1. Anatomy of Vagina2. Episiotomy and its repair3. Cervical tear
Presented by:
Ashok Kumar Yadav
Choodamani Nepal
Tapendra Koirala
1. Anatomy of Vagina
Vagina is fibromusculomembranous tube of 7-9cmCommunicates uterine cavity with exterior at vulva
Vagina
Uterus
Bladder
Rectum
Fornices
- Cleft formed at the top of vagina
- Projection of uterine cervix
Four fornices are:
1. One anterior fornix
2. One posterior fornix
3. Two lateral fornix
- Posterior deeper, - anterior shallow
Relations
Anterior: upper 1/3rd - base of bladder
lower 2/3rd - urethra
Posterior: upper – pouch of Douglas
middle – anterior rectal wall
lower – perineal body
Lateral: upper – ureter and uterine artery
middle – levator ani muscle
lower – bulbocavernosus muscle, vestibular bulbs & Bartholin’s glands
Layers:
From within outward:
1. Mucous coat: lined by stratified squamous epithelium
2. Sub-mucous layer: of loose areolar connective tissue
3. Muscular layer: inner circular & outer longitudinal layer
4. Fibrous coat: endopelvic fascia
Function:
- Canal for menstrual fluid- Forms the inferior part of the birth canal- Receives penis and ejaculate during sexual intercourse
Blood Supply
Arterial system- Vaginal artery: division of internal iliac artery- Cervicovaginal: branch of uterine artery- Middle rectal artery- Internal pudendal artery
Venous system- Corresponds with arteries
Lymphatic system
Above hymen: internal iliac group of lymph nodes
Below hymen: superficial inguinal group of lymph nodes
Nerve supplyautonomic nervous supply by pelvic plexus
Lower part: by pudendal nerve
2. Episiotomy and it’s repair
Episiotomy
- Definition
A surgically planned incision on the perineum and posterior vaginal wall during the second stage of labor
- Objectives- To enlarge the vaginal introitus so as to facilitate the
easy and safe delivery- To minimize the overstretching and rupture of perineal
muscles and fascia- To reduce the stress and strain on the fetal head
Advantages
- Maternal: - Reduction of trauma to pelvic floor muscle and fascia –
reduces incidence of prolapse and perhaps urinary incontinence
- Reduction in second stage of labor- Clear and controlled incision is easy to repair and heals
better than a lacerated wound
- Fetal:- Minimizes the intracranial injuries
Indication
- In-elastic perineum e.g. elderly primigravidae - Anticipated perineal tear e.g. big baby, face to pubis
delivery, breech delivery, shoulder dystocia- Operative delivery e.g. forceps delivery, ventouse
delivery- Previous perineal surgery e.g. pelvic floor repair,
perineal reconstructive surgery
Timing of the episiotomy
- If done early:- To much bleeding
- If done late:- Fails to protect micro lacerations and tear
- Bulging thinned perineum during the contraction just prior to crowning (when 3-4 cm of head is visible) is the ideal time
Types of episiotomy
1. Mediolateral
2. Median
3. Lateral
4. ‘J’ shaped
Commonest type is mediolateral
Cervical Tear
- Most common cause of traumatic postpartum haemorrhage
- Causes: Iatrogenic: forceps delivery, breech extraction through
incompletely dilated cervix
Rigid cervix: congenital, previous operation, carcinoma
Strong uterine contraction
Detachment of cervix
Diagnosis- Excessive vaginal bleeding immediately following delivery
DangersEarly: Deep cervical tear with major vessels lead to severe
- postpartum haemorrhage
- broad ligament hematoma
- pelvic cellulitis,
- Thrombophlebitis
Late: Ectropion- Cervical incompetence with mid-trimester- Abortion
Treatment
- Minor degree of cervical tear requires no treatment- Deep cervical tear should be repaired soon after
delivery of placenta- Suturing
Pre-requisites:- Sim’s posterior vaginal speculum- Vaginal wall retractors- At least two forceps- Assistant
Thank you!
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