Obstetrics and Gynecology - A.M. Hromova 2000

Birth injuries
Separation and rupture of the pubic symphysis

During Pregnancy, a moderate softening of the pelvic joints occurs due to intensive Blood supply, Swelling, and edema of the Cartilage and ligaments. The porosity of Bone Tissues and joint surfaces increases. As a result, a Separation of up to 0.5 cm occurs. In some cases, these changes exceed physiological limits, leading to excessive relaxation of the joints that require appropriate therapeutic measures.

Ruptures of the Pubic Symphysis are most frequently observed during operative delivery, as well as in the presence of a narrow pelvis and intense labor activity.

Clinical presentation: patients complain of pain in the pubic region, which intensifies on the 2nd to 3rd postpartum day during leg movements. The puerpera seems confined to bed; her thighs are somewhat externally rotated with partially bent knees (the "frog" position) — the M. M. Volkovich sign. Abducting the legs sharply exacerbates the pain. While walking, the woman waddles (waddling gait). The clinical picture depends on the degree of separation of the pubic bones.

There are 3 degrees of separation, which are diagnosed radiographically.

Grade I — separation of the pubic rami by 5–9 mm.

Grade II — separation of the pubic rami by 10–20 mm.

Grade III — separation of the pubic rami by more than 20 mm.

With Grade I separation of the pubic rami, the puerpera often makes no Complaints. Only a careful medical history and Palpation of the pubic symphysis may suggest the presence of a separation, while an X-ray Examination will definitively confirm the Diagnosis.

With Grade II separation of the pubic rami, the puerpera complains of pain in the symphysis and impaired gait.

With Grade III separation of the pubic rami, there is severe pain within the symphysis; the patient cannot make active movements with her legs or turn to her side. Palpation of the pubis reveals edema and tenderness in this area, along with mobility or wide separation of the pubic bones from each other. An X-ray examination definitively establishes the diagnosis. The pain persists for several weeks, and walking is impossible for 3 to 10 weeks depending on the severity of the injury.

Treatment: immobilization in a "hammock" for 3–5 weeks, vitamin therapy, and administration of calcium chloride.

Control Questions

1. What injuries occur during childbirth?

2. Name the Classification of cervical tears.

3. What are the types of cervical tears and their Diagnostics?

4. What is the treatment for cervical tears?

5. How frequently do perineal injuries occur?

6. What circumstances contribute to perineal injury?

7. Name the signs of threatened perineal rupture. Classification of perineal ruptures.

8. What Organs and tissues are injured in a third-degree perineal rupture?

9. WHAT IS A central perineal rupture, and what are its signs?

10. How are perineal ruptures diagnosed?

11. What are the principles of repairing first- and second-degree perineal ruptures?

12. Describe the technique for repairing a third-degree perineal rupture.

13. How is anesthesia performed during surgical repair of perineal ruptures?

14. How is postoperative care provided for postpartum women with a repaired Perineum?

15. What are uterine ruptures, and what is their classification?

16. What are the clinical signs of an impending Uterine rupture?

17. What are the clinical signs of a progressing uterine rupture?

18. What are the clinical signs of a completed uterine rupture?

19. How is the management of laboring women with a uterine rupture performed?

20. What fistulas can occur postpartum, and what is The Mechanism of their development?

21. How is the treatment of patients with fistulas conducted?

22. What is Postpartum inversion of the Uterus?

23. What is the mechanism of postpartum uterine inversion, and how is it diagnosed?

24. How is the management and treatment of postpartum women with uterine inversion carried out?

25. What is the mechanism of occurrence and diagnosis of pubic symphysis separation?

26. Treatment of postpartum women with separation of the pubic bones.