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INJURY OF MOTHER AND FRUIT.



During pregnancy, an increase in uterine extensibility occurs.

This is due to an increase in the number of blood and lymph vessels, as well as an increase in the level of hyaluronidase.



In childbirth, trauma to the soft birth canal always occurs; small tears of the uterus form.



Classification of birth injury.



1) uterine rupture

2) perineal rupture (three degrees)



3) cervical rupture

4) hematomas of the vagina and external genital organs



5) genitourinary and intestinal fistulas

6) postpartum inversion of the uterus

7) rupture of the pubic symphysis.



Relevance of the problem:



1. uterine ruptures are characterized by a high level of maternal mortality



2. In case of uterine rupture, women are disabled (hysterectomy, fistula)



3. other types of birth injury can lead to the development of pelvic floor insolvency, resulting in the omission or even prolapse of the genitals



4. fistula formation may occur



5. sexual dysfunction may occur (dyspareunia - pain during intercourse)



6. with ruptures of the cervix, ectropion (eversion of the cervix in the vagina), which is a precancerous disease, can form.



7. With birth injury there is a high risk of developing purulent-inflammatory complications, up to the development of sepsis.





Uterine tears.



The frequency of uterine ruptures is 1: 1000-2000 births (0.05-0.1%).

More often, uterine ruptures occur in multiparous - in 85% of cases.



Etiology and pathogenesis of uterine ruptures.



In 1875, Bandel created the theory of mechanical uterine rupture.

According to this theory, there is a violation of the interaction between the actively expandable upper segment and the passively expandable lower segment as a result of mechanical obstruction to the moving parts of the fetus.

In the lower segment, the wall thickness at the beginning of labor is 5 mm, and up to 3 mm towards the end.



The lower segment is overstretched, the contraction ring rises to the level of the navel, the uterus takes the form of an hourglass.

When the fetus enters the thinned lower segment, the uterus ruptures.



2 Ivanov's theory.



According to which uterine rupture is caused by pathology of the uterine wall and endometrial dysfunction.



These are changes such as:

1) replacement of muscle tissue by connective

2) loss of elastic tissue

3) the development of scar tissue after operations on the uterus or its injuries



In recent years, a combination of mechanical theory and uterine wall pathology has prevailed.

3 Baksheev's theory

According to which uterine rupture is caused by a biochemical trauma of the myometrium.



With prolonged labor with:

- prenatal discharge of amniotic fluid

- anomalies of labor

there is a violation of energy metabolism in the myometrium, oxidation processes are disrupted, cellular and organ acidosis develops. In this case, the fluid escapes into the interstitial space, the capillary blood flow is disturbed.



The elasticity of muscle tissue is reduced and muscle fibers are torn.



Causes of uterine rupture.



1 / Mechanical obstruction of the birth of the fetus:



1. Clinically narrow pelvis:



- anatomically narrow pelvis

- large (giant) fruit

- Anomalies of insertion of the fetal head

- hydrocephalus



2. transverse position of the fetus



2 / Histopathological changes in the myometrium:



1. Scars after:



- cesarean section

- restored uterine rupture



- myomectomy

- metroplastics

- accidental uterine injury (perforation during abortion)



- acute or dull injury (accident, knife or gunshot wound)



2. Dystrophic changes that develop when:



• acute or chronic inflammatory process (placental increment occurs)



• in multiparous women (more than 4 births)

• history of complicated past birth

• repeated complicated abortions



• in women with miscarriage

• with weak labor in previous births



• with a long anhydrous period, when chorionamnionitis, endometritis develops and purulent fusion of the myometrium occurs.



3 / Damage to the uterus during a real pregnancy:



1. with constant and strong contractions of the uterine muscles



2. with severe overstretching of the uterus with:

- polyhydramnios,

- multiple pregnancy,

- large fruit.



3. Obstetric manipulations:

- Internal-external rotation of the fetus

- obstetric forceps

- fetal extraction beyond the pelvic end

- fruit-destroying operations.



4 / Uterine changes not related to injury:



- birth defects

- pregnancy in an underdeveloped uterus and uterine horn



- invasive cystic drift

- true increment of the placenta

- adenomyosis.





Classification of uterine ruptures according to Persianinov

(on pathogenesis).



1) Spontaneous:



- typical (mechanical)



- atypical:

a) histopathic

b) mechano-histopathic



2) violent:



a) traumatic

- with gross intervention during childbirth



b) mixed

- with external exposure with overstretched lower segment



Clinical classification of uterine ruptures.



1. menacing

2. started

3. accomplished.



Classification of uterine ruptures according to the nature of the damage.

1) Crack



2) incomplete gap

- does not penetrate into the abdominal cavity



3) a complete break.



Classification of uterine ruptures by localization.



1) in the bottom of the uterus

2) in the body of the uterus

3) in the lower segment



4) separation of the uterus from the arches (colporexis)

- in this case, it is necessary to extirpate the uterus.

Clinic for uterine rupture.



Clinic of atypical uterine rupture.



With atypical uterine rupture, the clinical manifestations are erased, and the frequency of their occurrence has increased.



1) Obstetric and gynecological burdened history



2) The course of this pregnancy:



A / Pain:

- localized in the scar area

- or throughout the abdomen - as precursors



B) The appearance of spotting spotting from the genital

ways (4-5 weeks before birth)



3) In childbirth:

- complicated course:



A) anomalies of labor

B) unproductive attempts



It is necessary to solve the question of the need (possibility) of birth control.



C) The condition of the fetus:

- the development of acute hypoxia, which can lead to fetal death.



In childbirth, when the neck is opened, it is necessary to enter the pharynx and palpate the pharynx.

In this case, scar failure can be detected:



- niches

- hernia

- sharp pain.



If the scar is insolvent, a cesarean section must be performed.





Clinic of a typical uterine rupture.



It occurs in the second stage of labor.



A menacing break.



1. frequent, painful contractions

2. high standing contraction ring



3. soreness of the lower segment

4. overstretching of the lower segment



5. overstretching of the bladder

6. Cervical edema with spread to the vagina and external genitalia



7. Attempts occur with a high-standing fetal head.





The beginning of the uterine rupture.



1) contractions become painful, convulsive

2) severe persistent pain in the lower abdomen



3) a sense of fear of death

4) mydriasis



5) loud scream

6) spotting from the genital tract (this is the difference from the menacing gap)



7) a change in the condition of the fetus:

- muffled heartbeat

- active movements



8) involuntary attempts at incomplete opening of the pharynx.





A completed uterine rupture.



- hemorrhagic shock develops, the severity of which depends on the location of the gap and on the extent of damage.





Clinic:

1. "deathly silence":

- the woman is adynamic, apathetic, silent



2. pain

3. vomiting

4. nausea



5. forced position



6. increasing signs of hypovolemia

- weakness

- dizziness

- pallor

- acrocyanosis

- tachycardia

- tachypnea

- decrease in blood pressure



7. acute fetal hypoxia, intrapartum fetal death



8. change in the configuration of the uterus - as a tumor formation



9. under the anterior abdominal wall, parts of the fetus are defined



If the uterine artery is damaged, bleeding occurs in the retroperitoneal space.



Diagnosis of uterine rupture in the postpartum period:



1) moderate or heavy bleeding

2) the absence of signs of separation of the placenta



3) pain in the abdomen, uterus



4) uterus:

• irregular shape,

• not contoured,

• deviated to the side (since a parametric hematoma is formed)



5) manual examination of the uterine cavity is necessary

Treatment of uterine ruptures.



Treatment of menacing uterine rupture.



With a dead fetus - fruit-destroying operations.



With a living fetus, a cesarean section.

Treatment of the onset of uterine rupture.

- emergency operation cesarean section.



Treatment of an accomplished uterine rupture.



1) cesarean section



2) adequate pain relief

(endotracheal anesthesia)



3) adequate infusion-transfusion shock therapy



4) correction of hemocoagulation disorders

- treatment of DIC.



Surgery for uterine ruptures.



1. hysterectomy

2. uterine amputation

3. suturing the gap.



Indications for hysterectomy:



1) extensive trauma with great blood loss

2) separation of the uterus from the arches



3) uterine rupture with uterine artery rupture, in which retroperitoneal parametric hematoma is formed



4) upon attachment of infection

5) with a rupture of the cervix with the transition to the arches.





Indications for amputation of the uterus:



1. no signs of DIC

2. The cervix is ​​not damaged.



Indications for suturing the gap:



1) there is no suspicion of infection



2) a short interval between uterine rupture and the onset of surgery (less than 6 hours)



3) favorable localization of the gap (in the lower segment)

4) in young women.



Prevention of uterine ruptures.



It should be multi-stage and carried out from the moment of registration of the pregnant woman.



1) allocation of risk groups



2) hospitalization in the department of pathology of pregnant women with a period of 37-38 weeks.



3) If the scar is insolvent, an immediate hospitalization is carried out in the department of pathology of pregnant women, where the woman is until the moment of the operative delivery - cesarean section.





Birth injury to the fetus.



In the second stage of labor, the pressure in the uterine cavity reaches 70 kg per 1 cm2.
fetal heads.

For the first time, Littel described a fetal craniocerebral injury during childbirth.



Severity of fetal injury:



1st degree:

- without consequences



2 degree:

- there may be consequences



3 degree:

- complications for the mother.



The incidence of birth injuries of the fetus is up to 0.2-30%.



Types of injury to the fetus.



1. Traumatic brain injury



- hemorrhages can occur in all structures of the brain, in the posterior cranial fossa



- rupture of a sickle of the brain



2. Spinal cord rupture



- occurs with pelvic presentation of the fetus

- with excessive bending of the fetal head



3. Bone fractures

- in the first place in the frequency of occurrence are collarbone fractures, both violent and arbitrary.



- Fractures of the humerus (with improper release of the handles, throwing the handles of the fetus)



- Fractures of the thigh and lower leg



4. Damage to the peripheral nerves



- paresis of the facial nerve (when applying obstetric forceps)



- paresis of the brachial plexus (as a result of compression when the fetal handles are removed by the obstetrician).





Causes of fetal injury:



1) mismatch in the size of the fetal head and pelvis

- clinically narrow pelvis



2) improper technique for applying obstetric forceps, vacuum extraction



3) when removing the fetus by the pelvic end



4) infection and hypoxia contribute to the development of injuries

- This is a biochemical injury.



In the clinic of birth trauma of the fetus, 2 periods are distinguished:

- period of excitement

- period of oppression.



Treatment of birth injuries.

1. cold

2. antihemorrhagic therapy

3. peace.



Prevention of injury to the fetus.



1. delivery without protection of the perineum



2. in preterm birth:

- pereneotomy

- episiotomy.

Abroad, all primiparous episiotomy is performed.
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  6. ISOSEROLOGICAL INCOMPATIBILITY OF BLOOD OF MOTHER AND FRUIT
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