Perineal Lacerations
| A | Following Wertheim’s operation | |
| B |
Pressure necrosis during labour |
|
| C |
Improper repair of perineal tear |
|
| D |
Abnormal presentation |
Commonest cause of recto vaginal fistula is :
| A |
Following Wertheim’s operation |
|
| B |
Pressure necrosis during labour |
|
| C |
Improper repair of perineal tear |
|
| D |
Abnormal presentation |
Improper repair of perineal tear
A primipara who had a prolonged labour and difficult vaginal delivery three months ago presents with complains of incontinence of loose stools and flatus from the day of delivery. The most likely diagnosis :
| A |
Chronic diarrhoea |
|
| B |
Recto-vaginal fistula |
|
| C |
Haemorrhoids |
|
| D |
Complete perineal tear |
Complete perineal tear
Perineal hematoma after trauma is due to?
| A |
Rupture of membranous urethra |
|
| B | Rupture of bulbar urethra | |
| C | Pelvic organ blunt trauma | |
| D | Rupture of bladder |
Rupture of bulbar urethra REF: Sabiston Textbook of Surgery, 18th ed chapter 77
|
Bulbar urethral injury |
Membranous urethral injury |
|
More common |
Less common |
|
Due to direct blow to perineum |
Blunt trauma to pelvis and fracture |
|
Retention of urine seen |
Retention of urine seen |
|
Blood at urethral meatus |
Blood at urethral meatus |
|
Perineal hematoma |
Pelvic hematoma |
|
Superficial extravasation of urine into superficial perineal pouch and then passes into scrotum, penis and anterior abdominal wall |
Deep extravasation of urine into perivesical space |
| A | Inferior gluteal nerve | |
| B |
Pelvic splanchnic nerve |
|
| C |
Posterior femoral cutaneous nerve |
|
| D |
Pudendal nerve |
The pudendal nerve (from S2-S4) is the principal nerve to innervate structures of the perineum, including sensory innervation to the genitalia, and motor innervation to muscles of the perineum, the external urethral sphincter, and the external anal sphincter.
This innervation may have clinical significance, as babies can also have uterine prolapse, which can be due either to congenital weakness in the pelvic musculature or to defects in innervation.
The inferior gluteal nerve supplies the gluteus maximus.
The pelvic splanchnic nerve supplies the pelvic viscera via the inferior hypogastric and pelvic plexuses.
The posterior femoral cutaneous nerve supplies the skin of the buttock and upper portions of the medial and posterior aspects of the thigh.
Ref: Cunningham F.G., Leveno K.J., Bloom S.L., Hauth J.C., Rouse D.J., Spong C.Y. (2010). Chapter 2. Maternal Anatomy. In F.G. Cunningham, K.J. Leveno, S.L. Bloom, J.C. Hauth, D.J. Rouse, C.Y. Spong (Eds), Williams Obstetrics, 23e.
You are called to assess the perineal tear after a difficult labour. On examination the tear involves the perineal muscles but sparing the external and internal anal sphincters. You would classify the tear as which of the following?
| A |
1st degree perineal tear |
|
| B |
2nd degree perineal tear |
|
| C |
3rd degree perineal tear |
|
| D |
4th degree perineal tear |
1st degree perineal tears are superficial and doesn’t involve the muscles. 2nd degree perineal tear involves the perineal muscles but doesn’t involve anal sphincters. In 3rd degree perineal tears the sphincters are also involved. When rectal mucosa is also involved its called a 4th degree perineal tear.
| A |
Coccygeus |
|
| B |
Iliococcygeus |
|
| C |
Pubococcygeus |
|
| D |
Puborectalis |
The fetal head is supported during childbirth by the pelvic floor.
If injury occurs during the passage of the child through the dilated uterine cervix, this injury most frequently involves a tear of the perineum between the vagina and anus. This tear usually involves the pubococcygeus, which is the main part of the levator ani.
The pubococcygeus runs from the pubic bone anteriorly to the coccyx posteriorly, and contains an anterior opening for the urethra and vagina and a posterior opening for the rectum.
Tears to this muscle that heal poorly may consequently predispose for uterine prolapse, cystocele, and rectocele.
| A |
Immediately |
|
| B |
2 weeks |
|
| C |
After 6 weeks |
|
| D |
After 12 weeks |
After 12 weeks
III perineal tear is involvement of :
| A |
Vaginal mucosa |
|
| B |
Urethral mucosa |
|
| C |
Levator ani muscle |
|
| D |
Anal sphincter |
Anal sphincter
In a case of direct occipitoposterior position (Face to pubis delivery) most commonly encountered problem is :
| A |
Intracranial injury |
|
| B |
Cephalhematoma |
|
| C |
Paraurethral tears |
|
| D |
Complete perineal tears |
Ans. is d i.e. Complete perinea! tears
Occipitoposterior Position The occiput is in the posterior segment of the pelvis, overlying the sacroiliac joint or the sacrum. It is responsible for most cases of prolonged labour and second stage delay.
Engaging Diameters
- Suboccipitofrontal diameter in a deflexed head°.
- Occipitofrontal diameter in a head which is further deflexed°.
Course of Labour :
- Anterior rotation : In 90% of cases, the occiput rotates anteriorly through 3/8 of a circle and the baby is born as occipitoanterior. Engagement may be delayed and labour may be longer because of deflexion.
- Posterior rotation and face to pubis delivery : When the head is deflexed, the engaging diameter is the occipitofrontal and the sinciput is the leading part. hence, the sinciput touches the pelvic floor first and rotates anteriorly. The occiput thus rotates posteriorly into the hollow of sacrum and delivery occurs as face to pubis.
Most common complication in such cases is Perineal tears° as the occiput is posterior and it is the longer biparietal diameter (9.4 cm) which distends the perineum rather than the smaller bitemporal diameter (8 cm). Hence in all such cases a liberal episiotomy should be given.
Besides this due to extreme moulding there is elevation of falx cerebrii which favours tentorial tear. Occipitosacral position and face to pubis delivery are more common in an anthropoid pelvis.
Sometimes : There is failure to progress (arrest) inspite of good uterine contractions for about 1/2-1hr after full dilatation of the cervix– This is occipito sacral arrest.
Managei, or uccipito sacral arrest :
If head is engaged and occiput is below ischial Spines – Forceps application in unrotated head followed by extraction as face to pubis.
If occiput remains at or above the level of ischial spine – Cesarean section .
3. Failure of Rotation :
- Persistent occipito posterior position.
Partial anterior rotation Head is arrested with saggital suture in transverse diameter at the level of ischial spine, after full dilatation inspite of good uterine contractions called as Deep Transverse Arrest.
