Crotch stitching. Rupture of the cervix during childbirth is a dangerous complication. Injuries of the soft birth canal: ruptures of the perineum, vagina, cervix - causes, diagnosis and prevention

One stitch, two stitch, it will be fun! - the obstetrician used to say with a needle at the feet of a happy woman in labor. For some, this black humor becomes not a funny reality and causes a lot of trouble and trouble. We will tell about situations that inspire obstetricians to take up the needle, ways fast healing and pain relief.

When stitches are applied and the causes of ruptures

Childbirth does not always go smoothly and sometimes you have to pay for the happiness of having children. birth trauma- ruptures and incisions of the genital tract, on which external and internal seams after childbirth. Injuries are internal - tears on the cervix and vagina, and external - tears and incisions in the perineum.

After the birth that took place naturally, the obstetrician necessarily checks for gaps and, if detected, they are sutured. Otherwise, if suturing is not carried out, the postpartum period threatens to end. hospital bed due to the opened bleeding in the injured tissues and the attachment of infection to them, and in the future even provoke prolapse internal organs and urinary and fecal incontinence.

The process of applying external and internal sutures takes a long time and requires a highly qualified doctor, and in the case of ruptures in the cervix, passing to the vagina and uterus, and some virtuosity due to the inaccessibility and danger of damage to the nearby Bladder and ureters.

Internal sutures after childbirth on the cervix, vagina and uterus itself are superimposed using absorbable sutures from biological or semi-synthetic material. If only the cervix is ​​affected, then anesthesia is usually not required - after childbirth, it is insensitive. In all other cases, local or general anesthesia anesthesia or epidural anesthesia.

The muscle layers in case of tears and cuts of the perineum are also sutured with absorbable threads, and the skin is often made of non-absorbable silk, nylon and other materials that are removed in the maternity hospital or in antenatal clinic usually 3-7 days after delivery, when the suture is scarred. The procedure is quite painful and therefore anesthesia is required during execution.

The reasons for the gaps can be different. This is not following the advice of an obstetrician during the straining period, and the presence of scars from sutures imposed in previous births (the scar consists of an inelastic connective tissue), rapid, prolonged, premature and instrumental labor (forceps), anatomical features pelvic structure, large head in a child, breech presentation, low skin elasticity at the time of delivery.

What should a woman who has the seam has come apart after caesarean section

Attitude to episiotomy - dissection of the perineum, obstetricians are different. For some, this is a routine procedure that is applied en masse to avoid the risk of perineal rupture. Other doctors strive to make the birth process as natural as possible, intervening when it is already quite clear that a rupture cannot be avoided. If instrumental childbirth is performed with forceps or a vacuum extractor, then a preliminary dissection of the perineum is recommended.

Episiotomy does not help to avoid grade 3 tears when the anal sphincter is involved in perineal integrity and may even contribute to such injury. Nevertheless, surgical incision has a number of advantages over rupture. Dissected tissues are technically easier to take in than torn ones. The resulting wound has smooth edges, healing occurs faster and a more aesthetic scar is formed.

Healing and suture treatment

It is regrettable, but what happened happened, and as a result, after giving birth, you got stitches. At internal seams, if the suturing procedure is performed correctly and carefully, it hurts for about 2 days. special care they do not require and do not need to be removed, since they are made of absorbable thread.

Self-absorbable sutures after childbirth from natural material - catgut completely dissolve in about a month, and from synthetic - after 2-3 months. Internal heal faster and can disperse in extremely rare and exceptional cases.

Quite another matter - the outer seams of the crotch. With such a postpartum reward, it is painful to move around, it is problematic to go to the toilet and it is absolutely impossible to sit down due to the fact that the seams can disperse.

Ban on sitting position works for two weeks, after which you can gradually try to sit on hard surfaces.

If catgut sutures were placed on the perineum, then you should not be afraid if pieces of threads that have fallen off appear after a week - during this period the material loses its strength and breaks. The seams will not disperse, unless, of course, they start dancing. How long the material will absorb depends on the speed metabolic processes in the body. Sometimes there are cases when the catgut did not resolve even six months after suturing.

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Sutures from a non-absorbable thread from the perineum are removed 3-7 days after childbirth. If this was not done in the maternity hospital, then the removal of the stitches is carried out by the gynecologist in the antenatal clinic. During the removal procedure itself, it is a little unpleasant, but in most cases it does not hurt, or the pain is quite tolerable.

How long stitches heal after childbirth is affected by the individual speed of healing of damage received by the body - both from small scratches and from more serious injuries.

Usually this process does not take more than a month, but on average it takes 2 weeks.

Both before and after the removal of sutures, it is necessary to regularly treat them. This is especially important because postpartum discharge and constantly moist environment of the perineum contribute to the multiplication of various microorganisms on the wound surface. As a result, the sutures can fester and healing will be delayed indefinitely.

How and how to handle stitches after childbirth at home? Also, as in the maternity hospital, you need to carry out treatment two to three times a day antiseptic solutions and/or antibacterial ointments that suppress uncontrolled growth causing inflammation bacilli Most available funds- this is the well-known brilliant green, hydrogen peroxide, potassium permanganate, chlorhexidine, etc. From ointments - levomekol, etc. Processing should be carried out, avoiding a sitting position.

If you provide air access to the perineum, then healing will go much faster. To do this, you need to use "breathable" pads made of natural materials and refrain from wearing tight underwear. Perfect option- providing "ventilation" during sleep, when you can completely abandon underwear and sleep on a special absorbent diaper, or an oilcloth with a regular cloth diaper.

To speed up regeneration, it is also necessary good nutrition supplying building material to the site of injury. From folk remedies accelerates the healing of oil tea tree, sea ​​buckthorn oil. And of course hygiene rules and maintaining cleanliness are welcome on the path to rapid healing.

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How to ease the pain

In the process of suture healing, tissue contraction occurs - the wound surfaces are reduced, and the wound is closed with a scar. Therefore, it is quite normal that the stitches hurt after childbirth, like any other injury that violates the integrity of muscle and epithelial tissues. Discomfort - Pain and itching in the perineum can be experienced up to 6 weeks postpartum.

If the pain is of a different nature, and even more so when suppuration of the sutures has begun, you should consult a doctor.

If the pain is severe, which happens in the first days after childbirth, then applying cold to the perineum, painkillers can help to cope with it. In the maternity hospital they give injections, at home you can take ibuprofen (Nurofen), which is not contraindicated during breastfeeding and has an anti-inflammatory effect. To reduce the pain during urination, you can try to urinate while standing in the bathroom, legs apart.

Surely everyone has heard that in some cases the perineum is cut during childbirth, but not everyone knows why this is necessary. Many expectant mothers, at one hint of a possible dissection of the perineum during childbirth, are horrified, although in reality everything is not so scary.

There are 2 ways to cut the perineum.

Currently, in 95% of cases, the perineal incision is made obliquely, in the direction of the ischial tuberosities. This operation is called an episiotomy. Figure 2 and 3 show two types of episiotomy.

But in some cases, a direct incision is made towards the anus - perineotomy. Perineotomy does not cut the muscles, so this cut is less traumatic, but there is a danger that the cut will continue to the rectum and go to it. Because of this possible complication perineotomy is performed extremely rarely, mainly in women who have a sufficiently large distance from the vagina to the rectum (high perineum).

Indications for perineal incision

Most often, a perineal incision is made when there is a threat of rupture or when a rupture has begun. The smooth edges of the incised wound, compared with torn and crushed edges, recover more easily and heal better. After a rupture, the perineum may become deformed, the marks are more visible, the entrance to the vagina may become gaping. Suppuration many times more often also happens after a rupture. In addition, the rupture may occur in the direction of the rectum and extend into it. To avoid all these complications, a neat incision is made.

Rupture of the perineum is possible if the tissues of the perineum are poorly extensible, unyielding, if the genital gap is narrow, and the fetal head is large enough, if the birth is fast or rapid, if the head is incorrectly inserted, with breech presentation. In these cases, the perineal incision is made in the interests of both the mother and the child, as it creates additional space for the passage of the fetal head during childbirth.

A perineal incision must be made in cases where it is necessary to complete labor as soon as possible with premature birth, with fetal hypoxia or with anomalies in its development, because childbirth should be as gentle as possible for him. With weakness of attempts, episiotomy is also resorted to.

In some cases, it is necessary to weaken the attempts by expanding the genital gap due to maternal diseases, such as myopia (nearsightedness), previous eye surgery, high blood pressure, vascular aneurysms, respiratory diseases, etc.

How it's done?

An episiotomy is done as follows: the midwife inserts the index and middle fingers between the head of the fetus and the perineum of the mother, and at the height of the contraction, when cutting the head with blunt scissors, it makes an incision. The length of the incision is 2-3 cm. A woman on the background of a contraction, when the tissues of the perineum are stretched over the head, does not feel the incision. But in some maternity hospitals, local anesthesia is still used: the area where the incision is supposed to be made is injected with a spray of lidocaine.

After the end of childbirth, during the examination of the birth canal, layer-by-layer suturing of the perineal tissues is performed. Absorbable sutures are placed on the muscles and mucous membrane of the vagina. Absorbable sutures may also be placed on the skin, which do not need to be removed. If non-absorbable sutures are applied to the skin, they are removed on the 5th day.

Suturing is done under local anesthesia. Either an injection of novocaine is given, or the incision is treated with a lidocaine spray. If a woman has intolerance to these drugs, then she is anesthetized with promedol (the drug is administered intravenously). If epidural anesthesia was performed during childbirth, and the woman has a spinal catheter, then an anesthetic drug is injected into it, and additional anesthesia is not needed.

After suturing the incision, the area of ​​the vagina and perineum is treated with iodine.

Possible Complications

Complications of episiotomy include suppuration of the sutures or their divergence. Of course, the medical staff may be to blame for the occurrence of complications, but a lot also depends on the woman. It is necessary to follow the rules of hygiene and follow all the recommendations of doctors for the care of sutures.

In addition, if the sutures are placed incorrectly, hematoma formation is possible. This complication is usually detected in the first 2 hours after childbirth, while the woman is still in the maternity ward. In this case, it is necessary to open and remove the hematoma and re-suturing. This operation is performed under general intravenous anesthesia.

If, in addition to the incision, there are significant ruptures in the tissues of the birth canal, antibiotics are prescribed to prevent complications. They are also necessarily prescribed after removal of the hematoma.

postpartum period

In the postpartum period after an episiotomy or perineotomy, you can not sit down for 2-3 weeks so that the sutures do not open. In the first 2-3 days, it is not recommended to eat bread so that the stools are soft enough and in small quantities. After each trip to the toilet, you need to wash yourself. Pads or a diaper should be changed at least every 3 hours while the woman is in the ward, it is better not to wear underwear at all so that the seams are ventilated.

Suture treatment is done by a midwife 2 times a day in the morning and evening. Also, ultraviolet irradiation (quartzization) of the seams is carried out so that the seams do not become infected and subsequently become inflamed.

In 1-2 days, the stitches are quite painful, especially when coughing or laughing, but not so much as to prescribe painkillers. If it is still difficult to endure, you can use suppositories with ketanol, but not more than 2-3 times, because in small amounts the analgesic from the rectum is absorbed into the blood and can enter the milk.

On the 5th day, the sutures are removed (if non-absorbable sutures were applied). Before removing the stitches, you need to empty the intestines. If this is difficult to do, you can ask the midwife for a candle with glycerin.

After discharge from the hospital, it is necessary to continue to care for the perineum. In the morning and evening, the seam area should be lubricated with a solution of manganese or brilliant green and washed regularly. Also, do not forget that until the incision is completely healed, you can not sit. This is quite inconvenient, but there are pluses in this, since you have to stand and walk more (because it’s boring to lie down all the time!), And extra pounds go faster.

The scar after the incision is small and inconspicuous. It can only be seen by a gynecologist during an examination, and even then not always. Many midwives generally recommend that you do not tell your husband anything if he is overly impressionable, and he himself will not notice anything.

The incision will also not affect the sensitivity of the vagina and the quality of sexual life.

In the postpartum period, many women notice that the entrance to the vagina has become wider, during intercourse, even air can penetrate there. But this is not connected with the episiotomy, but with the birth itself.

Nowadays, many women tell each other that they cut the perineum of almost everyone in a row, because the midwife wants to finish the birth as soon as possible. Actually it is not!

Episiotomy is indeed done frequently, but only when indicated. In modern conditions, due to poor ecology, a large number infectious diseases, hormonal disorders in many women, this is reflected in the elasticity of the skin and muscles, including the perineum.

In addition, at present, doctors are fighting for the health of each child, and if it is difficult for him, they prefer not to take risks and help him in time. Nothing is done just like that, and doctors, like the mother, are interested in preserving the health of her and the child.

Why do stitches hurt after childbirth?

Let's see what suturing is, how they are applied and how a woman is treated in the future.

Internal - applied to ruptures of the cervix and vagina, usually do not hurt and do not require any special care. They are superimposed from absorbable materials, they do not need to be removed, they do not need to be processed either, there is no need to smear or douche, you just need to ensure complete sexual rest for at least 2 months, because here they are in far from ideal conditions.

In order for the wound to heal well, it needs rest and asepsis. Neither one nor the other can be fully provided, the mother will still have to get up to the child, she will have to walk. It is impossible to apply any bandage in this area, and postpartum discharge creates a breeding ground for microbes, which is why it is quite common for the sewn places to diverge.

Crotches can be sutured using different methods and materials, but almost always these are removable options (they will need to be eliminated for 5-7 days). Most often, if everything goes well, they are removed even in the hospital, before discharge.

Processing of sewn places in the maternity hospital is carried out by a midwife. This can be done both on the examination chair and right in the ward. Usually treated with brilliant green 2 times a day. In the first two weeks, the pain is very pronounced, it is difficult to walk, and it is forbidden to sit, mothers feed lying down, eat either standing or lying down.

After removing the surgical threads and discharge from the hospital, the woman will not be able to sit normally for almost a month. At first, you can only sit sideways on hard, and even from the hospital you will have to return reclining in the car in the back seat.

How long do stitches heal after childbirth?

Stitch care after childbirth

External threads require careful care. Their imposition is most often done in layers, using removable material.

After applying them, you will have to wash yourself after each visit to the toilet. clean water with the addition of potassium permanganate, and dry the crotch thoroughly with a clean towel.

Pads will need to be changed very often as the wound needs dryness. While you are in the hospital, the midwife will perform the treatment.

Removing the threads is a painless procedure, which largely eliminates discomfort.

In the first days, it will be necessary to delay the first stool as much as possible, especially with ruptures of the 3rd degree, in the future it will be called using candles.

It will be necessary for some time to refrain from cereals and bread, vegetables and other stool-stimulating foods. It usually doesn't cause big problems as it is carried out before childbirth cleansing enema, which in itself is capable of delaying stool.

The divergence of suturing most often occurs in the first days or immediately after their removal, rarely later. The reason may be early sitting down, jerky movements, as well as such a complication as suppuration. This is not a common complication that occurs with serious perineal tears, 2-3 degrees.

If there is inflammation, redness, sharp pains in the perineum, premature removal of the perineal rupture-retaining material before the wound is completely healed is not good, because this forms a rough scar. How to treat the wound, the gynecologist will tell you.

If a early period went well, healing is proceeding without complications, after discharge from the hospital, only hygienic measures will be required. Perhaps Bepanten or another softening and healing ointment will be recommended.

When do stitches heal completely after childbirth?

The choice of the most painless pose, which is different for each couple, and the use of ointments against scars, for example, contractubex, will help to cope with this.

Strange sensations in the vaginal area can bother you for quite a long time, up to six months. However, in the future, they completely resolve.

When to suspect that something is going wrong:

If internal stitched wounds hurt. Normally, after suturing vaginal tears, there may be slight pain for 1-2 days, but they quickly pass. A feeling of heaviness, fullness, pain in the perineum may indicate the accumulation of hematoma (blood) in the area of ​​damage. This usually happens in the first three days after childbirth, you will still be in the hospital, report this feeling to your doctor.

Sometimes suturing fester after discharge from the hospital. At the same time, a painful swelling is felt in the wound area, the skin here is hot, a high temperature may rise.

In all these cases, you should not think on your own how to smear the wound, you need to urgently contact a gynecologist.

Often during childbirth, ruptures of the perineum, vagina, or uterus occur - the situation is unpleasant, but not life-threatening. Doctors do an excellent job with the problem, they can quickly and efficiently sew up any gap.

But a full recovery and recovery after such an injury depends only on the woman. She should know not only the types of breaks, but also the rules of behavior / care for them during the recovery period.

Read in this article

Causes of breaks after childbirth

Childbirth is a painful process that is divided into several stages. Among them there is a straining - the period when the head or pelvic end of the child (depending on the presentation of the fetus) comes close to the cervix. At this point, pressure is applied to the muscles pelvic floor, which provokes a reflex desire to push. If the cervix is ​​already open, then the child passes through it almost freely and enters the vagina.

But it often happens that by the time the cervix has not opened, it seems to cover the head of the fetus. Overcoming such resistance, the fetus still continues to move, because the birth process cannot be stopped, the result of this is a rupture of the cervix. The same injury can occur with the full opening of the cervix, when too large a fetus is born.

In addition, cervical rupture can occur for the following reasons:

• violation of the process of opening the cervix;
• improperly provided assistance by medical workers;
• the first childbirth over the age of 30 years (tissue elasticity is lost);
• too large fruit;
• pelvic presentation of the fetus.

These same causes can lead to ruptures of the vagina and perineum. If the vagina is in any case injured involuntarily, then the doctor taking delivery can independently make an incision in the perineum.

When is a perineal incision needed?

The decision to make an incision is always the right one, because the torn edges of the wound heal worse and take longer, often becoming infected. But even edges after scissors can be sewn with just 2-3 stitches, and healing will be fast.

The doctor may suspect a perineal rupture and make an incision in the following cases:

• the child is born with "legs" - the fetus is in;
• childbirth is swift and fast;
• narrow genital gap of the woman in labor;
• the fruit is too large.

In such cases, a perineal incision will benefit both the mother and the child, because the fetus will be much easier to be born, and the woman will be able to recover quickly.

In addition, the doctor may resort to this procedure when:

• fetal hypoxia;
• anomalies of intrauterine development;
• premature birth.

In some cases, a woman needs to reduce the intensity of attempts: for example, she is diagnosed with a high degree of myopia, there are problems with blood pressure or diseases of the respiratory system.

Dissection of the perineum is necessarily carried out in case of complicated childbirth - with problematic removal of the child's shoulders or imposition obstetric forceps.

Degrees of discontinuities

Considered lesions of the cervix and perineum may have varying degrees gravity. The healing process of the wound surface and the duration of the recovery period depend on this.

Degrees of cervical rupture:

• 1 degree - the gap can be on one or both sides, differ in small sizes (maximum 2 cm);
• 2 degree - the gap has a length of more than 2 cm;
• Grade 3 - the wound surface is present at the junction of the cervix into her body or affects the uterus itself.

• 1 degree - the size of the injury is small, only the skin and vaginal mucosa are damaged;
• Grade 2 - a rupture of muscle tissue is added to the above parts of the perineum;
• Grade 3 - rupture damages the skin, vaginal mucosa, perineal muscle and sphincter.

How to sew up internal and external tears

Internal incisions are sutured with absorbable sutures (catgut). Such sutures on the cervix and in the vagina do not require any special care, after 7-10 days there is no trace of the suture material.

But the outer seams are superimposed when the perineum is torn. In this case, doctors adhere to the following rules:

• if the gap is 1 - 2 degrees, then the seam is superimposed with one thread, which captures all the damaged layers at once;
• in the case of grade 3 perineal rupture, sutures are applied separately to the muscles and skin. Absorbable sutures are used to suture the rupture of the muscle and mucous membrane, and for the skin - suture material, which is removed on the 5th - 6th day.

Sewing of the cervix is ​​carried out without anesthesia, but if a woman has a high threshold of sensitivity, then the damaged part of the organ can be sprayed with a solution of lidocaine. Work on the rupture of the perineum is carried out necessarily under local anesthesia.

Features of the recovery period

Childbirth, timely perineal incision and stitching of gaps is the work of doctors. The recovery period implies the observance of certain rules and recommendations by the woman herself.

Mom's behavior after childbirth

Internal seams do not affect the activity of a young mother in any way, there are no restrictions. But the rupture of the perineum and subsequent stitching implies the following:

1. A woman cannot sit for 14 days, although in some cases doctors reduce this period. The mother should feed the child, eat herself and carry out caring procedures in a standing or lying position. Even from the maternity hospital, a woman needs to be transported home in a half-sitting position. Therefore, it is worth warning relatives in advance that vehicle should be free.
2. It is allowed to sit on the toilet on the first day after childbirth. It is necessary to empty the intestines regularly, it is impossible to delay defecation - this leads to constipation. To facilitate the process, a woman can apply rectal suppositories(glycerin). They are safe and effective, help to empty the bowel without effort. The doctor may later recommend and.
3. It is forbidden to lift heavy things/objects. Doctors warn that the restrictions apply to weight over 3 kg, so if a large baby (4 kg or more) was born, relatives will need to be involved in caring for him until full recovery.

Watch the breakup video:

Stitch care after childbirth

In the maternity hospital, suture care is provided by nurse. Twice a day, she rinses them with hydrogen peroxide and treats them with brilliant green. Women in labor with external sutures must be "instructed" before being discharged from the hospital. It includes the following recommendations:

1. You should wear only natural (optimally - cotton) of the correct size. Tight underpants can put pressure on the seams, the rupture constantly rubs against the fabric, and synthetics can provoke skin irritation and inflammation.
2. need to be changed every 2 hours, accompanying the process with washing.
3. Washing with warm water should be done after each visit to the toilet.
4. The fullness of the bladder should not be allowed, as it puts pressure on the uterus and interferes with its contraction.
5. Twice a day, the perineum should be washed with regular soap. Flavored gels should be avoided. Best Choice will be baby soap.
6. The outer seam is washed with special care, you can direct the stream of water from the shower directly onto it.
7. After hygiene procedures it is necessary to dry the perineum by soaking with a towel, in no case should you rub the seams.

External seams require air treatments. Doctors recommend periodically resting without underwear lying on a bed / sofa with knees bent and legs apart.

Self-absorbable sutures

Absorbable threads sew up the ruptures of the cervix and vagina. There are no special rules for caring for such stitches, but a woman should follow the doctor's recommendations about sitting and emptying the intestines. In some cases, a young mother may feel light pulling pain lower abdomen is not critical.

Be sure to monitor your well-being and vaginal discharge. If mom notes bodies and viscous, brownish-red, with vaginal discharge then you should seek qualified medical attention.

When are the internal stitches removed?

Such seams are superimposed with catgut - a material that itself dissolves in the thickness of the tissues. Usually this process is completed within 90 days, a woman can see the remnants of threads on her underwear - this is normal.

You should not worry about absorbable material coming out of the tissues before the tear heals. This is impossible a priori.

What to do if the seam festered

After giving birth, the woman begins the process. And if missing breast-feeding, then the first discharge may appear as early as 10-15 days. They are brownish mucus, odorless.

If the mother noticed that the discharge has an extremely bad smell(sour-putrid), they become viscous, this may indicate. The external seam becomes painful during suppuration, purulent contents are released from it.

You need to contact a gynecologist and tell about the problem. The doctor will examine outer seam or conduct an instrumental examination of internal ruptures and prescribe drug therapy.

Usually, external seams are treated with balsamic liniment according to Vishnevsky, Solcoseryl or Levomekol ointments. Necessarily wound surface treat with a solution of hydrogen peroxide or chlorhexidine, and antibiotics are usually prescribed orally.

Any medications to solve the problem of suppuration of the sutures, a gynecologist should prescribe. These symptoms may indicate the onset of bleeding, and the divergence of the seams.

Causes of pain in the place of rupture after childbirth

Pain can accompany both external and internal sutures applied to tears during childbirth. If during the examination the doctor does not reveal any problems, then it will be possible to carry out several warm-up procedures.

But without prior consultation with a gynecologist, no curative measures not worth doing. There is no talk about taking painkillers - they will “wash out” clinical picture and through mother's milk enter the baby's body.

Most often, pain in the places of suturing appears with the development inflammatory process, discrepancies. If the gap was sewn up crookedly, then the woman will feel a pulling pain, which after a while will disappear on its own.

Often to get rid of pain gynecologists recommend lubricating the sutures with contractubex. Within 10 to 20 days, discomfort and pain will disappear.

Can the seam come apart

Internal seams almost never diverge. Even if this happens, the woman does not diagnose the problem on her own, and the gynecologist will not sew it up again.

But the outer seams diverge very often! The reasons for this are only non-compliance with the rules / recommendations for care. Often the discrepancy is observed in the first day after birth. The woman simply forgets the restrictions and sits on the bed, goes to the toilet to empty her bowels without first setting candles. If this happens, then the doctor simply re-sutures.

It also happens that the edges of the wound have already healed, but there was a gap. In such a situation, the decision next steps The doctor will take on an individual basis. In the case of a divergence of a pair of stitches, the sutures are not re-applied, in all other stitches the edges of the wound are excised, a new suturing of the perineal rupture occurs.

If a discrepancy occurs in a mother who has already been discharged home, then she should immediately seek qualified medical help.

When can you have sex after a tear during childbirth?

For young couples after the birth of a child, the issue of resuming intimacy becomes relevant. Usually, doctors warn about abstinence for one and a half to two months, even if the birth went without interruption. If stitches were applied, then this period increases to 3-4 months.

However, in this case, everything is strictly individual. Someone can have sex already a month after the external suture is applied, for some doctors forbid such pleasure even after 2 months. It would be wise to consult a gynecologist and listen to your own feelings. But in the first 4 weeks, sex is definitely not available.

Consequences of ruptures after childbirth

If there were ruptures of the cervix of the 3rd degree, then this can provoke a problem with the bearing of the next child. But in reality, this rarely happens because experienced doctors and level modern medicine allow you to avoid these.

External seams after ruptures during childbirth can provoke pain during sex. This is associated with excessive dryness of the vagina. In this case, lubricants will come to the rescue ( intimate gels). Usually after a few sex sessions all discomfort disappear.

It is impossible to foresee internal ruptures (cervix and vagina), it all depends on physiological features the body of the woman in labor and the size of the fetus. But to increase elasticity skin perineum, and thereby prevent rupture, is quite realistic.

To do this, the spouse / partner of a pregnant woman needs to regularly stretch the entrance to the vagina. This is done with two fingers, which slightly pull the entrance down and hold it in this position a little (literally for a few seconds). This procedure can be painful, so you need to pre-treat your fingers with a water-based vaginal lubricant.

Tears during childbirth are a common occurrence that doctors successfully cope with. A woman only needs to fulfill all the appointments and recommendations of gynecologists in order to avoid complications.

Perineal tears are one of the most frequent complications birth act. Ruptures of the perineum and walls of the vagina are observed most often in nulliparous women.

Etiology and pathogenesis

The onset of ruptures of the perineum is facilitated by a number of factors and, first of all, by those anatomical and functional changes in it that violate the extensibility of tissues and make them less durable, easily torn. R perineal tears faster and easier to occur with cicatricial changes after former breaks during childbirth or plastic surgery, with swelling of the tissues of the perineum. Unyielding, poorly extensible perineum in age-related primiparas (over 30 years old) is more likely to rupture. The onset of the gap is also facilitated by a high crotch with powerful muscles.

Great importance in the appearance perineal tears has the size of the fetus, especially the size of the head and shoulder girdle. At large fruits ruptures are more common; an important role is played by the density of the bones of the head, in particular during post-term pregnancy. Eruption through the genital gap of the head, which has even medium dimensions, in an unbent state, in the posterior view occiput presentation and with a low transverse standing of the swept seam increases the frequency of perineal ruptures. With rapid labor and breech presentation fetus, the number of ruptures also increases, apparently due to the fact that the perineum does not have time to stretch during the rapid eruption of the head and is torn before the use of the extensibility coefficient.

A narrow pubic arch, usually found in a generally uniformly narrowed pelvis, as well as a small inclination of the pelvis, lead to the head being pushed towards the perineum during eruption, leading to a more significant stretching and increasing the number of ruptures.

Operative delivery, especially the use of obstetric forceps, is usually accompanied by an increase in the number of perineal tears. This is due to excessive stretching of the tissues of the perineum. At the moment of eruption of the head, the anterior perineum is stretched so much that its height is 2 times higher than the original one; this is the limit of perineal extensibility at the most favorable conditions and good condition fabrics. If the stretch continues to increase, then there is a rupture of the perineum.

perineal tear occurs at the end of the period of exile when the head erupts or, more rarely, when the shoulders are brought out. The presenting part (head), moving along the birth canal, compresses soft tissues and easily compressible veins located in them. As a result, the outflow is difficult. venous blood and the bluish color of the perineum appears at first, and later, with continued venous stasis, blood plasma leaks into the tissue surrounding the vessels, which is accompanied by swelling of the perineum, which acquires a kind of luster, indicating a threat of rupture.

If the pressure of the presenting part on the tissues of the perineum continues to increase, then not only the veins, but also the arteries are compressed, and blood flow is disturbed. Bloodless tissues of the perineum turn pale, their resistance to overstretching decreases and a rupture occurs.

Perineal tears are:

• spontaneous, occurring without any external influence during childbirth;
• violent, resulting from the use of vaginal delivery operations or technical errors during delivery.

The rupture may begin in the vagina, then spread from the posterior wall of the vagina to the muscles of the perineum. At the same time, at first, the gap goes unnoticed and is detected only when the skin of the perineum is broken, which occurs from the inside out. Such a mechanism of origin often leads to the fact that with the preserved skin of the perineum, extensive damage to the walls of the vagina and muscles of the perineum is observed, which is recognized only upon examination after the birth of the fetus. A similar mechanism of rupture origin is usually observed when operative delivery and rarely in spontaneous childbirth.

perineal tears that occur during the eruption of the head during spontaneous childbirth, begin from the posterior commissure and, rapidly increasing, spread backward along the midline of the perineum and onto the walls of the vagina, going from outside to inside.

Clinic

Depending on the depth of tissue damage, there are three degree of perineal tear:

• Rupture of the perineum I degree: the posterior commissure, the walls of the vagina in the lower third and the skin of the perineum are torn;
• Rupture of the perineum II degree: in addition to the walls of the vagina and the skin of the perineum, the muscles of the pelvic floor are torn; the rupture of the vaginal wall usually does not go along the midline, but towards the side wall and, if it is bilateral, takes a forked shape.

Ruptures of the perineum I and II degree are called incomplete.

• perineal tear III degree- complete rupture: in addition to the above tissues, the pulp (sphincter) is torn anus, and sometimes part of the anterior wall of the rectum.

The frequency and depth of perineal tears, especially grade III, usually depends on the quality of obstetric care. Important role plays and independent preparation of the perineum for childbirth.

Any perineal tear accompanied by bleeding in varying degrees. But in the afterbirth and early postpartum periods, bleeding from the rupture may not be noticed, since bleeding from the uterus is observed at this time. Therefore, in recognizing a perineal tear, it has highest value examination of the external genitalia and the walls of the vagina in its lower third, which is performed immediately after the birth of the placenta. It should be noted that there may be isolated ruptures of the walls of the vagina, especially when applying obstetric forceps; in order to recognize them, it is better to examine the vagina with the help of vaginal mirrors. With complete ruptures of the perineum, incontinence of feces and gases is observed.

With a rupture in the clitoris and external opening urethra as a result of damage choroid plexus, as well as with ruptures of the perineum of the third degree, may be observed severe bleeding especially with varicose veins. Under such circumstances, one cannot wait until the placenta is released, but one must immediately begin to stop the bleeding until the placenta is discharged or squeeze it out first according to the Lazarevich-Krede method.

Treatment

Treatment of perineal tears should consist in their immediate stitching. Unsewn tears take a long time to heal secondary tension, torn tissues become infected, and open wound serves as an entrance gate for infection, leading to the occurrence of postpartum diseases.

Later, unsewn perineal tears adversely affect the health of a woman, accompanied by a functional failure of the pelvic floor, and can lead to prolapse and prolapse of the internal genital organs. The gaping genital slit contributes to the emergence of various inflammatory diseases vagina and cervix, the occurrence of erosion. Tears of the III degree, accompanied by incontinence of gases and feces, make a woman unable to work and intolerant among others. Therefore, all detected gaps are subject to suturing. And the sooner this is done after childbirth, the better the results.

If a gap is sutured with significant bleeding, then a large swab of sterile cotton or gauze should be inserted deep into the vagina, which will absorb blood during suturing. The tampon is removed immediately from the vagina after the rupture is closed.

When suturing a perineal tear, care must be taken to ensure that the wound surfaces fit snugly against each other. This promotes healing.

For the purpose of good exposure of the wound throughout, the vagina is opened with the help of a lift and vaginal mirrors. In the absence of an assistant, you can use two divorced fingers (index and middle) of the left hand in a sterile rubber glove push the entrance to the vagina and open the wound. As the wound is sutured in the depths of the vagina, the fingers are gradually removed and the edges of the wound are moved apart by them in the region of the posterior commissure and perineum. Sewing of perineal and vaginal ruptures is performed under anesthesia. Anesthesia not only relieves the woman of pain, but also allows you to open the wound well throughout, to accurately determine the size and direction of the gap. In the absence of these conditions, it is possible to sew up the skin of the perineum and the vaginal mucosa, and the damaged muscles of the perineum and pelvic floor will remain unrepaired. The operation will be cosmetic. Particularly serious should be taken to suture grade III tears. If, when sewing up such a gap, the ends of the damaged anal sphincter are not connected, the result of the operation will be unsatisfactory. The dispersed ends of the sphincter, contracting, hide in the depths of the wound and without careful careful examination and knowledge of topographic relationships, they are not easy to detect, especially with poor anesthesia.

Sewing of the rupture of the perineum of the 1st degree begins from above, conducting the first nodal catgut suture in the corner of the vaginal wound. Injection and puncture are performed, stepping back from the edge of the gap by 0.5-1 cm. The tissue lying in the depths of the wound is picked up with a needle. The skin of the perineum is sutured with silk. The edges of the skin wound can also be connected with metal brackets.

For perineal lacerations of the II degree, it is necessary to find the upper angle of the rupture. It is most often found to the left or right of the columnae rugarum. On the perineum, such a gap often reaches almost to the anus and in depth reaches the muscles of the pelvic floor. As a result of the divergence of the damaged muscles in the depth of the gap, cavities are formed that are filled with blood. Bleeding vessels are tied up with catgut ligatures and then they begin to sew the wound into the vagina. In the presence of two lateral gaps, they are sewn up alternately. Submerged catgut sutures or one continuous connect the wound surfaces in the depth of the torn perineum and then connect the edges of the perineal wound with interrupted silk sutures.

With ruptures of the III degree, the integrity of the sphincter of the anus is violated ( sphincter ani) and rectal walls. In this case, the rupture is often accompanied by significant damage to the paravaginal and pararectal tissue.

First of all, it is necessary to carefully connect the edges of the wound in the wall of the rectum and the torn circular muscle of the sphincter, the ends of which, due to retraction, go deep into the wound.

Thin ligatures made of silk, less often catgut, connect the edges of the intestinal wound in such a way that the needle does not pierce the mucous membrane, but only passes through the submucosa. For this purpose, a puncture is made on the left side of the wound, and on the right side, an puncture is made along the very border of the mucous membrane.

The skin wound is smeared with iodine tincture and the entire vulva, perineum, pubis and inguinal folds- sterilized vaseline oil, which prevents maceration of the skin and mucous membrane of the entrance to the vagina.

It is advisable to put sterile gauze bookmarks on the perineum, changing them several times a day. The external genital organs are washed 2-3 times a day and after defecation with a weak solution of potassium permanganate.

Enemas after suturing deep gaps are not used, and if there is no stool, a mild laxative is given on the 2-3rd day; with smooth flow postoperative period skin sutures removed on the 5-6th day.

After surgery for ruptures of the III degree, the patient in the first 5 days receives only sweet tea, coffee with a small amount milk, pure broth, mineral water and fruit juices; on the 6th day, puree of plums, apples, carrots is added. On the 7th day they give a laxative, from the 10th day they allow a common table. The sutures from the perineum are removed on the 5-6th day.

A rare complication of childbirth is central perineal tear. The latter occurs when the head does not move towards the genital gap, but presses against the recto-intestinal-vaginal septum, breaks through back wall vagina and works its way through the perineum, which protrudes strongly and tears in the center. The fetus is born through the opening.

Predispose to the occurrence of a central perineal tear:

• high crotch;
• narrow, unyielding, anteriorly lying genital gap;
• insufficient inclination of the pelvis;
• fast period of exile;
• rear view of the occipital presentation.

In order to prevent the occurrence of a central rupture of the perineum, it is recommended to cut the perineum during insertion of the head. If a central tear has already occurred, the remaining tissue bridge is cut with the edge of the tear, turning the central tear into a grade II or III tear, which is sutured accordingly.

Any rupture of the perineum is subject to suturing, except for small abrasions on the mucosa.

Together with the perineum, the large and small labia lips, as well as the tissues of the vestibule of the vagina, are often torn. Tears in the clitoris and in the area of ​​the external opening of the urethra usually bleed heavily. All of these gaps are subject to suturing, which is done using thin catgut sutures. When suturing near the urethra, a metal catheter is first introduced into the latter and the gap is sutured under its control.

Sometimes, when the perineum is ruptured, the skin of the perineum is preserved, and inside there is damage to the vaginal wall and muscles of the perineum, representing an extensive wound surface with crushed tissues. The skin of the perineum is cut and the gap is sutured in the usual way.

To provide good healing sewn ruptures of the perineum, careful care for the puerperal in the postpartum period is necessary. Some obstetricians consider it advisable to gently wash the external genitalia with a weak solution of potassium permanganate or boric acid, then dry them with sterile material and sprinkle (powder) with dermatol, xeroform or white streptocide. Others do not recommend washing the perineal area, but keeping it dry all the time, changing sterile gauze tabs.

If the intestines were well cleansed before the operation, which is rare in a parturient woman, opium can be dispensed with; however, it is considered more appropriate to prescribe an opium tincture of 10 drops 3 times a day in the first 3-4 days in order to prevent early defecation. Some obstetricians, without using opium, prescribe Vaseline oil inside 1 teaspoon 3 times a day. Application of any enemas after stitching complete breaks perineum is undesirable.

With incomplete ruptures, a laxative is given on the 3rd-4th day, skin sutures are removed on the 5th-6th day; in bed, the puerperal with smooth healing of the perineal rupture remains until the 7th day and with a smooth course postpartum period discharged on the 10th day.

Prevention

Prevention of perineal tears lies in the correct conduct of childbirth, especially during the period of exile. 4 main conditions contribute to the prevention of perineal tears:

1. Slow eruption of the head through the vulvar ring.
2. Cutting it in the smallest size.
3. Slow and uniform stretching of the tissues of the vulvar ring.
4. Careful observation of the eruption of the shoulders and their careful removal.

All these 4 conditions can be achieved with rational protection of the perineum or the so-called manual aid in head presentations.

Of great importance in the prevention of perineal ruptures is the psychoprophylactic preparation of pregnant women for childbirth, which ensures reasonable, calm and disciplined behavior of the woman in labor during the period of exile, especially during the eruption of the head.

In order to protect the perineum from rupture, it is proposed to use surgical intervention.

V.S. Gruzdev considered it most expedient to use episiotomy, which is performed 2-3 cm above the posterior commissure on one or both sides. An incision involving the skin and part of the muscle bundles of the vaginal constrictor is made with scissors, and its length must be at least 2 cm.

Küstner suggested that instead of a lateral incision, a median incision of the perineum - a perineotomy - be made. BEFORE. Ott was a supporter of perineotomy, proposing in order to prevent perineal ruptures, especially subcutaneous ruptures of the pelvic floor muscles, to perform perineotomy at each birth. Although in a certain percentage of women in labor there are violations of the integrity of the muscles of the pelvic floor with intact skin of the perineum, the proposal of D.O. Ott systematically perform perineotomy did not find supporters.

Currently, perineotomy is performed in women in labor in cases where, despite well-performed protection, there is a threat of perineal rupture. The incision is made when the perineum is sufficiently stretched and tense, that is, when it has thinned, turned pale and shiny.

Some obstetricians have been critical of the episiotomy.

In a perineotomy, if the incision is made 3 cm long, the vulvar ring expands 6 cm. Linear incised wound sews easily and heals well.

Third-degree perineal tears occur during childbirth without medical care or with inept and very rapid withdrawal heads in forceps or during extraction of the fetus by the pelvic end.

The use of labor anesthesia has a beneficial effect on reducing the number of perineal tears.

The basis in the prevention of perineal tears should be correct reception childbirth and gentle delivery in obstetric operations.

According to the book:
L.S. Persianinova, N.N. Rastrigin " Urgent care in obstetrics and gynecology"