected. This rupture represents stretching of the birth canal due to strong pressure on the pelvic muscles. Often this type of injury during childbirth depends on the mother’s preparedness for this process.

Perineal rupture during childbirth is divided into 3 degrees depending on the nature of the damage:

1. Damage to the skin of the perineum only.

2. Damage to the skin, muscles of the perineum and vaginal walls.

3. Third degree damage can be incomplete, complete or central. In the first case, in addition to the skin, muscles and walls of the vagina, the muscle that closes the rectum is also damaged. With a complete rupture, the walls of the rectum are torn. Central perineal rupture during childbirth is very rare and is characterized by damage to the posterior vaginal wall, pelvic muscles and skin of the perineum. In this case, both the posterior commissure and the orbicularis rectus muscle remain intact.

How to treat

Perineal lacerations should be sutured immediately after injury (no more than half an hour should pass). This is done under local anesthesia. Sutures can be temporary (which must be removed later) or self-absorbing.

The sutures must be treated with antiseptics twice a day for a week. If temporary ones were applied, they are removed after 4-5 days.

What is the danger

Perineal ruptures cause a lot of trouble and pain to a young mother. These could be:

● hematomas and swelling in the suture area;

● problems with urination;

● inflammation of sutures with suppuration;

● scar formation on the perineum;

● loss of sensitivity in the area of damage;

● divergence of seams;

● disruption of the rectum.

How to avoid

In order for the birth to go smoothly and without tearing the perineum, it is necessary to properly prepare physically and mentally for childbirth. In most cases, ruptures occur when the woman does not listen to the obstetrician. No matter how scary it may be, you need to be able to not lose your composure and follow all the doctor’s instructions - he is also interested in the successful outcome of the birth.

Starting from about 7 months of pregnancy, you need to massage the perineum. Also, muscle training (Kegel exercises) will not be superfluous: alternating contractions and relaxations.

It would be a good idea for the expectant mother to attend several classes on breathing exercises and relaxation skills during childbirth.

Conclusion

Ruptures during childbirth are quite common. Can they be avoided? It is impossible to answer this question unequivocally, but it is worth remembering that a lot depends on the woman and on how ready she is to follow all the doctor’s instructions.

To avoid breaks, expectant mother must do everything possible on its part. First of all, consciously prepare for birth process. You definitely need to find out how the process of giving birth to a child occurs, where it begins, how to breathe and relax correctly. How more woman knows about the normal course of labor, the more prepared she will be.

If it was not possible to avoid ruptures, it is worth knowing that the risk of complications or infection will be high. It is necessary to strictly observe the rules of personal hygiene and care of stitches. If there is the slightest change in the area of the sutures - swelling, suppuration, pain, twitching - you must immediately consult a doctor.