One stitch, two stitches, it will be fun! - the obstetrician said with a needle at the feet of the happy woman in labor. For some, this black humor becomes an unfunny reality and causes a lot of trouble and trouble. We'll tell you about situations that inspire obstetricians to take up the needle, ways fast healing and pain relief.

When to apply stitches and causes of ruptures

Childbirth does not always go smoothly, and sometimes you have to pay for the happiness of having children with birth injuries - ruptures and cuts in the genital tract, on which external and internal seams after childbirth. Injuries can be internal - ruptures in the cervix and vagina, and external - ruptures and cuts in the perineum.

After the birth occurred naturally, the obstetrician must check for ruptures and, if detected, they are sutured. Otherwise, if suturing is not carried out, postpartum period threatens to end in a hospital bed due to bleeding in injured tissues and the addition of infection to them, and in the future even provoke prolapse internal organs and urinary and fecal incontinence.

The process of applying external and internal sutures lasts a long time and requires high qualifications of the doctor, and in the case of ruptures in the cervix that extend to the vagina and uterus, and some virtuosity due to inaccessibility and the danger of damage to the nearby bladder and ureters.

Internal sutures after childbirth on the cervix, vagina and uterus itself are applied using absorbable threads made of biological or semi-synthetic material. If only the cervix is ​​affected, then anesthesia is usually not required - after childbirth it is insensitive. In all other cases, local or general anesthesia is used - anesthesia or epidural anesthesia.

The muscle layers in case of ruptures and cuts of the perineum are also sutured with absorbable threads, and the skin is often made of non-absorbable silk, nylon and other materials, which are removed in the maternity hospital or in antenatal clinic usually 3-7 days after birth, when the suture has scarred. The procedure is quite painful and therefore anesthesia is required.

The reasons for ruptures can be different. This includes not following the advice of the obstetrician during the pushing period, and the presence of scars from sutures placed in previous births (the scar consists of inelastic connective tissue), rapid, prolonged, premature and instrumental labor (forceps), anatomical features pelvic structure, large baby's head, breech presentation, low skin elasticity at the time of birth.

What should a woman do who has the seam came apart after caesarean section

Obstetricians have different attitudes toward episiotomy—dissection of the perineum. For some, this is a routine procedure that is performed en masse to avoid the risk of perineal rupture. Other doctors strive for the most natural course of the birth process, intervening when it is already quite obvious that a rupture cannot be avoided. If instrumental delivery is performed with forceps or a vacuum extractor, then preliminary dissection of the perineum is recommended.

Episiotomy does not help prevent third-degree tears when the anal sphincter is involved in the violation of the integrity of the perineum and may even contribute to such injury. Still, surgical dissection has a number of advantages over rupture. Dissected tissues are technically easier to repair than torn ones. The resulting wound has smooth edges, healing occurs faster and a more aesthetic scar is formed.

Healing and treatment of sutures

As unfortunate as it may be, what happened happened, and as a result, after giving birth, you were given stitches. At internal seams If the suturing procedure is performed correctly and carefully, it will hurt for about 2 days. Special care they do not require and do not need to be removed, since they are made of absorbable thread.

Self-absorbing sutures after childbirth made from natural material - catgut - completely dissolve in about a month, and from synthetic ones - after 2-3 months. Internal ones heal faster and can diverge in extremely rare and exceptional cases.

The outer crotch seams are a completely different matter. With such a postpartum reward, it’s painful to move, it’s difficult to go to the toilet, and you can’t sit down at all because the stitches can come apart.

Ban on sitting position lasts two weeks, after which you can gradually try to sit on hard surfaces.

If catgut sutures were placed on the perineum, then do not be alarmed if after a week pieces of threads appear that have fallen off - during this period the material loses its strength and breaks. The seams will no longer come apart, unless, of course, you start dancing. How long the material will take to dissolve depends on the speed metabolic processes in the body. Sometimes there are cases when the catgut does not dissolve even six months after suturing.

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Non-absorbable thread sutures from the perineum are removed 3–7 days after birth. If this was not done in the maternity hospital, then the sutures are removed by a gynecologist in the antenatal clinic. During the removal procedure itself, it is a little unpleasant, but in most cases it does not hurt, or the pain is quite tolerable.

How long it takes for sutures to heal after childbirth is influenced by the individual healing rate of damage received by the body - both from minor scratches and from more serious injuries.

Usually this process does not take more than a month, but on average is 2 weeks.

Both before and after removal of sutures, it is necessary to regularly treat them. This is especially important since postpartum discharge and the constantly moist environment of the perineum contribute to the proliferation of various microorganisms on the wound surface. As a result, the sutures may fester and healing will be delayed indefinitely.

How and with what to treat stitches after childbirth at home? Just like in the maternity hospital, you need to carry out treatment two to three times a day. antiseptic solutions and/or antibacterial ointments, suppressing uncontrolled growth causing inflammation bacilli The most available funds- this is the well-known brilliant green, hydrogen peroxide, potassium permanganate, chlorhexidine, etc. Ointments include levomekol and others. Treatment should be carried out avoiding a sitting position.

If you provide air access to the perineum, healing will go much faster. To do this, you need to use “breathable” pads made from natural materials and refrain from wearing tight underwear. Ideal option- providing “ventilation” during sleep, when you can completely abandon underwear and sleep on a special absorbent diaper, or oilcloth with a regular fabric diaper.

To speed up regeneration it is also necessary good nutrition, supplying building material to the site of injury. From folk remedies oil accelerates healing tea tree, sea ​​buckthorn oil. And of course, hygiene rules and maintaining cleanliness are welcome on the path to rapid healing.

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How to relieve pain

During the healing process of the sutures, tissue contraction occurs - the wound surfaces contract and the wound is closed with a scar. Therefore, it is quite normal that the sutures hurt after childbirth, like any other injuries that violate the integrity of muscle and epithelial tissue. Discomfort – pain and itching in the perineum may be experienced up to 6 weeks after birth.

If the pain is of a different nature, and even more so when the sutures begin to fester, you need to consult a doctor.

If the pain is severe, which happens in the first days after childbirth, then applying cold to the perineum and painkillers can help cope with it. In the maternity hospital they give injections, at home you can take ibuprofen (Nurofen), which is not contraindicated during breastfeeding and has an anti-inflammatory effect. To feel less pain when urinating, you can try urinating while standing in the bathroom with your legs apart.

Often during childbirth, ruptures of the perineum, vagina or uterus occur - an unpleasant situation, but not life-threatening. Doctors cope well with the problem and can quickly and efficiently stitch up any gap.

But full recovery and recovery from such an injury depends only on the woman. She should know not only the types of ruptures, but also the rules of behavior/care for them during the recovery period.

Read in this article

Causes of ruptures after childbirth

Childbirth is a painful process that is divided into several stages. Among them there is pushing - the period when the head or pelvic end of the baby (depending on the presentation of the fetus) comes close to the cervix. At this moment, pressure is exerted on the muscles pelvic floor, which provokes a reflexive desire to push. If the cervix is ​​already open, then the baby passes through it almost freely and ends up in the vagina.

But it often happens that by the time of pushing the cervix has not opened, it seems to cover the head of the fetus. Overcoming such resistance, the fetus still continues to move, because birth process cannot be stopped, the result of this is cervical rupture. The same injury can occur when the cervix is ​​fully dilated and a fetus that is too large is born.

In addition, cervical rupture can occur for the following reasons:

• disruption of the process of cervical dilatation;
• improper care provided by medical workers;
• first birth after the age of 30 (tissue elasticity is lost);
• the fruit is too large;
• breech presentation of the fetus.

The same reasons can lead to ruptures of the vagina and perineum. If the vagina is injured involuntarily in any case, the doctor delivering the baby can independently make an incision in the perineum.

When is a perineal incision necessary?

The decision to make an incision is always correct, because torn edges of the wound heal worse and take longer, and often become infected. But straight edges after scissors can be sewn with only 2 - 3 stitches, and healing will be quick.

The doctor may suspect a perineal rupture and make an incision in the following cases:

• a child is born with “legs” - the fetus is in;
• childbirth is rapid and rapid;
• narrow genital slit of a woman in labor;
• the fruit is too large.

In such cases, an incision in the perineum will benefit both mother and child, because it will be much easier for the fetus to be born, and the woman will be able to recover quickly.

In addition, the doctor may resort to this procedure when:

• fetal hypoxia;
• anomalies of intrauterine development;
• premature birth.

In some cases, a woman needs to reduce the intensity of her attempts: for example, she has been diagnosed with a high degree of myopia, has problems with blood pressure or diseases of the respiratory system.

A dissection of the perineum is necessarily carried out in case of complicated childbirth - when there is a problem in removing the baby’s shoulders or the application of obstetric forceps.

Degrees of ruptures

The considered injuries to the cervix and perineum may have varying degrees gravity. The healing process of the wound surface and the duration of the recovery period depend on this.

Degrees of cervical rupture:

• 1st degree – the gap can be on one or both sides, they are small in size (maximum 2 cm);
• 2nd degree – the gap is more than 2 cm long;
• 3rd degree - the wound surface is present at the junction of the cervix into its body or affects the uterus itself.

• 1st degree – the size of the injury is small, only the skin and vaginal mucosa are damaged;
• 2nd degree - a rupture of muscle tissue is added to the above parts of the perineum;
• 3rd degree - the rupture damages the skin, vaginal mucosa, perineal muscle and sphincter.

How to sew up internal and external tears

Internal incisions are sutured with absorbable threads (catgut). Such sutures on the cervix and vagina do not require any special care; after 7 - 10 days, not a trace remains of the suture material.

But external sutures are applied when the perineum is torn. In this case, doctors adhere to the following rules:

• if the gap is 1st - 2nd degree, then the suture is applied with one thread, which captures all the damaged layers at once;
• in the case of a 3rd degree rupture of the perineum, the sutures are applied separately to the muscles and skin. Absorbable threads are used to stitch up the muscle and mucous membrane rupture, and suture material is used for the skin, which is removed on the 5th - 6th day.

Suturing the cervix is ​​performed without anesthesia, but if a woman high threshold sensitivity, then the damaged part of the organ can be sprayed with lidocaine solution. Work on a perineal rupture must be carried out under local anesthesia.

Features of the recovery period

Childbirth, timely incision of the perineum and suturing of tears are the work of doctors. The recovery period implies compliance with certain rules and recommendations by the woman herself.

Mom's behavior after childbirth

Internal seams do not affect the activity of the young mother in any way; there are no restrictions. But the rupture of the perineum and subsequent suturing implies the following:

1. A woman should not sit for 14 days, although in some cases doctors shorten this period. The mother should feed the baby, eat herself and carry out nursing procedures in a standing or lying position. Even from the maternity hospital, a woman must be transported home in a semi-sitting position. Therefore, it is worth warning relatives in advance that vehicle should be free.
2. You are allowed to sit on the toilet on the first day after birth. You need to empty your bowels regularly; you cannot delay bowel movements - this leads to constipation. To facilitate the process, a woman can use rectal suppositories(glycerin). They are safe and effective, promoting bowel movements without effort. The doctor may later recommend and.
3. It is prohibited to lift heavy things/objects. Doctors warn that the restrictions apply to weights of more than 3 kg, so if a large baby is born (4 kg or more), relatives will need to be involved in helping to care for him until full recovery.

Watch the video about the breaks:

Caring for stitches after childbirth

In the maternity hospital, suture care is provided by nurse. Twice a day she washes them with hydrogen peroxide and treats them with brilliant green. Women in labor with external sutures are required to undergo “instruction” before being discharged from the hospital. It includes the following recommendations:

1. You should wear only natural materials (cotton is optimal). correct size. Tight panties can put pressure on the seams, the tear area constantly rubs against the fabric, and synthetics can cause skin irritation and inflammation.
2. need to be changed every 2 hours, accompanying the process by washing.
3. Washing warm water should be done after every visit to the toilet.
4. The bladder should not be allowed to become full as it puts pressure on the uterus and interferes with its contraction.
5. Twice a day the perineum should be washed with regular soap. Scented gels should be avoided. Optimal choice will become baby soap.
6. The outer seam is washed with special care; you can direct a stream of water from the shower directly onto it.
7. After hygiene procedures You need to dry the perineum by soaking it with a towel; under no circumstances should you rub the seams.

External seams require air procedures. Doctors recommend periodically resting without underwear, lying on a bed/sofa with your knees bent and your legs apart.

Self-absorbing sutures

Absorbable threads are used to close ruptures of the cervix and vagina. There are no special rules for caring for such sutures, but the woman must follow the doctor’s recommendations regarding sitting and bowel movements. In some cases, a young mother may feel a slight nagging pain in the lower abdomen - this is not critical.

It is imperative to monitor your well-being and vaginal discharge. If the mother notes the bodies and viscous, brownish-red, with vaginal discharge, then you should seek qualified medical help.

When are the internal stitches removed?

Such sutures are applied with catgut - a material that dissolves itself in the thickness of the tissue. Usually this process is completed within 90 days, a woman may see thread residues on her underwear - this is normal.

There is no need to worry about the absorbable material coming out of the tissue before the tear heals. This is a priori impossible.

What to do if the seam festers

After giving birth, a woman begins the process. And if missing breast-feeding, then the first discharge may appear as early as 10–15 days. They are a brownish, odorless mucus.

If the mother notices that the discharge has extremely bad smell(sourish-putrefactive), they become viscous, this may indicate. When suppurating, the external suture becomes painful and purulent contents are released from it.

You need to contact a gynecologist and tell about the problem. The doctor will examine outer seam or will conduct instrumental examination internal ruptures and prescribe drug therapy.

Typically, external seams are treated with balsamic liniment according to Vishnevsky, Solcoseryl or Levomekol ointments. It is imperative to treat the wound surface with a solution of hydrogen peroxide or chlorhexidine, and antibiotics are usually prescribed internally.

Any medicines To solve the problem of suppuration of the sutures, a gynecologist should prescribe. These symptoms may indicate the onset of bleeding and suture dehiscence.

Causes of pain at rupture sites after childbirth

Pain may accompany both external and internal sutures placed on tears during childbirth. If during the examination the doctor does not identify any problems, then several warming procedures can be performed.

But without prior consultation with a gynecologist, no therapeutic measures not worth doing. There is also no talk of taking painkillers - they will “wash away” clinical picture and through mother's milk enter the baby's body.

Most often, pain at the suture sites appears with the development of an inflammatory process or dehiscence. If the gap was stitched crookedly, then the woman will feel a nagging pain, which will disappear on its own after a while.

To relieve pain, gynecologists often recommend lubricating the seams with Contractubex. Within 10 - 20 days, discomfort and pain will disappear.

Can the seam come apart?

The internal seams almost never come apart. Even if this happens, the woman will not diagnose the problem on her own, and the gynecologist will not stitch it up again.

But the outer seams come apart very often! The only reason for this is non-compliance with care rules/recommendations. Often, discrepancies are observed in the first days after birth. The woman simply forgets the restrictions and sits on the bed, goes to the toilet to empty her bowels without first setting the candles. If this happens, the doctor simply re-stitches it.

It also happens that the edges of the wound have already healed, but a rupture has occurred. In such a situation, the decision to further actions The doctor will decide on an individual basis. If a pair of stitches diverges, the sutures are not re-applied; in all other cases, the edges of the wound are excised, and the perineal tear is sutured again.

If a discrepancy occurs in a mother who has already been discharged home, she should immediately seek qualified medical help.

When can you have sex after a breakup during childbirth?

For young couples after the birth of a child, the question of resuming intimacy becomes relevant. Usually doctors warn about abstinence for one and a half to two months, even if the birth took place without ruptures. If stitches were applied, then this period increases to 3 - 4 months.

However, in this case everything is strictly individual. Some people can have sex within a month after the external suture is applied; for some, doctors prohibit such pleasure even after 2 months. It would be wise to consult a gynecologist and listen to your own feelings. But in the first 4 weeks sex is definitely not available.

Consequences of ruptures after childbirth

If there were third-degree cervical ruptures, this may cause problems with pregnancy next child. But in fact, this happens extremely rarely, since experienced doctors and the level of modern medicine make it possible to avoid such incidents.

External stitches after tearing during childbirth can cause pain during sex. This is associated with excessive vaginal dryness. In this case, lubricants will come to the rescue ( intimate gels). Usually after a few sessions of sex everything discomfort disappear.

It is impossible to predict internal ruptures (cervix and vagina), it all depends on the physiological characteristics of the mother’s body and the size of the fetus. But to increase elasticity skin perineum, and thereby prevent rupture, is quite possible.

To do this, the husband/partner of a pregnant woman needs to regularly stretch the vaginal opening. This is done with two fingers, which slightly pull the entrance down and hold it in this position a little (literally for a few seconds). This procedure can be painful, so you need to pre-treat your fingers with a water-based vaginal lubricant.

Tears during childbirth - common occurrence, which doctors successfully cope with. A woman only needs to follow all the prescriptions and recommendations of gynecologists to avoid complications.

Immediately after the end of childbirth, in contrast to operations for old ruptures, they are performed without preliminary excision and separation of tissue flaps, despite irregular shapes wounds.

There are 3 degrees of perineal tears.

To the breaks I degree include ruptures of the posterior commissure, back wall vagina in the boat, the fossa of the vestibule of the vagina and the skin of the perineum.

For ruptures II degree, in addition to tissue ruptures present in grade I ruptures, there are also ruptures of the pelvic floor muscles: bulbospongiosus muscle (m. bulbospongiosus), superficial and deep transverse muscles of the perineum (mm. transversi perinei super-ficialis et profundus) and tendon center perineum (centrum tendineum perinei) with disruption or separation of the levator ani muscle. A II degree perineal rupture extends upward to the vagina, to one or both of its sides.

When the perineum ruptures III degree the external sphincter is partially torn (incomplete rupture) or completely anus and rectum (complete rupture of the perineum). In addition to ruptures of the indicated degrees, there is a central rupture of the perineum, in which the vagina, pelvic floor muscles, rectum and external anal sphincter are torn, usually with preservation of the integrity of the median suture.

Perineal ruptures occur in the second stage of labor at the birth of the head and shoulder girdle fetus The operation of suturing the rupture should begin, if possible, immediately after the birth of the placenta and examination birth canal, if there is no need for intrauterine interventions. When suturing ruptures, it should be remembered that the tissues of the birth canal immediately after childbirth are swollen, hyperemic and, although quite extensible, can be fragile; the edges of the wound are often crushed, and the entire wound bleeds or is filled with blood from the uterus. Therefore, torn tissues must be handled with great care. Due to a number of circumstances (night duty, etc.), the surgeon performs suturing of ruptures in the soft birth canal, excluding uterine rupture, with one assistant or without an assistant. However, this does not give the right to ignore the basic rules of conducting an operation and requires compliance with the rules of asepsis, since after the operation, postpartum women may experience various complications, especially septic ones.

Special preparation for the operation of suturing perineal tears is usually not required. But if the birth took place outside a maternity hospital and the postpartum woman was admitted not immediately after birth, but 2-3 days later, she should be prepared for surgery. In such cases, the day before the postpartum woman should be given a laxative (30-50 g castor oil), in the morning before the operation they give a cleansing enema and shave the hair on the genitals.

The operation is performed on the maternity bed or on operating table(gynecological chair). The postpartum woman is positioned as for vaginal surgery. The surgical field is treated with 70% ethyl alcohol and 0.5% alcohol iodine solution and isolated with sterile linen. Having cleared the wound of clots and liquid blood, all fabrics on which it is intended to produce surgery, thoroughly infiltrate with 0.25-0.5% novocaine solution. This operation can be performed under general anesthesia. It is completely unacceptable to stitch up tears in the birth canal without pain relief.

Before you begin suturing the perineal tear, you should carefully examine the cervix and vagina. If a cervical rupture is detected, it is immediately sutured.

• The best conditions for the operation are provided by endotracheal anesthesia with the use of muscle relaxants. In this case, the approach to an organ or tumor does not present any great difficulties; the surgeon is not distracted from the main task, because [...]
• Extraperitoneal cesarean section, as the most rational method of operation, can be recommended for widespread introduction into the practice of obstetric institutions on a par with the technique of transperitoneal cesarean section[...]
• An extraperitoneal cesarean section can be recommended for widespread implementation in obstetric practice, which will help preserve the health of mother and child [...]
• The operation can be performed under infiltration anesthesia. For correct orientation, the edges of the tears are first aligned and then secured with knotted catgut sutures. The vagina may be [...]
• Currently there is no consensus on how to surgical treatment uterine ruptures. Some recommend radical operations- complete extirpation or supravaginal amputation of the uterus; others - suturing uterine ruptures[...]
• Damage to the ureters is possible during vaginal operations. Thus, performing an operation of anterior colporrhaphy, high amputation of the cervix, complete vaginal extirpation uterus, can be captured along with loose connective tissue [...]
• Hiccups are rare after surgery and usually appear on the 2nd day after surgery. Hiccups after surgery are a symptom of intoxication and in this case stop as it decreases [...]

LECTURE No. 18. PART 2.

CROTCH RUPTURE.

This is the most common type of maternal birth trauma and complications of childbirth, more often found in first-time mothers. Consequences of perineal rupture:

bleeding

inflammation of the vagina, cervix and generalization of infection

prolapse and prolapse of the cervix and vagina

incontinence of gases and feces (with a 3rd degree rupture)

sexual dysfunction

ETIOLOGY AND PATHOGENESIS.

The causes of perineal tears are:

anatomical and functional state of the perineum

tall with well muscled crotch

inflexible, poorly extensible in elderly primigravidas

scar changes after trauma in previous births and after plastic surgery

swollen perineum

features of the bony pelvis (narrow pubic arch, small pelvic inclination angle);

improper management of labor (rapid and rapid labor, operative delivery, incorrect obstetric care during the removal of the fetal head and shoulders).

Rupture of the perineum occurs when the head erupts, less often when the shoulders of the fetus are removed.

The RP mechanism (sequence of changes) is as follows.

As a result of compression of the venous plexus, the outflow of blood is disrupted;

cyanosis of the skin of the perineum (venous stagnation), swelling of the skin (sweating of the liquid part of the blood from the vessels into the tissue) appears; a peculiar shine and pallor of the skin (compression of the arteries);

decreased tissue strength due to metabolic disturbances; rupture of perineal tissue.

The described signs are signs of a threat of perineal rupture.

The sequence of tissue damage during spontaneous ruptures (from outside to inside):

posterior commissure, skin, perineal muscles, vaginal wall. When obstetric forceps are applied, the rupture begins from the vaginal side, but the skin may remain intact.

CLASSIFICATION.

There are spontaneous and violent ruptures, and according to degree - 3 degrees of perineal rupture:

1st degree - rupture of the posterior commissure, part of the posterior vaginal wall and perineal skin.

2nd degree - the pelvic floor muscles (levators) are additionally involved in the rupture.

3rd degree - rupture of the sphincter (sphincter) of the anus, and sometimes part of the anterior wall of the rectum.

A rare type of RP (1 in 10 thousand births) is a central rupture of the perineum, when an injury occurs to the posterior wall of the vagina, pelvic floor muscles and perineal skin, but the posterior commissure and anal sphincter remain intact, and childbirth occurs through this artificial canal.

CLINIC AND DIAGNOSTICS.

Any rupture of the perineum is accompanied by bleeding. Diagnosed by examining the soft birth canal. If a third degree perineal rupture is suspected, it is necessary to insert a finger into the rectum. An intact sphincter creates resistance when a finger is inserted into the rectum. A rupture of the intestinal wall is easily determined by the specific appearance of the inverted intestinal mucosa.

If there is significant bleeding from the perineal tissue, a clamp is applied to the bleeding tissue without waiting for the birth of the placenta.

TREATMENT. Treatment of all ruptures consists of suturing them after the birth of the placenta.

SEQUENCE OF URGENT ACTIONS.

Treatment of external genitalia, obstetrician's hands.

Pain relief with general anesthetic drugs (1 ml 2% promedol solution), local infiltration anesthesia with 0.25 - 0.5% solution of novocaine or 1% solution of trimecaine, which is injected into the tissues of the perineum and vagina outside birth trauma; The needle is inserted from the side of the wound surface in the direction of undamaged tissue.

Stitching of a perineal rupture when the wound surface is exposed with mirrors or fingers of the left hand. Sutures are placed on the upper edge of the tear in the vaginal wall, then sequentially from top to bottom, knotted catgut sutures (No. 2-4) are applied to the vaginal wall, spaced 1-1.5 cm apart until a posterior adhesion is formed. The injection and puncture of the needle are carried out at a distance of 1 -1.5 cm from the edge.

Application of knotted silk (lavsan, letilan) sutures to the skin of the perineum - with 1st degree of rupture.

In case of 2nd degree rupture, before (or as) suturing the posterior wall of the vagina, the edges of the torn pelvic floor muscles are sewn together with knotted catgut sutures, then silk sutures are placed on the skin of the perineum. When applying sutures, the underlying tissues are picked up so as not to leave pockets under the suture where blood will accumulate. Individual heavily bleeding vessels are tied with catgut under a clamp. Deflated, necrotic tissues are first cut off with scissors.

At the end of the operation, the suture line is dried with a gauze swab and lubricated with a 3% solution of iodine tincture.

When suturing a central perineal rupture, the remaining tissue in the area of ​​the posterior commissure is first cut with scissors, that is, it is first turned into a 2nd degree perineal rupture, and then the wound is sutured layer-by-layer in 2-3 layers in the usual way.

SEQUENCE OF MEASURES FOR 3 DEGREE PERINEAL RUPTURE.

Preparation surgical field and the hands of a surgeon according to the rules adopted for obstetric operations.

General anesthesia.

Disinfection of the exposed area of ​​the intestinal mucosa (with alcohol or chlogexidine solution after removing feces with a gauze swab).

Suturing the intestinal wall: thin silk ligatures are passed through the entire thickness of the intestinal wall (including through the mucous membrane) and tied from the intestinal side. The ligatures are not cut off and their ends are removed through the anus (in postoperative period they come off on their own or are pulled up and cut off 9-10 days after surgery).

Change of gloves and tools.

Connection of the separated ends of the sphincter using a knotted suture.

The operation continues as for a 2nd degree tear.

PREVENTION.

Prevention of perineal ruptures consists of rational management of labor, qualified delivery, and timely perineotomy in case of threat of perineal ruptures.

EVERION OF THE UTERUS.

The frequency of this complication is 1 in 45 - 450 thousand births. The essence of uterine inversion is that the fundus of the uterus from the side of the abdominal covering is pressed into its cavity more and more, but complete inversion of the uterus will not occur. The uterus turns out to be located in the vagina with the endometrium facing outwards, and from the side of the abdominal cavity the wall of the uterus forms a deep funnel, lined with a serous covering, into which the uterine ends of the tubes, round ligaments and ovaries are drawn.

CLASSIFICATION.

There are complete and incomplete (partial) inversion of the uterus. Sometimes complete inversion of the uterus is accompanied by inversion of the vagina. Eversion can be acute (fast) or chronic (slowly occurring). Acute inversions are more common, with 3/4 of them occurring in the afterbirth and 1/4 in the first day of the postpartum period. According to the etiological factor, uterine inversion is divided into forced and spontaneous, although at the end of the 19th century it was proven that uterine inversion is always spontaneous and is associated with uterine pathology. Violent is understood as an inversion that occurs when the umbilical cord is pulled or rough use Lazarevich-Crede's reception - with a relaxed uterus.

ETIOPATHOGENESIS.

The main reason is relaxation of all parts of the uterus, loss of elasticity of its myometrium. In this condition, even an increase in intra-abdominal pressure during pushing, coughing, or sneezing can lead to inversion of the uterus. The predisposing factor is the bottom attachment of the placenta, as well as large submucosal fibroids emanating from the fundus of the uterus.

CLINIC. Clinic of acute uterine inversion: sudden severe pain lower abdomen, state of shock, uterine bleeding. It can begin before uterine inversion due to atony and continues after its occurrence.

Complete inversion of the uterus may or may not be accompanied by vaginal inversion. In the first case, the uterus and placenta are located outside the vulva. In the second, the uterus is identified in the vagina when examined in the speculum. In both cases, upon palpation there is no uterus above the womb.

With incomplete uterine inversion general condition changes are not so fast and difficult. For differential diagnosis with other complications (for example, uterine rupture), a bimanual examination is performed, which determines an unusually low position for the placenta and early postpartum period. top edge uterus and the presence of a funnel-shaped depression in place of the fundus of the uterus.

Forecast if not provided urgent help- death of the patient from shock and blood loss, and in the following days - from infection (peritonitis, sepsis). Spontaneous correction of inversion does not occur.

Reduction of the uterus under anesthesia with preliminary manual removal of the placenta.

SEQUENCE OF EMERGENCY MEASURES WHEN REPOSITION OF THE UTERUS BY MANUAL TECHNIQUES:

administer general anesthesia and antishock therapy

disinfect the genitals and hands of the surgeon

inject subcutaneously 1 ml of 0.1% atropine to prevent cervical spasm.

Empty your bladder

grab the inverted uterus right hand so that the palm is at the bottom of the uterus, and the ends of the fingers are near the cervix, resting against the cervical-uterine ring fold.

Adjust the uterus; pressing on the uterus with your whole hand, first straighten the inverted vagina into the pelvic cavity, and then the uterus, starting from its bottom or isthmus. Left hand located on the bottom abdominal wall, walking towards the screwed-in uterus. With recently occurring uterine inversion, its reduction is performed without much difficulty. Massage of the uterus with a fist should not be performed, since against the background of shock and blood loss, squeezing thromboplastic substances from the uterus into the general bloodstream can lead to impaired blood clotting and continued uterine bleeding;

introduce contractile agents (simultaneously oxytocin, methylergometrine), continuing to administer them for several days.

In case of delayed medical care, when the ectopia is a day or more old, it is necessary to resort to removal of the uterus. This depends on areas of necrosis in the uterine wall that occur due to sudden disruptions in blood supply and infection of the organ after inversion.

PREVENTION.

Prevention of uterine inversion consists of proper management afterbirth, discharge of the placenta externally in the presence of signs of placental separation without pulling on the umbilical cord.

HEMATOMA OF THE VULVA AND VAGINA.

Localization - below and above the main pelvic floor muscle (mm. Levator ani) and its fascia. More often, a hematoma occurs below the fascia and spreads to the vulva and buttocks, less often - above the fascia and spreads along the paravaginal tissue retroperitoneally up to the perinephric region.

Etiopathogenesis. The main cause of hematomas is changes in the vascular wall. Occurs with varicose veins of the external genitalia and pelvis, hypovitaminosis C, hypertension, chronic glomerulonephritis, gestosis in pregnant women. Against this background, a hematoma is formed not only as a result of complicated labor (long or rapid, with a narrow pelvis, application of obstetric forceps, extraction by the pelvic end), but also during spontaneous uncomplicated labor.

Hematomas are more often formed on the left, which is associated with asymmetry of development venous system and more frequent formation of 1 position with the longitudinal position of the fetus.

Clinic and diagnostics. The size of hematomas can vary, and the severity of clinical manifestations depends on this. Symptoms of a hematoma of significant size: pain and a feeling of pressure at the site of localization (tenesmus due to compression of the rectum), as well as anemia with an extensive hematoma. When examining postpartum women, a tumor-like formation of a blue-purple color is discovered, protruding outward towards the vulva or into the lumen of the vaginal opening, deforming it. On palpation, the hematoma fluctuates. Diagnosis of vaginal hematoma is more difficult. It is necessary to use vaginal examination, speculum examination and rectal examination to determine the size and topography of the hematoma. If the hematoma spreads to the parametrial tissue vaginally, a vaginal examination reveals the uterus pushed to the side and between it and the pelvic wall an immobile and painful tumor-like formation. In this situation, it is difficult to differentiate a hematoma from an incomplete uterine rupture in the lower segment.

Treatment of hematoma - conservative or surgical; it depends on its location, size and clinical course. Small, non-progressive hematomas of the vagina and vulva, which gradually resolve, are treated conservatively. Emergency surgical treatment is required if the hematoma rapidly increases in size with signs of anemia; with a hematoma that produces profuse external bleeding; with a large hematoma that occurred before the onset of labor and in the first period. The latter will create an obstacle to the birth of a child and contribute to additional trauma and crushing of tissues.

The operation is performed under general anesthesia and consists of the following stages: incision of tissue above the tumor; removing blood clots; ligation of bleeding vessels or stitching with 8-shaped catgut sutures; closing and draining the hematoma cavity. A hematoma of the broad uterine ligament requires transection, opening of the peritoneum between the round ligament of the uterus and the infundibulopelvic ligament, removal of the blood tumor, and ligation of damaged vessels. The operation is limited to this unless the uterus ruptures.

Prevention of vaginal hematomas consists of the treatment of diseases that affect the condition of the vascular wall, as well as the qualified management of labor and delivery operations.

OBSTETRIC FISTULAS.

This concept includes genitourinary and enterogenital fistulas. They arise as a result of severe birth trauma and lead to permanent loss of ability to work, disorders of a woman’s sexual, menstrual and generative functions. Fistulas contribute to the development of ascending infection of the genital organs and urinary system.

Classification. Based on the nature of their occurrence, fistulas are divided into spontaneous and violent. According to localization, vesicovaginal, cervicovaginal, urethrovaginal, ureterovaginal, and enterovaginal fistulas are distinguished.

Etiology and pathogenesis. Spontaneous fistulas are more common, and according to localization - vesicovaginal. The formation of fistulas is associated with necrosis of a section of the walls of the bladder or rectum when blood circulation in them is impaired as a result of prolonged (more than 3-4 hours) compression of tissues by the fetal head. This is observed with a functionally narrow pelvis or with severe weakness of labor. Fistulas of a violent nature are rarely formed and occur during childbirth operations (fetal destruction operations, obstetric forceps, cesarean section). Rectovaginal fistulas can form as a result of unsuccessful suturing of a 3rd degree perineal tear.

CLINIC AND DIAGNOSTICS.

With genitourinary fistulas, urine leaks from the vagina of varying intensity, and with entero-genital fistulas, gas and feces are released. The time when these symptoms appear is of diagnostic importance: injury to adjacent organs is indicated by the appearance specified symptoms in the first hours after surgical delivery. When a fistula forms as a result of tissue necrosis, these symptoms appear 6-9 days after birth. The final diagnosis is made by examining the vagina in speculums, as well as with the help of urological and X-ray methods diagnostics

Treatment of fistulas is only surgical. If adjacent organs are injured by instruments and there is no tissue necrosis, the operation is performed immediately after childbirth; in case of fistula formation as a result of tissue necrosis - 3-4 months after birth. Small fistulas sometimes close as a result of conservative local treatment.

PREVENTION.

Identification of a risk group for clinical discrepancy between the fetal head and the mother’s pelvis, early hospitalization of these pregnant women in the antenatal department to resolve the issue of a planned caesarean section.

Rational management of childbirth

timely diagnosis and treatment of clinical discrepancy between the fetal head and the mother’s pelvis, treatment of weakness of labor, preventing the fetal head from standing in one plane for more than 2-3 hours,

monitoring bladder and bowel function

competent performance of delivery operations