Obstetrics and Gynecology - A. M. Hromova 2000

Operative Obstetrics
Operations performed in the third stage of labor and the early postpartum period
Suturing of perineal and cervical lacerations

Perineal tears are predisposed to by the following factors: tissue loss of elasticity (rigidity), scarring from previous deliveries, a high Perineum; crowning of the fetal HEAD in an unfavorable diameter, as seen in deflexion presentations, a large fetal head, dense cranial bones, and inadequate molding (Post-term Pregnancy); operative delivery (forceps application, etc.); a narrow pelvis, particularly flat rachitic (due to the potential for rapid head descent) and infantile pelves (a narrow subpubic angle); and improper Management of Labor, premature deflexion, and rapid crowning of the head.

Perineal tears are classified as spontaneous or artificial. Spontaneous tears refer to injuries occurring independently of external interventions. Artificial tears are those resulting from errors in labor management or associated with surgical Procedures that terminate labor.

There are three degrees of perineal tears:

First-degree tear — characterized by disruption of the posterior fourchette (a small area of the perineal Skin and vaginal wall); the perineal Muscles remain intact.

Second-degree tear — characterized by a breach in the integrity of the perineal skin, vaginal wall, and perineal muscles extending to the area of the external anal sphincter.

Third-degree tear — diagnosed when the integrity of the perineal skin, vaginal wall, and perineal muscles is compromised, along with the external anal sphincter, and occasionally the anterior wall of the rectum.

In a first-degree tear, catgut sutures are first applied to the vaginal mucosa, followed by silk sutures to the perineal skin. Suturing begins at the upper angle. The distance between sutures is 1 cm. The needle is passed beneath the entire wound surface.

In a second-degree tear, a suture is first placed at the upper apex of the wound, after which several buried catgut sutures are used to approximate the torn perineal muscles (these sutures must involve neither the skin nor the mucosa). Subsequently, catgut sutures are placed along the vaginal mucosa up to the posterior fourchette. The ends of the ligatures are trimmed, except for the suture placed on the fourchette. This final suture is pulled upward to facilitate the approximation and suturing of the perineal skin. Silk sutures are applied to the perineal skin, and their ends are trimmed.

In a third-degree tear, the injured rectal wall is repaired first, followed by identifying the retracted ends of the torn sphincter and approximating them with sutures. Afterward, sutures are placed in the same sequence as for a second-degree tear.

Cervical lacerations most frequently occur As a result of: operative deliveries (forceps, internal podalic version, manual aid in breech presentation, destructive operations); deflexion presentations, where the head circumference significantly exceeds that of standard flexion (i.e., vertex) presentations; precipitous labor, in which the cervical os lacks sufficient time for gradual dilation; cervical rigidity, particularly in primigravidas over the age of 30; prolonged labor; macrosomia (large fetus); and Placenta Previa, where the cervix behaves essentially as cavernous tissue.

There are three degrees of cervical lacerations:

First degree — tissue tear up to 2 cm.

Second degree — tear exceeding 2 cm that does not reach the vaginal fornices.

Third degree — tear extending to the fornix, occasionally involving injury to the vaginal fornix.

Suturing technique. The cervix is exposed using specula, and the edges of the tear are grasped with three fenestrated forceps. By applying downward traction and repositioning the clamps, the entire cervix is progressively inspected. Interrupted catgut sutures are placed along the laceration without puncturing the internal (mucosal) surface of the cervix.

The first suture is placed 0.5 cm above the apex of the wound, taking into account vessel displacement During Muscle contraction. Subsequent sutures are placed at 1 cm intervals from the apex of the tear to the edge of the cervix. Upon completion of wound repair, the suture lines are treated with an iodine solution (Iodonat, Iodopyron).