Maternal Complications After Childbirth
(Vaginal tears, Cervical tears, Periurethral tears)
Written by Dr.M.D.Mazumdar, MD
Most maternal injuries occur during the second stage of labour but the diagnosis is made in the third stage after the delivery of the baby. Some of the commoner ones are described below.
Vaginal Tears can occur at any part of the vaginal wall, but are seen mostly at the junction between the lateral and posterior walls. These tears may be superficial with only minor lacerations of the vaginal mucosa. But, sometimes the tears may be deep enough to expose the inner muscles.
First degree and second degree perineal tears are similar to vaginal wall tears and treated the same way.
Vaginal tears that involve only the skin around the vagina typically heal within a few weeks. There may be stinging pain , especially when passing urine when the acidic urine passes over the raw surface but this will gradually decrease and fade as the tears heal.
Tears can also occur on the labia, both labia majora and labia minora. Tears to the minora are not very uncommon but tears to the majora occur only in excessive manipulation of the vulva during childbirth. Tears to the labia can be either superficial abrasions or actual tearing of the labia.
Treatment / Management of Vaginal Tears
The vagina should always be examined under proper light immediately after the delivery of the baby for any such tears. All tears should be repaired immediately.
- The woman should sit on a soft cushion for a few days after childbirth to help in decreasing the pain.
- A cold pack applied to the vulva for 10 minutes every two hours will decrease the inflammation and the swelling.
- Pouring warm water over the vulva while passing urine will decrease the stinging pain.
- Pain relievers to decrease the pain and stool softeners to keep the stools soft will help prevent constipation and the need to push hard while passing stool will also help.
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Minor tears of the cervix are very common during delivery, especially in a woman who is delivering her first child and may not need to be repaired. But sometimes, major lacerations which can cause severe bleeding may also occur . In fact, cervical tears are the commonest form of traumatic post partum hemorrhage.
Tears can occur with a normal childbirth but are more common with instrumental deliveries like Forceps or Vacuum aspiration.
Cervical tears are commonest at the lateral angle, between the anterior and posterior lips of the cervix,especially at the three o'clock and the nine o'clock positions.
Vaginal bleeding after childbirth which occurs despite a well-contracted uterus and which does not appear to be arising from the vagina or perineum is an indication for examining the cervix. The cervix should be thoroughly examined with a speculum and vaginal wall retractor and under proper light for an accurate diagnosis.
Causes of Cervical Tears
- Delivery through an undilated cervix whether spontaneously, or by forceps.
- Precipitate labour.
- Rigid cervix due to previous operations like the LEEP procedure, conisation, or cervical amputation.
- Very vascular cervix as can occur in low level placenta previa.
Treatment / Management of Cervical Tears
The aim of treatment is to control bleeding as early as possible by repairing the tear. Minor lacerations without active bleeding does not require to be repaired - they heal spontaneously with no ill effects.
Major cervical lacerations or tears need to be repaired in the Operating theater under anesthesia, good light and proper exposure of the tear.
Vaginal tears can also occur at the region around the urethra - the opening through which urine comes out. These are then called ' Periurethral tears'. The problem with these type of tears is that there may be profuse bleeding from even a small tear since the region has a rich blood supply.
The commonest cause for a periurethral tear is a sudden extension of the fetal head at the time of delivery.
Normally, the fetal head is in a position of flexion with the chin touching the chest. At the time of delivery, after crowning occurs, the head is born by extension. A gradual extension will not put much presure on the anterior or upper part of the vagina. But a sudden extension will cause a sudden pressure on upper vaginal area resulting in a periurethral tear.
It is important for the doctor or midwife to press gently on the fetal head at the time of delivery and guide it to a slow and gradual extension at the time of birth.
Treatment / Management of Periurethral Tears
Periurethral tears need to be stitched carefully under proper light. If not repaired well or if it is not diagnosed after the delivery, it can bleed continuously for quite some time. Infections can also occur readily in the tear causing severe pain and inflammation. There may even be retention of urine due to inability of the woman to pass urine through the inflamed urethra.
It is advisable for the woman to use cold packs on the site of the tear for at laeast 7-10 days to hasten healing. Using anti-inflammatory painkillers like Ibuprofen aslo helps.
Thankfully, during the course of a pregnancy the body is primed to heal quickly. The immune system is more efficient than usual and therefore wounds will heal within a few weeks after childbirth.
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