Childbirth is considered a complex and unpredictable process, and often it leads to many unpleasant consequences and complications. Including a newly-made mother sometimes faces a perineal rupture after childbirth. At the moment, in medical practice, it is approximately 4.6% of birth injuries. Modern medicine has managed to bring this indicator to such a low level.
How's it going?
The perineum is the bottom of the small pelvis, it consists of muscles. In the process of childbirth, the head of the fetus presses on them in the strongest way. As a rule, rupture of the perineum, vagina occurs with head presentation of the fetus. The outcome will depend on the elasticity of the muscles - whether they will be able to cope with the pressure and stretch in such a way that the head passes. The muscles here become less elastic due to the developed muscles, the age of the woman is more than 35 years. At the same time, the first birth is a threatening factor for perineal rupture.
At the same time, scars left after previous births or operations also increase the likelihood that such an unpleasant consequence will disturb a woman. Puffiness during prolonged labor also leads to this negative phenomenon.
There are descriptions of perineal rupture due to illiterate obstetric care. So, protection for a woman in labor during the removal of the shoulders and head of the child is not always provided, and this is an additional risk factor. The rapidity of the process also leads to a similar phenomenon.
Sometimes the very structure of the bones in the pelvis with a narrowed exit suggests a future rupture of the perineum during childbirth.
Varieties
Tears can be spontaneous, when everything happens due to the passage of parts of the body of the fetus, and violent - such occur due to the actions of obstetricians. There are three degrees of perineal rupture during childbirth.
The first degree is manifested in damage to the posterior adhesions, the skin of the vagina. The second is determined by muscle damage in the pelvis. In the third degree, there is a rupture of the sphincter of the anus, and sometimes the rectum.
Very rare, occurring in 1 in 10,000 cases, is considered a central tear, when the walls of the vagina, the musculature of the pelvic floor with skin are affected, while the sphincter is not affected. The higher the degree of perineal rupture, the more difficult and longer the woman's rehabilitation will be.
Features
The clinical picture is a protrusion between the anus and the vagina, edema, cyanosis. At the same time, the woman is pathologically pale, cracks are noted on the skin, the integrity of the tissues is violated. Diagnose perineal rupture during childbirth immediately upon examination. Certainly, such a situation requiressurgery to repair damaged areas.
Symptomatics
With any degree of perineal rupture, a woman suffers from sharp pain in this area, the skin becomes cyanotic - it's all about venous congestion. The outflow of blood is disturbed, because of this, pallor is observed. Damaged areas often bleed. Sometimes the phenomenon occurs only because the fetus turned out to be large, and sometimes inflammation provokes such an outcome.
Treatment
Therapy after perineal rupture will consist in immediate stitching of the damaged area. This is done within the first half hour after diagnosis. Anesthesia is both local and intravenous. To prevent the seams from coming apart, a woman is forbidden to sit for 3 weeks.
Complications
Edema may subsequently appear at the suturing site, the phenomenon accompanies a pronounced pain syndrome. There are also purulent inflammations of the seams, tissues can scar. Damaged areas may lose sensation and stitches may come apart. If some stage of the procedure was carried out illiterately, in the end the woman will suffer from the prolapse of the uterus, and sometimes from its final prolapse. There may also be negative consequences in the rectum - gas incontinence, feces will begin.
Prevention
In order to prevent perineal rupture, you need to visit a gynecologist at least once a month, and do it more often according to his recommendations in different trimesters. It is important that a woman registers before the 12th week of pregnancy. It is believed that to help avoid the consequencesKegel exercises help. Prevention will also be provided by massage performed on a regular basis from the 7th month of pregnancy. It is important that any inflammation of the genital organs that occurs be treated in a timely manner.
It is necessary to strictly follow all the recommendations of gynecologists. Following a prepartum diet of reduced animal protein in the diet and increased oil reduces the risk of having to repair a perineal tear later on. It is important to learn in advance the correct breathing and relaxation, psychologically prepare for the process.
In Progress
It is worth taking into account the fact that such a phenomenon is always preceded by a special condition - the threat of perineal rupture during childbirth. This is a direct indication for doctors to perineotomy or episiotomy. The threat is manifested in puffiness, cyanosis, the formation of cracks, violation of the integrity of tissues. Starting from the third degree, blood loss becomes simply massive. At any degree, there is a high risk of getting a bacterial complication.
After surgery
When the diagnosis has already been made, it is required every day to ensure that the sutures grow together correctly. They are treated with antiseptics after each act of defecation and urination. If pus does not appear, the stitches are removed after 4-6 days. The surgical operation is carried out only by the most experienced gynecologists, several specialists should assist. The thing is that suturing a perineal rupture of the 2nd degree, and even the first, is considered a complex surgical operation.
Forecast
If all rules are met, forecastmost often favorable. Once the stitches are removed, pelvic function will begin to recover. But as for the next pregnancy, this issue is solved differently for each woman. In most cases, there are no contraindications to it.
If a grade 2 perineal tear is left unsutured for a long time, it begins to heal with infection. After all, this is an open wound, which easily lets in infections. As a result, the woman suffers from serious illnesses.
Subsequently, this will always manifest itself in a woman's he alth - the pelvic floor will lose functionality, internal organs will begin to fall out. Often, an unsewn rupture of the perineum of the 2nd degree leads to inflammation in the uterus, the appearance of erosion. If the degree is third, incontinence of gases and feces occurs. As a result, a woman loses her ability to work, loses her position in society. For this reason, such a phenomenon must be eliminated in a timely manner. The sooner the surgery is carried out, the better the result will be.
In cases where there is heavy bleeding, it must be urgently eliminated. For this purpose, a large cotton or gauze swab is inserted into the vagina. He will absorb the blood in the process of how the doctors will suture. After the procedure, the swab is removed. It is important to ensure that the damaged areas fit tightly together - this will speed up healing.
In order for the wound to be as exposed as possible, the vagina is additionally stretched during surgery, mirrors are used. If there is no assistant, the surgeon himself pushes the entrance apart with two fingers, revealingwound. During the operation, he spreads the edges of the wound with his fingers.
Suturing the gap is always done under anesthesia. In addition to the fact that the patient thus gets rid of pain, the wound opens up as much as possible. This, in turn, gives the doctor maximum visibility. If the view is impaired, there is a risk that the skin or mucous membrane will be sewn up, and the muscles that have torn will not be restored. In this case, the operation will have only a cosmetic effect. And all the consequences of a rupture of the perineum of the 2nd degree will affect later.
You should take it seriously if there is a third degree. In this case, it is necessary to connect the damaged sphincter. Otherwise, the results will be unsatisfactory. To prevent this, a very thorough inspection is necessary. Often, during sphincter contractions, the wounds disappear from view, and it becomes difficult to detect them, especially if anesthesia is not enough.
The suturing operation starts at the top, the needles capture tissues that are located deep. As a rule, silk seams are used. But joining the edges with metal brackets is also allowed.
If a 2nd degree perineal rupture is diagnosed, the upper angle of the damage is detected first. Usually it reaches up to the anus, its depth is such that it reaches the pelvic floor. As a result, entire cavities are formed in the depths of the damage, which are filled with blood. If there are several lateral gaps, they begin to sew up in turn. In the presence of a rupture of the 3rd degree, the paravaginal, adrectal tissue is damaged. The first thing you need to do is connect the edges of the wounds in the rectum and in the sphincter: due to retraction, they sometimes go deep. Skin wounds must be treated with iodine, as well as the entire vagina, pubis, folds in the groin. To prevent maceration of the skin and mucous membranes, this is done with sterilized vaseline oils.
In addition to this, several sterile gauze bookmarks are applied here. Then they are replaced several times a day. It is important that the genitals are treated two to three times a day, and also after each act of defecation with potassium permanganate.
Enemas after this kind of surgery are contraindicated. In cases where the patient does not have a chair, she is prescribed the lightest laxatives on the second or third day. If the recovery is planned, the stitches can be removed after five or six days.
Diet after surgery
If the degree of rupture was 3rd, during the first five days from the moment of surgery, the woman drinks only sweet tea, coffee with milk, broth, mineral water and juice. On the sixth day, the menu of such a diet is supplemented with apple and carrot puree. On the seventh day, the patient takes a laxative, and on the tenth day, the food becomes normal.
It is important to consider that the operation must be carried out with any perineal rupture, with the exception of only the smallest abrasions on the mucous membranes.
Often, in addition to the perineum, the labia and tissues at the vestibule of the vagina are also torn. As a result, bleeding occurs severe, as well as pain duringthis. In this case, suturing is also carried out as soon as possible, using catgut sutures. If they are superimposed near the urethra, a metal catheter is inserted into it, under its control, and a surgical operation takes place.
Sometimes when the perineum ruptures, the skin of the perineum remains intact. While inside there are damage to the walls, muscles. The dissection of the skin is performed by the most common methods.
To ensure the best healing of ruptures, the woman is carefully cared for after childbirth. A number of obstetricians begin to wrap the external parts of the genital organs at least two or three times a day with gauze with potassium permanganate or boric acid. After the area is dried with powders. Someone advises not to touch the damaged area once again, just keep it dry, doing only the replacement of gauze tabs.
Difficulties can occur in cases where the intestines were not completely cleared before surgery. This happens often. If the intestines are well cleansed, opium is dispensed with. It is advisable to prevent early defecation for the first 3-4 days to take opium 10 drops three times a day. Someone avoids prescribing this remedy by giving patients vaseline oil, one teaspoon three times a day.
If the gap was incomplete, laxatives are given to the patient on the third or fourth day, and the stitches are removed by the fifth or sixth day. She is discharged on the tenth day.
Warning in progress
With competent actions, it is possible in many cases to prevent perineal rupture. So,it is necessary to slowly pass the fetal head through the vulva, cut through it in the smallest size, slowly stretch the tissues, carefully observe how the shoulders are cut through, remove them as carefully as possible. Compliance with such recommendations allows you to protect the perineum if the presentation is cephalic.
A big role in preventing such a negative phenomenon is assigned to the psychological and physical preparation of the expectant mother for childbirth. Preparation allows you to be disciplined at the moment of exile, especially when the head is cut through. Often, surgery is used to prevent rupture. The surgeon simply cuts the perineum.
Some surgeons suggested that the lateral incision, often used in this case, be replaced by a median one. D. O. Ott advocated perineotomy. He claimed that it helps prevent perineal rupture. In particular, if there were subcutaneous ruptures, he advised to carry out a similar procedure for any childbirth. But his point of view was not approved in professional circles.
Currently, perineotomy is performed on patients if, despite providing protection, there is still a risk that the perineum will rupture. The incision is performed if the perineum has already stretched, become tense, thinned, turned pale. In this case, the vulva is expanded by 6 cm. Such a wound will be easily sutured, healing will occur quickly enough.
If the rupture of the perineum is already in the 3rd degree, this indicates that the birth probably occurred without medical assistance or with excessively ineptremoving the head in forceps. Sometimes this happens due to the fact that the fetus was removed by the pelvic end. The prognosis becomes more favorable with the threat of perineal rupture, if childbirth is anesthetized.
Cerineal slit
A perineotomy is an incision in the perineum. There are several types of cuts. The choice is made by the doctor depending on the specific indications. Perineotomy is less traumatic than episiotomy.
Surgical intervention of this kind is carried out as soon as there is a threat of rupture or it is already beginning. The thing is that the wound after the surgeon will heal much faster than the one formed naturally. After all, the gap leaves more noticeable and severe traces, the risk of suppuration in this case is higher.
The incision is always made if it is important to complete the birth process as quickly as possible - when it is premature, there is fetal hypoxia or its development is abnormal. In this case, a gentle mode is needed. If the efforts are weak, the incision is also considered a necessary procedure. It is also resorted to if there are difficulties in extracting the shoulders of the child.
And sometimes the incision is necessary because the mother has a disease - myopia, for example, or if she has undergone eye surgery, suffers from high blood pressure or has respiratory problems. In this case, surgery ensures her own safety. Complications after an incision are the same as with a rupture of the perineum. Although rehabilitation is much faster, it is still not easy. For the first few days, a woman will be accompanied by a constant pain syndrome. The sutures are removed on the fifth day. It is important to constantly care for the damaged area, its regular treatment.
