Maternal and Child Health PDF

# MATERNAL AND CHILD HEALTH ## PERFORMANCE AND REPAIR OF EPISIOTOMY INCISION/LACERATION ### INTRODUCTION Episiotomy is the most common surgical operation performed in obstetrics. The use of episiotomy has been said to decrease trauma to the fetus, decrease the frequency of extensive perineal tear...

# MATERNAL AND CHILD HEALTH ## PERFORMANCE AND REPAIR OF EPISIOTOMY INCISION/LACERATION ### INTRODUCTION Episiotomy is the most common surgical operation performed in obstetrics. The use of episiotomy has been said to decrease trauma to the fetus, decrease the frequency of extensive perineal tears, and protect the soft maternal tissues. In current obstetric/midwifery practice, incision of the perineal body and vagina to enlarge the vaginal opening and facilitate delivery is referred to as an episiotomy. The term episiotomy actually refers to an incision into the external genitals. The more precise name for the obstetric incision is perineotomy, an incision made in the perineum. Nevertheless, episiotomy has been used over the years and it has come to stay. ### ANATOMY OF THE PERINEUM The perineal body is one of the areas of the human body not well understood. In actuality, it is simply a mass of dense connective tissue. The perineum is the area extending from the base of the labia minora to the anal canal and consists of connective tissue, muscle and fat. When examining the area between the anus and the vagina, the following structures can be found in the midline: Vaginal mucosa, dense connective tissue, external anal sphincter, internal anal sphincter, and anal wall. - **Shape**: It is roughly triangular. - **Position**: It lies between the lower parts of the vagina with the apex uppermost. It is the central point where the levator ani and superficial muscles unite. - **Size**: Each side of the triangle shape is between 3.5cm-4cm **Structure**: The perineal body consists of an outer layer of skin and the following superficial and deep muscles of the pelvic floor. They are: - The superficial muscles: bulbocavernosus and transverse perineal. - Deep muscle: Pubococcygeous. **Blood supply**: Pudendal arteries **Venous return**: corresponding veins **Nerve supply**: Perineal branch of Pudendal nerve ### DIAGRAM OF PERINEUM AND DEEP PELVIC FLOOR MUSCLES [ IMAGE DESCRIPTION: This diagram depicts the anatomy of the perineum and the deep pelvic floor muscles, labeled with the name of each muscle. ] The levator ani, bulbocavernosus, and transverse vaginal muscles all have attachments to or near the perineal body but do not actually cross the midline. If the perineal body is transected and not repaired, the important connections between the two sides of each of these structures are lost. The continuity of structures across the midline in the perineal body can be appreciated by feeling the ridge that is palpable just inside the hymenal ring as the perineum is distended. This probably represents the attachment of structures from both sides through their midline perineal body attachments. The structural importance of the pelvic floor can be appreciated by looking at its position relative to the abdominal and pelvic contents. If the abdomino-pelvic cavity is thought of as having a barrel shape, the lid of the barrel is the respiratory diaphragm and the floor is the pelvic diaphragm. Like the respiratory diaphragm, the pelvic diaphragm is a muscle stretched across a relatively circular opening in the pelvis. It is composed of the levator ani and coccygeus muscles. It is in the shape of a fan that has its apex at the coccyx and its opposite edge attached to the pubic bones and the pelvic walls. Its muscle fibers form a series of slings that begin ventrally and loop around the back of the rectum, attaching to its wall and the wall of the vagina. The effect of their activity is to pull the rectum and perineal body toward the pubic bones and to squeeze the lumina of the pelvic viscera closed, occluding any opening in the pelvic floor. In addition to the levator ani muscles, the perineal membrane (urogenital diaphragm) spans the pelvic outlet. Its broad sheets of connective tissue attach the perineal body to the ischiopubic rami and suspend it. The perineal membrane does not traverse the perineal body as an identifiable structure but is attached to either side of it. The ability of the urogenital diaphragm to suspend the pelvic floor is dependent on a continuity to the two sides, connected through an intact perineal body. ### INDICATIONS FOR AN EPISIOTOMY Several indications have been proposed for the use of an episiotomy. These include - Prevention of maternal perineal lacerations - Prevention of Fetal intracranial injury - A prolonged second stage of labour - Rigid perineum - Maternal conditions such as cardiac disease or any other medical reason to minimize intra-abdominal pressure - Fetal distress - Prematurity - Breech presentation of a fetus. - Episiotomy is often performed as a prophylactic measure to prevent vaginal and perineal lacerations ### CONTRA-INDICATIONS - Abnormalities of the perineum. - Inflammatory bowel disease - Lymphogranuloma venereum - Severe perineal scarring - Perineal malformation are some to consider. - Coagulation disorders have been suggested as a contraindication, but an episiotomy would be preferable to a caesarean section or a complex laceration if a shortened second stage of labour is all that is needed. - Patient’s absolute refusal for the procedure to be performed. ### FACTORS TO BE CONSIDERED BEFORE PERFORMING AN EPISIOTOMY 1. **CONSENT** - Consent should be obtained from the client during ante natal care/visit. - Consent should not be obtained while the patient is in labour, unless the patient did not attend ante natal throughout the pregnancy in that facility. 2. **TIMING** - a. When an episiotomy is done to prevent lacerations, it is best performed when the fetus is expected to be delivered within the next three or four contractions. An episiotomy performed close to the time of delivery will prevent excessive blood loss. It is done at the peak of contraction when the presenting part has distended the vaginal orifice. If performed too early haemorrhage from cut Vessels may ensue and the levator ani muscles will not have been displaced laterally and may be incised as well. - b. To prevent subsequent pelvic relaxation, it is recommended that episiotomy should be given when the fetal head begins to part the levator ani pillars and just begins to stretch the fascia between them. The area of the fetal scalp visible at the introitus at this time is about 4 cm. - c. To minimize soft-tissue damage, the incision must be made before the supporting structures have been damaged to the extent that they cannot recover. Gainey believed that the absence of visible tears did not guarantee that the pelvic floor was left undamaged, again emphasizing early episiotomy. Blood loss is increased with this method, but delivery is thought to occur within the next few contractions, if not with maternal effort alone then with outlet forceps. 3. **TYPES AND TECHNIQUES** - There are two main types - Median episiotomy - Mediolateral episiotomy ### MEDIAN EPISIOTOMY - A midline incision made through the fourchette and perineal body and stops just before the anal sphincter. **REQUIREMENT** - Plain Lidocaine - Syringes and needles - A kidney dish containing episiotomy scissors - Sanitary towel or gauze **PROCEDURE FOR MEDIAN INCISION** - a. Infiltrate the area where the incision will be made. - b. The median episiotomy incision is made in the perineal body from the midline of the hymenal ring through the connective tissue that unites the bulbocavernous muscle, the superficial transverse perineal muscles, and the perineal membrane (urogenital diaphragm). - c. A sharp episiotomy scissors is used with two fingers inserted into the vaginal before the open blades are positioned to avoid injury to the fetus. - d. The incision is made down to but not including the anal sphincter (Fig. 1A). - e. The vagina should be incised 3 to 4 cm above the hymenal ring, with the incision entering the rectovaginal space. The risk of vaginal lacerations is thus avoided. Scissors is used with care to avoid injury to the fetus. - f.. This incision is associated with reduced blood loss, easier to repair and results in less pain (Painful Intercost and dyspareunia, but a higher incidence of damage to anal sphincter. - g. The depth of the incision is limited to the distance between the vagina and the anal sphincter and thus poses restrictions on the amount of enlargement of the birth canal. If more room is needed, extension into the rectum either spontaneously or intentionally is inevitable. - h. Intentional extension of the incision to involve the anorectal area is referred to as an episioproctotomy. It is not surprising that a median episiotomy is not elected when the perineal body is short or when the infant is thought to be very large. Opinion varies about whether a mediolateral incision is preferable to episioproctotomy. - i. Episioproctotomy carries the risk of fistula and anal incontinence, whereas a mediolateral episiotomy causes greater blood loss and may be more painful. Mediolateral episiotomy, because it can be extended to incise the levator ani (which episioproctotomy does not), provides more room for delivering impacted shoulders or for managing breech delivery. ### REPAIR OF MEDIAN INCISION Repair of the median incision is often deferred until the placenta has been delivered and inspection of the cervix and vaginal canal has been performed. Such delay provides adequate exposure for repair of vaginal and cervical lacerations, if present, and manual removal of the placenta, if necessary. Midline episiotomies may bleed briskly at the time of the incision, but after delivery of the fetus there is remarkably less bleeding. This has been believed to be due to a change in the venous congestion of the perineal tissues at the time of delivery. Many methods may be used to repair a midline episiotomy, but all require meticulous surgical technique. Polyglycolic acid suture causes less tissue reaction and provides greater tensile strength than chromic or plain catgut. - Infiltrate the tissues with lidocaine before the commencement of the repair - The perineum is reconstructed in layers after adequate anaesthesia has been obtained. Whatever the method of repair, the following principles seem evident. - Take care to explore the entire extent of the episiotomy to avoid fistulas that can be created by an incomplete repair. Avoid causing ischemia and trauma to the tissues and restore to the midline all of the tissues that have been separated. - The vaginal wall is closed first with a continuous suture that starts 1 cm above the apex of the incision, including any retracted blood vessels, which may otherwise result in haematoma formation. The closure continues to the hymenal ring. Each bite should include the rectovaginal fascia so that posterior vaginal support is maintained. - In some instances, it is preferable to close the vaginal fascia as a separate layer before closing the vaginal mucosa. - The connective tissue of the perineal body is then approximated by first using deep interrupted stitches that include the levator fascia. - Next, the more superficial tissues in the region of the cut edges of the perineal membrane (urogenital diaphragm) and the transverse perineal muscles are approximated. This is done either as a continuation of the vaginal suture or as interrupted sutures. - The skin is then closed with a continuous subcuticular stitch. Sutures must not be placed so tight that they interfere with tissue vascularity, and dead space should be obliterated. - Avoid placing sutures in the mucocutaneous portion of the fourchette to help prevent postpartum dyspareunia. - The number of knots should be reduced as much as possible on the skin surface and in muscle layers. - Careful approximation of the incised tissues layer by layer is required to ensure proper healing. Sutures should be placed perpendicular to the incision line to ensure adequate approximation. Occasionally, when the incision or laceration is curved, approximation can still be achieved by placing the sutures at unequal distances on one side. When the repair is completed, the vaginal and rectal mucosa is palpated to ensure that repair is adequate, that no suture material extends through the rectal mucosa, and no sponge is left in the vagina. The perineum is rinsed, and an ice pack is applied. [ IMAGE DESCRIPTON: This figure depicts how a median episiotomy is repaired from the perineal incision to the subcuticular skin closure. ] ### MEDIOLATERAL EPISIOTOMY Mediolateral incisions are only rarely extended into the rectum and anal sphincter and are often used when more room is required for the delivery process. The direction of an episiotomy is dependent on the handedness of the surgeon. A right-handed obstetrician usually incises from the posterior fourchette at the midline toward the patient’s left ischial tuberosity. While a left-handed obstetrician usually incises from the posterior fourchette at the midline toward the patient’s right ischial tuberosity. The incision begins at the midpoint of the fourchette and is directed at an angle of 45° to the midline towards a point midway between the Ischia tuberosity and the anus. This line avoids the danger of damage to both the anal sphincter and Bartholin’s gland. The structures separated are same as with the median incision, and the ischiorectal fossa is exposed. In addition, when extra room is needed for a difficult delivery, a mediolateral incision has the advantage that it can be extended through the levator ani muscles, expanding the outlet. This additional room is not available with a median incision, which when extended cannot alleviate resistance from these muscles and their fascia. [ IMAGE DESCRIPTON: This diagram shows the anatomy of the vulva highlighting the structures included in the medialateral episiotomy. ] [ IMAGE DESCRIPTON: This figure depicts the anatomy of a mediolateral episiotomy incision showing the repair of the vaginal wall, approximation of the levator muscles, the approximation of the bulbocavernosus muscle, the reconstruction of the urogenital diaphragm, and the skin closure. ] ### PROCEDURE FOR A MEDIOLATERAL INCISION **THE REQUIREMENT IS THE SAME AS FOR A MEDIAN EPISIOTOMY** It is important to begin the incision at the midline. If the episiotomy is begun in a lateral position on the vaginal outlet, the Bartholin’s duct may be incised; at least theoretically, this error could lead to subsequent cyst formations. A mediolateral episiotomy should be performed by first incising the soft tissues of the fourchette and the vagina, followed by the perineum, extending in the mediolateral direction. ### REPAIR OF A MEDIOLATERAL INCISION - This should be done as soon as possible. - A good source of light is essential. - Place patient in a lithotomy position or dorsal position with the leg well flexed and abducted. - This position allows for a clear view of the wound. - Observe other aseptic technique such as wearing of mask, cap, sterile gown, and gloves - The vulva and the wound are thoroughly cleaned with Savlon or any available antiseptic solution. - Infiltrate the wound with a local anaesthesia. - If an attempt is made to repair an episiotomy immediately after the delivery of the placenta, there may be no further need to infiltrate the perineum for this would have been done prior to making an episiotomy. **Technique of repair** - Start suturing from apex of the vagina wound. - Continuous or interrupted stitches are inserted from the apex to the foruchette and bringing the two edges of the wound together. - Absorbable sutures are used in the muscle layer while nylon chromic can be used on the skin. -- Care should be taken to secure a proper alignment of the skin. Take care to explore the entire extent of the episiotomy to avoid fistulas that can be created by an incomplete repair. Avoid causing ischemia and trauma to the tissues and restore to the midline all of the tissues that have been separated. - Ensure an optimal anatomical approximation at the time of repair. - At the end of the procedure a gloved finger is put in the anal canal and two fingers of the other hand in the vagina to ensure no damage has been done. -- If non-absorbable sutures were used for the skin the number of stitches inserted should be written down on the patient’s notes for cross-checking when the sutures are removed. -- The initial stitch is placed 1 cm above the apex of the incision. The vaginal closure allows re-approximation of the hymenal ring and subsequent anatomical accuracy. When a deep incision has been made, the levatores and deep tissues should be sutured first before the overlying mucosa is closed. - The deep tissues of the perineal body are closed with interrupted fine absorbable suture (Fig. 2C-E). Continuous attention to anatomical approximation is critical. More tissue will appear to be present laterally than medially. Attention made to close the dead space as well as to obtain haemostasis is important, as it is for the median closure. - The skin is closed as with the median closure (Fig. 2F). The subcuticular closure is commonly used. Vaginal and rectal examination at the conclusion of the procedure is again important to ensure that no suture has been placed in the rectal mucosa and that the closure is adequate. ### PERINEAL LACERATIONS Although prevention of lacerations has been cited as one indication for performing an episiotomy, it has not, as previously discussed, been a consistent finding when studied further. Care in performance of an episiotomy is clearly necessary to obtain this benefit. The risk of a major laceration by extension of an existing episiotomy can be in the range of 9.5%-13%. ### CAUSES OF PERINEAL LACERATION DURING PARTURITION Lacerations may occur as a result of iatrogenic, fetal, or maternal factors. **Iatrogenic causes:** This include - The use of forceps - Delay in timing or inadequate episiotomy - Uncontrolled delivery, or neglected delivery. **Fetal factors:** The fetal factors include - Large fetal size - Mal-presentation of malposition - Shoulder dystocia - Congenital anomalies. **Maternal factors include** - Contracted pelvis - Congenital pelvic anomalies - Scarring. ### CLASSIFICATION//TYPES OF PERINEAL LACERATION The areas commonly affected Perineum and Posterior Vagina. Injury to the perineum and posterior wall of the vagina is the most common type of laceration that occurs at the time of delivery. Perineal lacerations are defined according to their extent. Some authors do not use the term fourth-degree laceration; instead, they use third-degree complete. In this nomenclature. rupture of the anal sphincter without involvement of the rectum is termed an incomplete third-degree laceration. **TABLE 3. Perineal Lacerations and areas affected** - First degree: Involvement of mucosa and skin only - Second degree: Extension into the submucosa - Third degree: Disruption of the anal sphincter - Fourth degree: Lacerations extending through the rectal mucosa **A first-degree laceration:** A first-degree laceration involves the mucosa and skin only. This type of laceration often does not require repair unless there is uncontrolled bleeding. However, if the laceration exposes a raw surface that may cause increased discomfort, repair may be indicated as well. Repair is performed with fine absorbable suture on a small needle after the area has been properly anesthetized. Interrupted stitches are placed to approximate the torn mucosal edges. **A second-degree laceration**: A second-degree laceration frequently mimics a midline episiotomy and is closed in the same fashion. If the torn edges are jagged, trimming the edges may help. The best anatomical approximation is then made in order to restore anatomy. **A third-degree laceration:** A third-degree laceration involves the deeper structures. The anal sphincter not only is involved but the deep transverse perineal muscle and perhaps the perineal membrane as well. To repair a third-degree extension or laceration, the rectal sphincter and its capsule are first identified. The dead space created around the sphincter should be closed as well. An Allis’s clamp is placed on the capsule of the sphincter and pulled to the midline. Figure-of-eight sutures are placed in the capsule from both sides to approximate the sphincter. The rest of the repair resembles a midline approach. **A fourth-degree laceration:** A fourth-degree laceration disrupts all the previously described tissue planes as well as violates the integrity of the rectum, often creating a cloacal communication between the rectum and vagina. An extension into the rectum is important to recognize. If it is not identified and repaired, the risk of fistula formation is increased. Once the apex of the extension into the rectum has been identified, interrupted sutures of fine absorbable material are placed firmly into the submucosa. A Gelpi's self-retaining retractor is often helpful in identifying the apex of the wound. Generally, a second row of sutures is placed on top of the submucosal layer to give strength to the closure as well as to reapproximate the internal and sphincter. After this, the external anal sphincter and perineal body are closed as previously discussed (Fig. 3). [ IMAGE DESCRIPTON: This figure depicts how a fourth-degree perineal tear is repaired, from the rectal mucosa with interrupted sutures to the second degree laceration. ] Lacerations of the anterior vulva occur frequently in patients in whom the fetal head is forced into the anterior segment of the pelvic outlet during delivery. The lacerations often occur on either side of the midline close to the urethral opening. Pressure alone often controls the bleeding. If suture is needed, a catheter placed in the urethra helps define the urethral margins before closure if these are unclear. Fine suture on an atraumatic needle is necessary for repair. An injury may occasionally extend into the area of the clitoris. The deep and dorsal vessels of this region may bleed excessively. A combination of suture and tamponade is often necessary. The deeper anterior vaginal lacerations involve the urethral supports and occasionally violate the integrity of the pubococcygeal portion of the levator muscles. Deeper damage may involve the bladder itself or the urethrovesical neck. Vesicovaginal fistulas due to pressure necrosis following prolonged labour are still encountered in Third World countries today. ### High Genital Tract Upper vaginal sulcus lacerations occur often in addition to deep perineal tears. These frequently occur as a result of an inadequate episiotomy at the time of operative delivery. These lacerations can be caused by inexpertly directed forceps or the injudicious use of forceps rotation. Higher genital tract lacerations involve the lateral walls of the vagina in the region of the ischial spines or the posterior lateral vaginal wall. Lateral vaginal wall injuries may extend out to the levator ani muscles and in some instances actually detach the origins of this muscle from its insertion on the pubis. Lacerations in the upper posterior vaginal wall may enter the cul-de-sac, providing communication with the peritoneal cavity. The extent of any laceration should be thoroughly determined. Treatment of vaginal sulcus tears can be awkward because of excessive bleeding and difficulty with exposure. Suitable lighting, patient positioning, anaesthesia, and adequate retraction are essential in beginning the repair. Placement of an initial suture as high as possible in the tear, followed by retraction to reach the apex, is often helpful. After repair, a vaginal examination to assess for mucosal defects is imperative in a difficult repair. Repair is at times not adequate for complete haemostasis. In this situation, tamponade by placing a pack in the vagina for 24 hours is especially helpful. Catheter drainage is often necessary secondary to pressure exerted on the urethra. ### CARE OF EPISIOTOMY Daily attention should be directed to the episiotomy. Discomfort should progressively abate. Any evidence of infection is then promptly acted on to avoid such serious complications as necrotizing fasciitis. An episiotomy is a wound, and its care parallels that of any other wound. The perineum needs to be kept clean and dry. Unlike most wounds, cleanliness is made difficult by defecation and micturition. Daily cleansing with soap and water is helpful in keeping the area clean and free from secretions. A squeeze bottle of water to irrigate the perineum has also been found to be helpful for maintaining cleanliness as well as for providing comfort. **Medications:** Many patients with perineal incisions or lacerations require oral analgesics for several days after delivery. The requirements for a good postpartum analgesic are that it be rapid acting and highly effective. It should also allow new mothers to be free of pain but alert and should be safe for patients who are still experiencing pain but are ready to be discharged. Anti-prostaglandins are often sufficient to reduce swelling and offer analgesia. Weak opioids is sometimes necessary initially. Regardless of what drug is used, symptoms should improve daily. **Diet:** Adequate diet rich in protein and vitamins ### COMPLICATIONS As with any surgical procedure, episiotomy is not without risk. Extension of an episiotomy to involve deeper structures, lacerations, excessive blood loss, and infection are some of the immediate complications of episiotomy. Dehiscence of the wound and dyspareunia may occur shortly after discharge from the hospital. A relatively rare complication of endometriosis in an episiotomy scar has been reported. A tender nodule producing cyclic symptoms at the site of an episiotomy is highly suggestive of this phenomenon. ### CIRCUMCISION Circumcision is the surgical removal of the foreskin, which is the skin covering the tip of the penis. The procedure is typically done on a new-born for personal or religious reasons. Circumcision in older children and adults may also be done for the same reasons. Additionally, older children or adults may need circumcision to treat several conditions. **INDICATIONS** - Balanitis (swelling of the foreskin) - Balanoposthitis (inflammation of the tip and foreskin of the penis) - Paraphimosis (inability to return a retracted foreskin to its original position) - Phimosis (inability to retract the foreskin) - In healthy new-borns, there is no medical need for circumcision. If there are health-related reasons to circumcise new born males, most of them are not factors until young adulthood, however, circumcision is a decision best left to parents or to the child himself when he is older. - Doctors can help parents better understand the benefits and risks. Despite rumours to the contrary, circumcision has no effect on a man’s fertility, and there are mixed results from the few studies on how circumcision affects sexual pleasure. Some found no effect, while others found increased sensitivity **Advantages and disadvantages of circumcision** Here are some of the pros and cons of male circumcision. **Advantages of circumcision** - Decreases risk of urinary tract infections in infancy - Decreases risk of sexually transmitted diseases, including female-to-male transmission of HIV - Decreases risk of cervical cancer and some infections in female partners - Prevents balanitis, balanoposthitis, paraphimosis, and phimosis - Makes it easier to maintain good genital hygiene **Disadvantages of circumcision** - May be seen as disfigurement by some - May cause pain, although safe and effective medications may be administered to reduce pain - May cause rare complications, including - cutting the foreskin too long or too short, - poor healing, - bleeding, - infection **Preparation for circumcision** Circumcision may be done while new-borns are still in the hospital or after discharge on outpatient basis. - Different practitioners are trained to perform circumcision in new-borns, including paediatric surgeon, obstetricians, midwives, nurses etc. - Informed consent is obtained from parent(s). - For older children and adults, general anesthesia may be considered. **REQUIREMENTS FOR CIRCUMCISION** - Circumcision set containing at least 4 artery forceps curved and straight, scissors, needle holder, sponge holding forceps - Plastibel of different sizes - Examination gloves - Xylocaine - Water for injection to dilute the xylocain - 5 ml Syringes - Gauze and cotton wool - Kidney dish and gallipot - Savlon (antiseptic lotion) - Drape **PROCEDURE FOR CIRCUMCISION** - Place the child in a supine position with his arms and legs secured. - An anaesthetic agent is given via infiltration to numb the penis. - There are several techniques for performing circumcision. - The choice of which technique is used depends on the physician’s preference and experience. - The three major methods of circumcision are the Gomco clamp, Plastibell device and Mogen clamp. - Each one works by cutting off circulation to the foreskin to prevent bleeding when the doctor cuts the foreskin. - The procedure takes about 15 to 30 minutes. - First, estimate the amount of foreskin to be removed. - The tip of the foreskin is picked with artery forceps, opened via the preputial orifice to reveal the glans underneath and ensures it is normal before bluntly separating the inner lining of the foreskin (Preputial epithelium) from its attachment to the glans. - The foreskin is pulled to show the glans, the glans is inspected before proceeding. - A dorsal slit is made on the foreskin - The circumcision device is placed over the glans and the foreskin pulled over the device and tied firmly to hold the ring in place and to cut off the blood supply. The also serve as a means of securing haemostasis. - Finally, the foreskin is amputated. - The baby is cleaned up and given to the mother after ascertaining that there is bleeding. [ IMAGE DESCRIPTON: This figure shows a diagram explaining the procedure for circumcision including the dorsal slit of the foreskin as well as the frenulum. ] ### FOLLOW UP CARE - After the procedure, the baby may be fussy. - Give prescribed analgesics to decrease any discomfort. - Penicillin ointment is applied on the glans twice daily. - Healing time for a new-born’s circumcision is about 5 to 10 days. - It’s normal for the penis to be slightly red or bruised for a few days after the circumcision. - Educate mother that she can bathe the baby, wash the penis avoid using commercial diaper wipes. - Change diapers often. Rinse the area with water. - Keep the diaper slightly loose to help the tip of the penis heal. **Call the child’s doctor if the child has any of the following:** - continued fussiness (in babies) - increased pain (in children) - trouble with urination - fever - foul-smelling drainage - increased redness or swelling - persistent bleeding - a plastic ring that does not fall off after two weeks ### LABOUR The transition from pregnancy to labour is a sequence of events that often begins gradually. In this transition there are numerous changes that occur both physically and psychologically. Every system in the body is affected and the experience, although not joyous for all, represents a major transition in a woman’s life.. ### Changes during the last few weeks of pregnancy - A number of physical and psychological changes may occur during this period: - Mood swings are common and a surge of energy may be experienced. - 2 to 3 weeks before the onset of labour, the lower uterine segment expands and allows the fetal head to sink lower and it may engage in the pelvis. - When this happens, there is drop in fundal height i.e. the fundus of the uterus descends and there is more room for the lungs, which makes breathing more easy. - The above signs are referred to as lightening. - Lightening is therefore, the relief experienced in pregnancy 2 to 3 weeks before the onset of labour, when the fetus sinks into the pelvis and ceases to press on the diaphragm. [ IMAGE DESCRIPTON: This figure depicts the diagram of a pregnant female showing the difference in position of the fetus before and after lightening. ] - Relief of pressure at the fundus results in an increase in pressure within the pelvis, which may be accounted for by the presence of the fetal head causing venous congestion of the whole pelvis. - The presence of the fetal head in the pelvis results in pressure on the urinary bladder which give rise to frequency of micturition, urgency and some degree of stress incontinence. - Braxton's Hicks' contraction become more intensified and patient becomes more conscious of them. - There is also pain in pelvic girdle and backache due to the relaxation of the pelvic joints (sacroiliac joint). - Braxton's Hicks' contraction and backache could make a patient erroneously believe that she is in labour. - Under hormonal influence, the symphysis pubis widen and the pelvic floor become more relaxed and softened, allowing the uterus to descend further into the pelvis and engagement of the fetal head. - Walking may become more difficult for some women at the end of pregnancy because the symphysis pubis is more mobile. - Vaginal secretion may also increase at this time. - As birth approaches, the non-progressive Braxton Hicks contractions experienced during pregnancy), alter and intensify to become the progressive form of labour. - The cervix, which has remained firm and closed, becomes soft and able to dilate. - Accompanying the physical changes the woman may have feelings of great intensity varying from excited anticipation to fearful expectancy. ### Formation of upper and lower uterine segments By the end of pregnancy, the body of the uterus is described as having divided into two segments. - The upper uterine segment, formed from the body of the fundus - It is thick and muscular and it is mainly concerned with contraction and retraction. - The lower uterine segment formed from the isthmus and the cervix. - It is about 8-10cm long and it is prepared for distension and dilatation. [ IMAGE DESCRIPTON: This image depicts the uterus showing the upper and lower uterine segment including the cervix. ] [ IMAGE DESCRIPTON: This image shows the three stages of labor in a pregnant uterus and shows where the cervix is situated during the stages of labor. ] ### Definitions of Labour - Labour is a process by which the uterus empties its contents after 28th weeks of pregnancy. It entails the contraction and retraction of the uterine muscle fibres, the dilatation of the cervical os and expulsion of the baby, liquor amnii, placenta and membranes. - Labour can also be seen as a physiologic process during which the fetus, placenta, membranes, and umbilical cord are expelled from the uterus. - According to WHO 1997, normal labour has low risk throughout, spontaneous in onset with fetus presenting by the vertex, culminating in the mother and infant in good condition following birth. ### Labour - Normal labour is a sequential pattern that involves painful regular uterine contractions stimulating progressive effacement and dilatation of the cervix with descent of the fetus through the pelvis, culminating in the spontaneous vaginal birth of the baby, followed by the expulsion of the placenta and membranes. - Normal labour can also be seen as that which starts spontaneously at term with the foetus presenting by the vertex and the process is accomplished within 24 hours by unaided maternal effort without any serious injury to the mother and infant. - Labour occurs between 37 and 40 weeks gestation. ### Causes of onset of labour - What initiates labour is not known but many theories have been offered. - Labour starts at term because of the overstretching and over distension of the uterus. - This explains why patients with multiple pregnancy or conditions where there is over-distention of the uterus, e.g. Hydramnios, tend to go into premature labour. - The placenta efficiency is diminished towards term, resulting in reduction in the level of oestrogen and progesterone. - The uterus become more sensitive to the effect of oxytocin from the posterior pituitary gland and the patients goes into labour - There is an increased contractibility of the uterus towards term. - The Braxton Hicks' contraction increase in amplitude and may bring about the onset of labour ### Stages of Labour - There are three stages of labour: - The first, second and third stage #### First stage - This stage take about 12 to 14 hours for primigravidae, and 6 to 10 hours for multigravidae - This consist of latent, active and transitional stage. - **Latent phase:** - This is prior to the active first stage of labour and - It may last 6-8hrs for primigravida (first time mothers) when - the cervix dilates from 0 cm to 3-4cm and the cervical canals shortens from 3cm long to <0.5cm - **Active phase:** - This is the time when the cervix undergoes rapid dilatation. - This begins when the cevix is 3-4cm dilated in the presence of rhythmic contractions. - It is completed when the cervix is about 8cm dilated. - **Transitional phase:** - This is the stage when the cervix is around 8cm dilated until it is fully dilated (or when the expulsive contractions during the second stage are felt by the woman) #### Second stage - This stage starts from the full dilatation of the cervical os to the complete expulsion of the baby from the uterus. - It take about 1 hour for primigravidae and upto 30 minutes for multigavidae #### Third stage - This starts from the when the baby is born. - It entails complete separation and expulsion of the placenta and membranes, usually within 5 to 15 minutes after the birth of the infant. - This stage also involves the control of bleeding. - It last from the birth of the baby until the placenta and membranes have been expelled. - This stage takes between 20-30 minutes, or 5-15 minutes with active management for primigravidae, and 20-30 minutes, or 5-15 minutes with active management for multigravidae. ### Physiology of the first stage of labour The first stage of labour, although difficult to diagnose, is usually recognized by the onset of regular uterine contractions and finally culminates in complete effacement and dilatation of the cervix. Once it commences, its progress is measured by descent of the head and dilatation of the cervix. ### U