GENITAL TRACT INJURIES

A genital injury is an injury to male or female sex organs, mainly those outside the body.
It also refers to injury in the area between the legs, called the perineum. Injury to the
genitals can be very painful. It may cause a lot of bleeding. Such injury can affect the
reproductive organs and the bladder and urethra.
Damage may be temporary or permanent.

1. PERINEAL TEARS

The perineum is the region between the vaginal opening and the anus. The perineum may
get injured when there is overstretching or rapid stretching during the delivery of
the baby. An inelastic perineum due to the presence of a scar can also lead to a perineal
tear. Some of the causes of overstretching of the perineum leading to perineal tear are:
 A big baby - usually babies more than 4kgs are considered big.
 Malpresentation of the baby like occipito posterior position or face presentation.
 Average sized baby with a narrow maternal vaginal outlet
 Forceps delivery or other instrumental deliveries
 Shoulder Dystocia

DEGREES OF PERINEAL TEAR: There are three degrees of perineal tear.

  First Degree perineal tear: This is only a mild degree of laceration or tear of the
skin at the edge of the vaginal opening. The lower part of the vagina as well as the
perineal skin may be torn but the major muscles of this region are not affected.

 Second degree perineal tear: This involves rupture of the muscles of the
perineum with deep tears in the vaginal wall. The tear may extend right up to the
anus, but does not involve the anal sphincter.

 Third degree perineal tear: In a complete perineal tear, the tear extends from the
vaginal opening through the posterior vaginal wall and the perineal muscles upto
the anus with injuries to the external anal sphincter. The anal or the rectal canal
may or may not be involved

MANAGEMENT/TREATMENT OF PERINEAL TEARS

Prevention is the best management. The second stage of labour should be properly
conducted. An episiotomy should be performed wherever deemed necessary to prevent
tear
of the perineum.

 Immediate Repair: A first or second-degree tear should be immediately repaired,

preferably within the first 24 hours.

 Delayed Repair: If the tear is diagnosed after 24 hours, then the woman is given
antibiotics and the wound dressed so that infection, if any, is controlled. Then the
tear is repaired.

 Third Degree tear: A third degree tear is always repaired after 3 months of the
delivery of the baby to allow the tissues to regain the pre-pregnant state.
 2. VAGINAL TEARS

Vaginal Tears can occur at any part of the vaginal wall, but are seen mostly at the
junction between the lateral and posterior walls. These tears may be superficial with only
minor lacerations of the vaginal mucosa. But sometimes the tears may be deep enough to
expose the inner muscles. Vaginal tears can also occur at the region around the urethra -
the opening through which urine comes out. These are then called ' Paraurethral tears.
The problem with these types of tears is that there may be profuse bleeding from even a
small tear since the region has a large blood supply.

First degree and second-degree perineal tears are similar to vaginal wall tears and treated
the same way.

Vaginal tears that involve only the skin around the vagina typically heal within a few
weeks. There may be stinging pain , especially when passing urine when the acidic urine
passes over the raw surface but this will gradually decrease and fade as the tears heal.

Tears can also occur on the labia, both labia majora and labia minora. Tears to the minora
are not very uncommon but tears to the majora occur only in excessive manipulation of
the vulva during childbirth. Tears to the labia can be either superficial abrasions or actual
tearing of the labia.

TREATMENT / MANAGEMENT OF VAGINAL TEARS

The vagina should always be examined under proper light immediately after the delivery
of the baby for any such tears. All tears should be repaired immediately.
 The woman should sit on a soft cushion for a few days after childbirth to help in
decreasing the pain.
 A cold pack applied to the vulva for 10 minutes every two hours will decrease the
inflammation and the swelling.
 Pouring warm water over the vulva while passing urine will decrease the stinging
pain.
 Pain relievers to decrease the pain and stool softeners to keep the stools soft will
help prevent constipation and the need to push hard while passing stool will also
help.
 3. CERVICAL TEARS

Minor tears of the cervix are very common during delivery, especially in a woman who is
delivering her first child. But sometimes, major lacerations which can cause severe
bleeding may also occur. In fact, cervical tears are the commonest form of traumatic
post-partum hemorrhage.
Cervical tears are commonest at the lateral angle, between the anterior and
posterior lips of the cervix. Tears can occur with a normal childbirth but are more
common with instrumental deliveries like Forceps or Vacuum aspiration.
Vaginal bleeding after childbirth which occurs despite a well-contracted uterus and
which does not appear to be arising from the vagina or perineum is an indication for
examining the cervix. The cervix should be thoroughly examined with a speculum and
vaginal wall retractor and under proper light for an accurate diagnosis.

Causes of Cervical tear:

 Delivery through an undilated cervix whether spontaneously, or by forceps.

 Precipitate labour.
 Rigid cervix due to previous operations like the LEEP procedure, conisation, or
cervical amputation.
 Very vascular cervix as can occur in low level placenta previa.

TREATMENT / MANAGEMENT OF CERVICAL TEARS

The aim of treatment is to control bleeding as early as possible by repairing the tear.
Minor lacerations without active bleeding does not require to be repaired - they heal
spontaneously with no ill effects.
Major cervical lacerations or tears need to be repaired in the operating theatre under
anesthesia, good light and proper exposure of the tear.

Repair of vaginal and perineal tears

There are four degrees of tears that can occur during delivery:
 First degree tears involve the vaginal mucosa and connective tissue.
 Second degree tears involve the vaginal mucosa, connective tissue and underlying
muscles.
 Third degree tears involve complete transection of the anal sphincter.
 Fourth degree tears involve the rectal mucosa.
Note: It is important that absorbable sutures be used for closure. Polyglycolic sutures are
preferred over chromic catgut for their tensile strength, non-allergenic properties and
lower probability of infectious complications. Chromic catgut is an acceptable
alternative, but is not ideal

Repair Of First- and Second-Degree Tears

Most first-degree tears close spontaneously without sutures.
 Review general care principles.
 Provide emotional support and encouragement. Use local infiltration with
lignocaine. If necessary, use a pudendal block.
 Ask an assistant to massage the uterus and provide fundal pressure.
 Carefully examine the vagina, perineum and cervix.
 If the tear is long and deep through the perineum, inspect to be sure there is no
third- or fourth-degree tear:
 Place a gloved finger in the anus;
 Gently lift the finger and identify the sphincter;
 Feel for the tone or tightness of the sphincter.
 Change to clean, high-level disinfected gloves.
 If the sphincter is injured, see the section on repair of third- and fourth-degree
tears.
 If the sphincter is not injured, proceed with repair.

Exposing a perineal tear

 Apply antiseptic solution to the area around the tear

 Make sure there are no known allergies to lignocaine or related drugs.

Note: If more than 40 mL of lignocaine solution will be needed for the repair, add
adrenaline to the solution.
 Infiltrate beneath the vaginal mucosa, beneath the skin of the perineum and deeply
into the perineal muscle using about 10 mL 0.5% lignocaine solution

Note: Aspirate (pull back on the plunger) to be sure that no vessel has been penetrated. If
blood is returned in the syringe with aspiration, remove the needle. Recheck the position
carefully and try again. Never inject if blood aspirated. The woman can suffer
convulsions and death if IV injection of lignocaine occurs.
 At the conclusion of the set of injections, wait 2 minutes and then pinch the area
with forceps. If the woman feels the pinch, wait 2 more minutes and then retest.
Anaesthetize early to provide sufficient time for effect.
 Repair the vaginal mucosa using a continuous 2-0 suture.
 Start the repair about 1 cm above the apex (top) of the vaginal tear. Continue the
suture to the level of the vaginal opening;
 At the opening of the vagina, bring together the cut edges of the vaginal opening;
 Bring the needle under the vaginal opening and out through the perineal tear and
tie.

Repairing the vaginal mucosa

 Repair the perineal muscles using interrupted 2-0 Suture. If the tear is deep, place a
second
 layer of the same stitch to close the space.
 Repair the skin using interrupted (or subcuticular) 2-0 sutures starting at the
vaginal opening
 If the tear was deep, perform a rectal examination. Make sure no stitches are in the
rectum.

Repairing the skin

Repair of Third- and Fourth-Degree Perineal Tears

Note: The woman may suffer loss of control over bowel movements and gas if a torn
anal sphincter is not repaired correctly. If a tear in the rectum is not repaired, the woman
can suffer from infection and rectovaginal fistula (passage of stool through the vagina).

Repair the tear in the operating room.

Review general care principles.
 Provide emotional support and encouragement. Use a pudendal block or ketamine.
Rarely, if all edges of the tear can be seen, the repair can be done using local
infiltration with lignocaine (see above) and pethidine and diazepam IV slowly (do
not mix in the same syringe).
 Ask an assistant to massage the uterus and provide fundal pressure.
 Examine the vagina, cervix, perineum and rectum.
 To see if the anal sphincter is torn:
 Place a gloved finger in the anus and lift slightly;
 Identify the sphincter, or lack of it;
 Feel the surface of the rectum and look carefully for a tear.
 Change to clean, high-level disinfected gloves.
 Apply antiseptic solution to the tear and remove any faecal material, if present.
 Make sure there are no known allergies to lignocaine or related drugs.
  Infiltrate beneath the vaginal mucosa, beneath the skin of the perineum, and deeply
into the perineal muscle using about 10 mL 0.5% lignocaine solution.

Note: Aspirate (pull back on the plunger) to be sure that no vessel has been penetrated. If
blood is returned in the syringe with aspiration, remove the needle. Recheck the position
carefully and try again. Never inject if blood is aspirated. The woman can suffer
convulsions and death if IV injection of lignocaine occurs.
 At the conclusion of the set of injections, wait 2minutes and then pinch the area
with forceps. If the woman feels the pinch, wait 2 more minutes and then retest.
Anaesthetize early to provide sufficient time for effect. Repair the rectum using
interrupted 3-0 or 4-0 sutures0.5 cm apart to bring together the mucosa.
Remember: Place the suture through the muscularis (not all the way through the
mucosa).
 Cover the muscularis layer by bringing together the fascial layer with interrupted
sutures;
 Apply antiseptic solution to the area frequently.

Closing the muscle wall of the rectum

If the sphincter is torn:
 Grasp each end of the sphincter with an Allis clamp (the sphincter retracts when
torn). The sphincter is strong and will not tear when pulling with the clamp
 Repair the sphincter with two or three interrupted stitches of 2-0 suture.

Suturing the anal sphincter.

 Apply antiseptic solution to the area again.
 Examine the anus with a gloved finger to ensure the correct repair of the rectum
and sphincter. Then change to clean, high-level disinfected gloves.
 Repair the vaginal mucosa, perineal muscles and skin

Post-procedure care
 If there is a fourth-degree tear, give a single dose of prophylactic antibiotics:
ampicillin 500 mg by mouth;
 PLUS, metronidazole 400 mg by mouth.
 Follow up closely for signs of wound infection.
 Avoid giving enemas or rectal examinations for 2 weeks.
 Give stool softener by mouth for 1 week, if possible.

MANAGEMENT OF NEGLECTED CASES

A perineal tear is always contaminated with faecal material. If closure is delayed more
than 12 hours, infection is inevitable. Delayed primary closure is indicated in such cases.
 For first- and second-degree tears, leave the wound open.
  For third- and fourth-degree tears, close the rectal mucosa with some supporting
tissue and approximate the fascia of the anal sphincter with 2 or 3 sutures.
Close the muscle and vaginal mucosa and the perineal skin 6 days later.

COMPLICATIONS

 If a hematoma is observed, open and drain it. If there are no signs of infection and
the bleeding has stopped, the wound can be reclosed.
 If there are signs of infection, open and drain the wound. Remove infected sutures
and debride the wound:
 If the infection is mild, antibiotics are not required;
 If the infection is severe but does not involve deep tissues, give a combination of
antibiotics: ampicillin 500 mg by mouth four times per day for 5 days;
 PLUS metronidazole 400 mg by mouth three times per day for 5 days.
 If the infection is deep, involves muscles and is causing necrosis (necrotizing
fasciitis), give a combination of antibiotics until necrotic tissue has been removed
and the woman is fever-free for 48hours: penicillin G 2 million units IV every 6
hours;
 PLUS gentamicin 5 mg/kg body weight IV every 24 hours;
 PLUS metronidazole 500 mg IV every 8 hours;
 Once the woman is fever-free for 48 hours, give ampicillin 500 mg by mouth four
times per day for 5days;
 PLUS metronidazole 400 mg by mouth three times per day for 5 days.

Note: Necrotizing fasciitis requires wide surgical debridement. Perform secondary

closure in 2-4 weeks (depending on resolution of the infection).
 Fecal incontinence may result from complete sphincter transection. Many women
are able to maintain control of defecation by the use of other perineal muscles.
When incontinence persists, reconstructive surgery must be undertaken 3 months
or more after delivery.
 Rectovaginal fistula requires reconstructive surgery 3 months or more postpartum
 4. LACERATIONS

Definition
Vaginal lacerations are tears in the vagina or in the skin and muscle around its opening.
Tears are most common in the space between the opening of the vagina and the rectum
(perineum). The tear may be minor or very deep.

Causes
Deep tears may happen during vaginal delivery when:
 The baby's head is too large to fit through the vaginal opening
 Labor is very rapid
 Delivery is done using instruments
 Minor tears may also happen during sex or from an injury to the crotch.

Risk Factors
Birth factors that may raise the risk are:
 Having a very large baby
 Having a baby for the first time
  Having had tears with a prior pregnancy
 Delivery with instruments
 Baby's shoulder gets stuck
 Uncontrolled, forceful extension of the fetal head.
 Pushing prior to complete cervical effacement and dilatation.
Other things that may raise the risk are:
 Putting an object in the vagina
 Thinning of the vagina

Symptoms
Vaginal tears cause pain and bleeding.
(a) Obvious body injury after delivery of the infant—if perineal laceration.
(b) Bright red bleeding despite a well-toned fundus-if vaginal or cervical laceration and
not detected at time of delivery.
(c) Signs of shock-rapid, thready pulse, falling blood pressure, increasing anxiety of the
patient.

Common sites - Sites of lacerations are the vaginal side wall, the cervix, the lower
uterine segment, and the perineum.

Degrees of perineal lacerations.

(a) First degree-tear of the vaginal and perineal mucous membranes.

(b) Second degree-tear of the vaginal and perineal mucous membrane and the perineal
muscles.
(c) Third degree-tear of the vaginal and perineal mucous membrane, the perineal
muscles, and the capsule of the rectal sphincter.
(d) Fourth degree-tear of the vaginal and perineal mucous membrane, the perineal
muscles, and through the rectal sphincter and anterior wall of the rectum.

Medical treatment
 Suturing of the laceration
 Vaginal packing.
 Blood transfusions if the patient's hematocrit is low and the patient is symptomatic.

Nursing interventions.
 Observe closely for continued vaginal bleeding.
 Monitor the patient's vital signs.
 Flag the patient's chart for vaginal packing in place. This is helpful to the nurse
who is checking for vaginal bleeding doesn't mistake a lack of obvious signs of
 blood for no bleeding. The vaginal packing could "hide" a hemorrhagic episode of
bleeding.

5. HEMATOMAS

Vulvar hematoma is a localized collection of blood in the connective tissue beneath the
skin covering the external genitalia or vaginal mucosa. It generally forms as a result of
injury to the perineal blood vessels during the delivery process.

Causes of Hematomas.
(1) Rapid, spontaneous delivery.
(2) Perineal varicosities.
(3) Episiotomy repairs.
(4) Laceration of perineal tissues.

Signs and Symptoms.

(1) Severe, sharp perineal pain.
(2) Appearance of a tense, sensitive mass of varying size covered by discolored skin.
(3) Swelling in the perineal wall.
(4) Often seen on the opposite side of the episiotomy.
(5) Inability to void due to pressure/edema on or around the urethra.
(6) Complaint of fullness or pressure in the vagina.

Hematoma of The Genital Tract Vulval (Infra-Levator) Haematoma Causes:

 Traumatic due to:
 Incomplete haemostasis during repair of episiotomy or tear.
 Direct trauma as kick or falling down. Spontaneous: due to rupture of a varicose
vein.

Clinical picture:
 The hematoma usually appears 12-48 hours after deliverv.
 The collection of blood is limited by the levator and above but laterally it may
extend to fill the ischiorectal fossa reaching a volume of 500 ml or more.
 There is a progressive enlarged, painful, tender, tense, bluish swelling at the vulva.
 Manifestations of hypovolaemia (e.g. hypotension and rapid pulse) and anemia
may be present.

Management:
 Small not- increasing hematoma: is managed conservatively as it usually resolves
spontaneously. Prophylactic antibiotic may be given to guard against secondary
infection.
 Large increasing haematoma:
o It is incised longitudinally,
o evacuation of the clotted blood,
o bleeding points are ligated,
o the gap is closed in layers.

Vaginal (Supra-Levator) Haematoma Causes:

Deep vaginal lacerations.

Clinical picture:
 The blood is collected paravaginally above the levator
 ani muscle.
 It may not be visible externally.
 It may not be painful until reaching a large size.
 Manifestations of hypovolaemia and anemia may be present.

Management:
As vulval haematoma.
Broad Ligament (Retroperitoneal) Haematoma Causes
Upper vaginal,cervical or uterine tears which usually involve the vaginal or uterine
artery.

Clinical picture:
 Hypovolaemia, anemia or shock: is usually present due to large amount of internal
haemorrhage.
 Swelling on one side of the uterus which increasingover a period of hours or days
and may reach up to the lower pole of the kidney or even the diaphragm.
 The uterus is felt separate and deviated to the opposite side.
 Fever, ileus and unilateral leg edema: may develop later.

Management:
 Small not-increasing hematoma: is managed conservatively as vulval haematoma.
 Large increasing haematoma:
 Laparotomy.
 Incision in the anterior leaflet of the broad ligament.
 Evacuation of the blood clots.
 Securing haemostasis, bilateral internal artery ligation or hysterectomy may be
indicated.

Medical Treatment. This is consists of analgesics given for discomfort, opening the
hematoma so blood clots can be evacuated and the bleeders can be ligated, and packing
for pressure.

Nursing Interventions.
(1) Apply ice to area of hematoma.
(2) Observe for evidence of enlarged hematoma.
(3) Flag the patient's chart if packing was inserted.
 6. RUPTURE OF THE UTERUS

Definition
Dissolution in the continuity of the uterine wall any time beyond 28 weeks old pregnancy
is called rupture of uterus.

Incidence
About 1:4000, 95% of cases occur in multipara particularly grand multipara.

Causes
During pregnancy
a. Spontaneous:
 Rupture of a uterine scar: e.g. previous C.S. especially upper segment,
myomectomy, hysterotomy, uteroplasty or perforation.
 Abruptio placenta with severe concealed haemorrhage.
 Anterior sacculation in case of incarcerated retroverted gravid uterus or posterior
sacculation due to previous ventrofixation of the uterus.
 Rupture of a rudimentary horn at the 4th- 5th month.
  Perforating vesicular mole.
b. Traumatic
 Perforation during vaginal evacuation.
 External trauma.

During labour:
a. Spontaneous:
 Obstructed labour.
 Rupture of a uterine scar.
 Grand multipara: due to degeneration and overthinning of the uterine muscles.
b. Traumatic:
 Internal version: particularly after drainage of liquor.
 Manual separation of the placenta.
 Destructive operations.
 Extending cervical tear due to e.g. forceps or ventouse applications before full
cervical dilatation.
 Improper use of oxytocins.

Weak uterine scar may be a result to:

 Imperfect suture with improper coaptation of the edges.
 Bad haemostasis results in blood clot formation which prevents good coaptation
and predisposes to wound infection.
 Wound infection.
 Subsequent implantation of the placenta over it.
 Subsequent overdistension of the uterus e.g polyhydramnios or multiple
pregnancy.
 Upper segment caesarean section scar is weaker than lower segment scar.
 Repeated vaginal deliveries after a previous C.S. weaken the scar.

Types
 Complete: involving the whole uterine wall including the peritoneum.
 Incomplete: not involving the peritoneal coat.

Sites
It depends upon the cause of rupture.
 In obstructed labour:
 It is usually in lower uterine segment. Usually oblique or transverse.
 More on the left side due to;
 dextrorotation of the uterus.
 left occipito-positions are more common.
  Extended tear may pass laterally injuring the uterine vessels leading to broad
ligament haematoma formation. This rupture may involve the ureter or bladder.
 In rupture scar:
 At the site of the scar.

Clinical Picture
Impending rupture
 Before actual rupture the following manifestations may be detected:
 Lower abdominal pain.
 Tender uterine scar.
 Vaginal spotting (minimal bleeding).

Actual rupture:
Symptoms:
 Sudden severe abdominal pain: It is differentiated from labour pain being
continuous.
 If the patient was in labour there is cessation of uterine contractions.
 Shoulder pain on lying down due to irritation of the phrenic nerve by accumulating
blood under the diaphragm.
 Silent rupture: minimal symptoms may occur in rupture lower seqment scar due to
presence of fibrosis and minimal internal haemorrhage.

Signs
-General examination:
 Variable degrees of collapse are present according to amount of blood loss. This
may appear postpartum in case of traumatic rupture uterus.

-Abdominal examination:
 Scar of the previous operation.
 Fetal parts are prominent and felt easy.
 The presenting part recedes upwards.
 Abnormal foetal attitude and lie.
 FHS usually not heard.
 The uterus is felt separated from the foetus
 In incomplete rupture, the foetus still inside the uterus with suprapubic painful
tender swelling which is an accumulated blood in the vesico-uterine pouch.
-Vaginal examination:
 The presenting part recedes upwards.
 Vaginal bleeding may be present.
 Contracted pelvis may be detected.
  A cervical tear may be found extending to the lower uterine segment and a broad
ligament haematoma may be present.

Management
Prophylactic:
 Early detection of causes of obstructed labour as contracted pelvis and
malpresentations.
 Proper use of oxytocins.
 Version is not done if liquor amnii is drained.
 Forceps application and breech extraction should not be done before full cervical
dilatation.
 Elective caesarean section for susceptible scars for rupture as upper segment C.S.
 Exploration of the genital tract after difficult or instrumental delivery.

Curative:
 Blood transfusion and antishock measures.
 Immediate laparotomy.
 Deliver the foetus and placenta.
 Explore the rupture site:
 If it is amenable for repair and the patient did not complete her family ® repair is
done.
 If it is not amenable for repair, hysterectomy or
 Subtotal hysterectomy is less time consuming so it is done if there is no cervical
tear.
 Exploration of the other viscera mainly the bladder.
 Internal iliac artery ligation may be needed in case of broad ligament hematoma as
the uterine artery is usually retracted and difficult to be identified.
 Vaginal repair: may be amenable if there is slight extension of a cervical tear with
accessible apex.
 Hysterectomy

Complications
Maternal:
 Shock.
 Haemorrhage.
 Paralytic ileus.
 Bladder, ureter or visceral injuries.
  Infection.
Foetal:
 Death due to asphyxia from detachment of the placenta.

SUMMARY

Injury to the genitals can be very painful. It may cause a lot of bleeding. Such injury can
affect the reproductive organs and the bladder and urethra.
They are: Perineal tear, Vaginal tear, Cervical tear, Laceration, Haematoma and Rupture
of the uterus. The sign and symptoms are bleeding, falling of blood pressure, injury and
increase anxiety of the patient. It may cause due to large fetus, inadequate practice of
conducting a delivery, extreme bear down effort, used of instrument during delivery and
minor tear during intercourse.
Proper ante natal checkup, institutional delivery can prevent complication, suturing and
packing the vagina can also reduce the risk factor of genital injury.

CONCLUSION

Genital tract trauma, specifically lacerations/episiotomies, hematomas, uterine rupture,

and uterine inversion, can each cause significant blood loss. The risk for lower genital
tract trauma is increased if there has been a prolonged second stage, use of forceps or
vacuum, episiotomy, or vulvar varicosities. Episiotomy is the most common risk factor
for hematoma, but other risks include primiparity, preeclampsia, multiple gestation,
vulvar varicosities, and coagulopathy. Moderately forceful blunt trauma often results in
perineal tears and hematoma formation. Vaginal hematomas can result from submucosal
tears of the vagina or even mucosal separation with resultant vaginal bleeding or vaginal
hematoma formation.

BIBLIOGRAPHY

1. Bhaskar N. Midwifery and Obstetric Nursing.1st ed. Bangalore: emmess medical

publishers; 2012.

2. Dutta DC. Textbook of Gynecological. 7th ed. New delhi: The health science
publisher; 2016.

3. Genital injury [internet] 2020 [cited 2022 17 september] Available from;

https://medlineplus.gov/ency/article/000044.htm#:~:text=A%20genital%20injury%20is
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