genital tract
injuries,VVF,RVF
Specific objectives
definition of genital tract injuries
types of genital tract injuries
causes and clinical features of genital tract injuries
diagnosis and management of genital tract injuries
definition of VVF and RVF
causes of VVF and RVF
diagnostic techniques and management of VVF and RVF
complications and nursing management of VVF and RVF
GENITAL INJURIES
1.VULVA
Lacerations of the vulval skin posteriorly and the
paraurethral tear on the inner aspect of the labia
minora are the common sites.
Management
Paraurethral tear may be associated with brisk
haemorrhage.
Repaired by interrupted catgut sutures,
preferably after introduction of a rubber catheter
into the bladder to prevent injury of the urethra.
2. PERINEUM
While minor injury is quite common specially during
first birth, gross injury (third and fourth degree) is
invariably a result of mismanaged second stage of
labor.
Overall risk is 1 per cent of all vaginal deliveries.
CAUSES
Over stretching
Rapid stretching of the perineum specially when
the perineum is inelastic.
Classification (RCOG)
PREVENTION
Delivery by early extension is to be avoided
Delivery of the shoulders
Delivery of the trunk
MANAGEMENT
Repair of complete
perineal tear
Step -I
Step-II
Step-III
Step-IV
Aftercare
A low residual diet
Lactulose 8 ml twice daily beginning on the
second day and increasing the dose to 15 ml on
the third day is a satisfactory regime to soften the
stool.
Broad spectrum antibiotics
3. VAGINA
Isolated vaginal tears or lacerations without
involvement of the perineum or cervix are not
uncommon.
CAUSES
These are usually seen following instrumental or
manipulative delivery.
In such cases, the tears are extensive and often
associated with brisk haemorrhage.
TREATMENT
The tears are repaired by interrupted or continuous sutures
using chromic catgut No. ’0’ .
In case of extensive lacerations, in addition to sutures,
haemostasis may be achieved by intravaginal plugging
by roller gauze, soaked with glycerine and acriflavine.
The plug should be removed after 24 hours.
4. COLPORRHEXIS
Rupture of the vault of the vagina is called colporrhexis.
Primary(vault)
Secondary(cervical tear).
TREATMENT
Laparotomy
Evacuation of haematoma and arterial ligation may
be needed.
5. CERVIX
Minor degree of cervical tear is invariable during
first delivery and requires no treatment.
Extensive cervical tear is rare. It is the commonest
cause of traumatic postpartum haemorrhage.
CAUSES
Iatrogenic
Rigidcervix
Strong uterine contractions
DIAGNOSIS
Excessive vaginal bleeding
Hard and contracted uterus raises the suspicion
of a traumatic bleeding.
Exploration of the uterovaginal canal under good
light not only confirms the diagnosis but also helps
to know the extent of the tear.
DANGERS
Early Late
Deep Ectropion
cervical tears- severe
postpartum haemorrhage. Cervical incompetence
Broad ligament haematoma with mid-trimester
Pelvic abortion.
cellulitis
Thrombophlebitis.
TREATMENT
PROCEDURES
5. PELVIC HEMATOMA
DEFINITION
Collection of blood anywhere
in the areas between the
pelvic peritoneum and the
perineal skin is called pelvic
hematoma.
ANATOMICAL TYPES
Supralevator
hematoma
Infralevator
hematoma
Infralevator hematoma
ETIOLOGY
1. Improper haemostasis during repair of vaginal or
perineal tears or episiotomy wound
Failure to take precaution while suturing the Apex of
the tear.
Failure to obliterate the dead space while suturing the
vaginal walls.
Cont…
2. Rupture of
paravaginal venous
plexus either
spontaneously or
following instrumental
delivery.
Symptoms
Persistent,severe pain on the perineal region
Rectal tenesmus.
Retention of Urine.
Signs
Shock
Tense swelling at the
vulval which becomes
dusky and purple in colour
and tender to touch.
Treatment
<5cm may be treated with cold compress
Large hematomas should be explored in the
operation theatre under general anesthesia.
Deep mattress sutures and a closed suction drain
maybe kept in that place for 24hours.
Prophylactic antibiotics Administration
SUPRALEVATOR
HEMATOMA
CAUSES
Extension of cervical laceration or primary colporrhexis
(vault rupture).
Lower uterine segment rupture.
Spontaneous rupture of para vaginal venous plexus
adjacent to the vault.
DIAGNOSIS
Vaginal examination Rectal examination
MANAGEMENT
Broad ligament peritoneum is incised and the blood
clot is scooped out.
Random blind sutures should not be placed to
prevent ureteric damage.
6. RUPTURE OF THE
UTERUS
Disruption in the
continuity of the
uterine layers beyond
28 weeks of
pregnancy.
CAUSES
Spontaneous
Scar rupture
Iatrogenic or
traumatic
TYPES
COMPLETE
RUPTURE
INCOMPLET
E RUPTURE
CLINICAL PICTURE
Before actual rupture
Actual rupture
examination
General Vaginal
Abdominal
Management
PROPHYLACTIC CURATIVE
Early detection of cause Blood transfusion
Proper use of Oxytocin Immediate laparotomy
Version is not done Repair or hysterectomy
No instrumental delivery Vaginal or cervical repair
Elective caesarean section
COMPLICATIONS
MATERNAL FETAL
Shock Fetal death due to
Haemorrhage asphyxia from
Paralytic ileus detachment of the
Bladder, urethral or visceral placenta.
injuries
Infection
Genito-urinary fistulas
It is an abnormal
communication
between the genital
tract with the urinary
system.
types
Vesicovaginal fistula
Vesicovaginal fistula (VVF)
is an abnormal opening
between the bladder and
the vagina that results in
continuous and unremitting
urinary incontinence.
classification
Simple fistulas small in size (≤0.5cm)
Complex fistulas large-sized (≥2.5 cm)
Intermediate-sized Fistulas (between 0.5 and
2.5 cm)
etiology
Abdominal hysterectomy
Prolonged labor
Instrumental delivery
Signs and symptoms
Constant urinary drainage per vagina
Perineal skin irritation
Recurrent cystitis
Vaginal fungal infections
Pelvic pain
DIAGNOSIS
History and physical examination
Pelvic examination with speculum
Urine culture and analysis
Cystoscopy and biopsy
Double dye test
management
Non surgical Surgical
Catheter drainage Trans-abdominal
Fulguration Trans-vaginal
Fibrin glue Bilateral percutaneous
Injection of platelet rich nephrostomies and
plasma ureteric occlusion.
Bilateral percutaneous nephrostomies and
ureteric occlusion
Rectovaginal fistula
Definition: It is the fistulous communication between
vagina and the rectum or anal canal.
causes
Injury during childbirth
Crohn's disease
Radiation treatment
Previous surgery in the
pelvic area.
symptoms
Passage of gas, stool or Irritation or pain in the
pus from the vagina vulva, vagina and the area
Foul-smelling vaginal between the vagina and
discharge anus (perineum)
Recurrent vaginal or Pain during sexual
urinary tract infections intercourse
diagnosis
Physical examination Anorectal manometry
Contrast tests
Blue dye test
CT
MRI
Anorectal ultrasound
management
Antibiotics
Patch of biologic tissue into the fistula
Repairing the anal sphincter muscle
Performing a colostomy before repairing a fistula
in complex or recurrent cases
STROMAL VASCULAR
FRACTION
Cells of SVF help to:
Stimulate Blood
Circulation
Reduce Inflammation
Reduce the Immune
response
• Fecal incontinence
• Hygiene problems
• UTI
COMPLICATION • Inflammation of
S vagina, perineum and
skin around anus
• Infection
• Fistula reoccurrence
LIFE STYLE AND HOME
REMEDIES
Wash with water
Avoid irritants
Dry thoroughly
Avoid rubbing with dry toilet paper
Apply a cream or powder
Wear cotton underwear and loose clothing
ASSIGNMENT
Write nursing care plan for genital tract
injuries
Submission date: 14/12/2019 at 10am
Marks: 10
Evaluation
Explain the degrees of perineal tear____________
What are the types of hematomas______________
What is vesicovaginal fistula______________
What is rectovaginal fistula_____________
JOURNAL REFERENCE-
3
TITLE: Pattern of episiotomy use and it’s
immediate complications among vaginal deliveries
in 18 tertiary care hospitals in India.
Shalini Singh et al.
