Childbirth is considered a complex and unpredictable process, and often it leads to many unpleasant consequences and complications. Including a newly minted mother sometimes faces a crotch rupture after childbirth. Currently, in medical practice, it accounts for approximately 4.6% of birth injuries. Modern medicine has managed to bring this indicator to such a low level.
How is it going?
The crotch is the bottom of the pelvis, it consists of muscles. During childbirth, the fetal head 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 so that the head passes. The muscles here become less elastic due to the developed muscles, the woman's age is more than 35 years. At the same time, the first birth is a threatening factor for rupture of the perineum.
At the same time, the scars that remained after the previous birth or surgery also increase the likelihood that such an unpleasant consequence will disturb the woman. Swelling during prolonged childbirth also leads to this negative phenomenon.
There are descriptions of the perineal rupture that occurred due to illiterate obstetric care. So, protection of a woman in childbirth during the withdrawal of the shoulders and head of the child is not always provided, and this is an additional risk factor. The swiftness of the process also leads to a similar phenomenon.
Sometimes the very structure of the bones in the pelvis with a narrowed exit suggests in the future the perineum rupture during childbirth.
Varieties
Gaps can be spontaneous when everything happens due to the passage of parts of the body of the fetus, and violent - these arise 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 out of 10,000 cases, is a central rupture, when the walls of the vagina are affected, the muscles of the pelvic floor with the skin, while the sphincter is not affected. The higher the degree of rupture of the perineum, the more difficult and longer the rehabilitation of a woman will be.
Characteristics
The clinical picture is a protrusion between the anus and vagina, edema, cyanosis. At the same time, the woman is pathologically pale, cracks are noted on the skin, tissue integrity is impaired. Diagnose perineal rupture during childbirth immediately upon examination. Of course, this situation requires surgical intervention to restore damaged areas.
Symptomatology
At any degree of perineal rupture, a woman suffers from sharp pain in this area, the skin becomes cyanotic - it is all about venous stasis. The outflow of blood is disturbed, because of this, pallor is observed. Damaged areas often bleed. Sometimes the phenomenon occurs only due to the fact that the fetus turned out to be large, and sometimes inflammation provokes such an outcome.
Treatment
Therapy after rupture of the perineum will consist in immediately suturing the damaged area. This is done within the first half hour after diagnosis. Anesthesia is both local and intravenous. So that the seams do not diverge, the woman is forbidden to sit for 3 weeks.
Complications
Edema may subsequently occur at the suture site, a phenomenon accompanied by a pronounced pain syndrome. There are also purulent inflammation of the sutures, tissues can scar. Damaged areas can lose sensitivity, and the seams - to disperse. If some stage of the procedure was carried out illiterate, in the end the woman will suffer from the prolapse of the uterus, and sometimes from its final loss. There may be negative consequences in the rectum - the incontinence of gases, 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 is registered before the 12th week of pregnancy. Kegel exercises are believed to help avoid consequences. Prevention will also be provided by massage performed on a regular basis from 7 months of pregnancy. It is important that all genital inflammation that occurs is treated promptly.
It is necessary to strictly follow all the recommendations of gynecologists. Compliance with the prenatal diet, which consists in reducing animal proteins in the diet and increasing oil, reduces the risk of having to subsequently suture the perineal gap. It is important to learn proper breathing and relaxation in advance, psychologically prepare for the process.
During
It is worth taking into account the fact that such a phenomenon is always preceded by a special condition - the threat of rupture of the perineum during childbirth. This is a direct indication to doctors for perineotomy or episiotomy. The threat is manifested in swelling, 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 threat of a bacterial complication.
After operation
When the diagnosis has already been made, it is required every day to ensure that the sutures are fused correctly. They are treated with antiseptics after each act of defecation and urination. If pus does not appear, the sutures are removed after 4-6 days. Surgery is performed only by the most experienced gynecologists, several specialists should assist. The thing is that suturing a perineal rupture of the 2nd degree, and the first, is considered a complex surgical operation.
Forecast
If all the rules are followed, the forecast is most often favorable. As soon as the sutures are removed, the pelvic functions 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 perineal rupture of 2 degrees for a long time is not sutured, it begins to heal with infection. After all, this is an open wound that easily lets in infections. As a result, a woman suffers from serious illnesses.
Subsequently, this will always manifest itself in the woman’s health - the pelvic floor will lose functionality, prolapse of the internal organs will begin. Often, non-stitched perineal rupture of the 2nd degree leads to inflammation in the uterus, the appearance of erosion. If the degree is third, there is incontinence of gases and feces. As a result, a woman loses her ability to work, loses her position in society. For this reason, this phenomenon must be addressed in a timely manner. The faster the surgery will be performed, the better the result.
In cases where there is heavy bleeding, it is urgent to eliminate it. For this purpose, a large cotton or gauze swab is inserted into the vagina. It absorbs blood in the process of how doctors will suture. After the procedure, the tampon is removed. It is important to ensure that the damaged areas adjoin each other tightly enough - this will speed healing.
To make the wound as bare as possible, the vagina is additionally stretched during surgery, and mirrors are used. If there is no assistant, the surgeon himself pushes the entrance with two fingers, revealing the wound. During the operation, he spreads the edges of the wound with his fingers.
Stitching of a gap always occurs under anesthesia. In addition to the fact that the patient thus gets rid of pain, the wound opens up to the maximum. This, in turn, gives the doctor maximum visibility. If the review is violated, there is a risk that the skin or mucous membrane will be sewn up, and the muscles that are torn will not be restored. In this case, the operation will have only a cosmetic effect. And all the consequences of rupture of the perineum 2 degrees will affect later.
Serious should be taken 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, wounds go out of sight, and it becomes difficult to detect them, especially if anesthesia is not enough.
The stitching operation begins at the top, the needles capture tissues that are located deep. As a rule, silk seams are used. But the connection of edges by means of metal brackets is also allowed.
If a perineal rupture of degree 2 is diagnosed, the first thing that is discovered is the upper angle of damage. Usually it comes down 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 be sewn up in turn. In the presence of a gap of 3 degrees, paravaginal, pararectal fiber is damaged. The first thing you need to do is connect the edges of the wounds in the rectum and in the sphincter: they sometimes go deep due to retraction. Skin wounds must be treated with iodine, like the entire vagina, pubis, folds in the groin. In order to prevent maceration of the skin and mucous membranes, this is done with sterilized vaseline oils.
In addition to this, several gauze sterile tabs are placed 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.
Enema after this kind of surgical intervention is contraindicated. In cases where the patient has no stool, she is prescribed the easiest laxatives on the second or third day. If restoration occurs as planned, the sutures can be removed after five to six days.
Diet after surgery
If the degree of rupture was 3rd, during the first five days from the time 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, carrot puree. On the seventh day, the patient takes a laxative, and on the tenth day, the diet becomes normal.
It is important to consider that the operation must be performed at any rupture of the perineum, with the exception of only the smallest abrasions on the mucous membranes.
Often, in addition to the perineum, the labia and the tissues near the vagina are torn. As a result, bleeding occurs severe, like pain in this case. In this case, suturing is also carried out as soon as possible using catgut seams. If they are superimposed near the urethra, a metal catheter is inserted into it, and surgery is performed under his control.
Sometimes with a rupture of the perineum, the skin of the perineum remains intact. While inside there are damage to the walls, muscles. Dissection of the skin is performed by the most conventional methods.
To ensure the best healing of gaps, a woman is carefully looked after after childbirth. A number of obstetricians begin to wrap the external parts of the genital organs at least two to 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, only to keep it dry, only dealing with the replacement of gauze bookmarks.
Difficulties can occur if the intestines are not completely cleaned before surgery. This happens often. If the intestines are cleaned well, opium is dispensed with. It is advisable for the prevention of early bowel movements the first 3-4 days to take opium 10 drops three times a day. Someone avoids prescribing this drug by prescribing vaseline oil to the patient one teaspoon three times a day.
If the gap was incomplete, on the third or fourth day they give the patient laxatives, and the sutures are removed by the fifth or sixth day. They write it out on the tenth day.
Warning in progress
By competent actions, it is possible in many cases to prevent a rupture of the perineum. So, it is necessary to slowly pass the fetal head through the vulva, cut through it with the smallest size, slowly stretch the tissues, carefully observe how the shoulders cut, remove them as carefully as possible. Compliance with such recommendations allows you to protect the perineum, if the presentation is head.
A major 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 behave disciplined at the time of exile, especially when the head cuts out. Often, to prevent rupture, surgical intervention is used. The surgeon simply cuts the perineum.
Some surgeons have proposed a lateral incision, often used in this case, to replace the median one. D.O. Ott advocated perineotomy. He argued that this helps prevent perineal rupture. In particular, if there were subcutaneous tears, he advised to carry out a similar procedure during any birth. But his point of view did not find approval in professional circles.
At the moment, perineotomy is performed in relation to patients if, despite providing protection, there is still a threat that the perineum will rupture. The incision is performed if the crotch has already been stretched, has become tense, has become thinner, has turned pale. In this case, the vulva is expanded by 6 cm. A similar wound will be sutured easily, healing will occur quite quickly.
If the perineal rupture is already in the 3rd degree, this suggests that the birth must have occurred without medical assistance or with an excessively inept withdrawal of the head in the forceps. Sometimes this is due to the fact that the fetus was removed by the pelvic end. The prognosis for the threat of a rupture of the perineum becomes more favorable if childbirth is anesthetized.
Crotch incision
Perineotomy is a section of the perineum. The cuts are available in several varieties. The choice is made by the doctor, depending on the specific indications. Perineotomy is a less traumatic procedure than an episiotomy.
Surgery of this kind is carried out as soon as the threat of a gap arises or it already begins. The thing is that the wound after the surgeon will heal much faster than formed naturally. After all, the gap leaves more noticeable and heavier traces, the danger of suppuration in this case is higher.
An incision is always made if it is important to complete the birth process as soon as possible - when it is premature, there is fetal hypoxia or its development is abnormal. In this case, sparing mode is required. If the attempts are weak, the incision is also considered a necessary procedure. They also resort to it if there are difficulties with removing the child's shoulders.
And sometimes an incision is necessary due to the presence of diseases in the mother - myopia, for example, or if she underwent eye surgery, suffers from high blood pressure or has respiratory problems. In this case, surgery provides 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. The woman will be accompanied by a constant pain syndrome for the first few days. Sutures are removed on the fifth day. Important is the constant care of the damaged area, its regular treatment.