Keywords

Obstructed labour, intact perineum, tears, repair.

Introduction

Usually, the study of lower genital tract trauma during parturition is given little importance during undergraduate or postgraduate period, even though the incidence of third and fourth degree perineal tears is 11%.[1] Isolated recto-vaginal tears with intact perineum are rare, small (button-hole) and may go unnoticed unless looked for. They are not included under classification of perineal tears.[²] The following case is being reported not only because of it being a rare presentation of obstructed labour but also to emphasize the importance of the study of pelvic floor anatomy and acquisition of appropriate repairing skills.

Case report

A twenty year old second gravida from a village came to the hospital emergency with nine months pregnancy and labour pains for the last two days. The fetal head could be seen at the vaginal opening as well as through the overdilated anal canal (5.0 cm diameter). The pressure of the fetal head had caused the perineum to overstretch (10 cm from fourchette to anus) but there was no perineal tear (Figure 1). Her previous term pregnancy had terminated in a still birth at home. No other details of her previous labour could be elicited.

Her pulse rate was 92/min, blood pressure was 100/60 mm of Hg, temperature was 1000 F, was pale and dehydrated. Abdomen was distended till xiphisternum but uterine fundus could not be distinctly palpated due to overdistended bladder. After separating the swollen-up vulva, a urinary catheter was inserted in external urethral meatus under all aseptic precaution but the catheter came out through the vagina. Head of the fetus was impacted in the vagina and could be seen through the dilated anus as well, hence she was diagnosed as a case of obstructed labour with extensive urethro-vaginal and recto-vaginal tears or fistulae with an intact perineum and anus.

Inside the emergency operation theatre, general anaesthesia was administered and the perineum was divided completely in the midline from fourchette to anal canal thus converting it to a complete fourth degree perineal tear. A dead baby with separated placenta was delivered. The weight of the baby was 3.4 kg with no apparent congenital anomaly particularly hydrocephalus. Moulding and caput of baby’s head indicated that the pelvis was not adequate for it. After the delivery, the vagina was found to be enormously stretched and dilated suggesting that at least half of the baby had been lying in the vagina itself for a long time. On exploring the vagina, a cystic bladder lump could be felt bulging through all the vaginal fornices and extending till xiphisternum. The uterus could be located only after introducing almost whole of the forearm in the overstretched vagina. It was found lying high up above the bladder lump in the right hypochondrium underneath the subcostal margin and was of sixteen weeks size, well contracted, hard and globular. Whole of the posterior vaginal wall and rectum were torn irregularly just short of posterior fornix. Posterior urethral wall was torn between external urinary meatus and internal urethral opening. Bladder could be catheterized with difficulty by splinting the urethra with a finger in vagina.

Immediate repair of rectum and vagina was done under all aseptic precautions and antibiotic cover. The rectum was repaired in two layers with interrupted vicryl (2-0) sutures. Then the internal and external anal sphincters were identified and stay sutures were placed. Next, the posterior vaginal wall was sutured till fourchette with interrupted vicryl (2-0) sutures. Stay sutures were now tied together (end to end method of repair) so as to approximate the anal sphincters as accurately as possible. This was followed by repair of perineal muscles, subcutaneous tissue and skin. Lastly, posterior urethral wall was repaired over Foley’s catheter with interrupted vicryl (2-0) sutures, taking care not to stitch the catheter.

Post-operatively, the patient was kept on intravenous fluids for forty-eight hours. Clear liquids were started on the third post-operative day. Soft diet along with stool softeners was given on fifth day. Intravenous broad spectrum antibiotic coverage was given for five days. Oral medication and normal diet was started from sixth day onwards. Urinary catheter was retained for 21 days and it was removed after training the bladder. All the wounds healed by primary intention.

She was discharged from the hospital on twenty-third day. She was counseled about the need to have regular follow-up and an elective cesarean section in the next pregnancy due to inadequate pelvis, high rate of recurrence of this condition during subsequent birth and chronicity of complications associated with it. On follow up after one month and three months of discharge, there was no complaint of incontinence of urine, flatus or feces.

Discussion

Old monographs dating back from sixteenth to nineteenth centuries report delivery of small extra uterine fetuses through the anus. [³] In1981, Dawson reported a case of delivery with a hand prolapsing through rectum. [4] In 2007 Thirumagal reported a case of small isolated recto-vaginal tear but the baby delivered vaginally without perineotomy.[5] Various guidelines now emphasize that even without any apparent tear of perineum or anal sphincter, their overstretching during parturition causes occult dehiscence and subsequent weakening in as high as 33% of vaginal deliveries.[2,6] This may cause utero-vaginal prolapse and incontinence later on which may require surgery. Timely repair of tears by a senior person within twenty-four hours, good anatomical approximation and broad spectrum antibiotic coverage is considered essential for satisfactory healing.[2,6] Colostomy is not a prerequisite for healing of ano-rectal tears as has been the practice of ano-rectal surgeons. Further, keeping the patient constipated to prevent soiling of repair is discouraged. In case of delayed, improper or inadequate repair, there can be troublesome wound dehiscence, fistulae and incontinence within two weeks of repair. Chronicity of these conditions despite repeat repair may lead to serious physical and psycho-social problems and even to medico-legal suits. [7] Hence, a thorough training of undergraduate and postgraduate medical students to recognize pelvic floor anatomy and repair of all degrees of tears is advocated. [6, 7 ]

References

1. Dudding TC, Vaizey CJ, Kamm MA: ‘Obstetric anal sphincter injury: incidence, risk factors, and management’. Ann. Surg., 2008 Feb; 247(2):224-37.
2. Grady KM., Howell C, Grady C, Cox C, Howell K ed: ‘Perineal and anal sphincter trauma’. Managing Obstetric Emergencies and Trauma (course manual), 2nd ed. Great Britain, Royal College of Obstetricians and Gynecologists. 2007: p- 349.
3. Gould GM, Pyle WL, ed: ‘Birth by the Rectum’. Anomalies and curiosities of medicine, 1937: 1 page. url : http://www.books.google.co.in/books?isbn=1603032142.[accessed in April’09].
4. Dawson WG: ‘Delivery with prolapse of the childs arm through the rectum and anal canal’. J Obstet Gynecol, 1981; 2 (1): pages 27 – 28.
5. Thirumagal B, Bakour S: ‘Rectal tear during normal vaginal delivery with an intact anal sphincter: a case report’. J Reprod Med., 2007; 52(7):659-60.
6. EJ Adams, RJ Fernando: ‘Management of third- and fourth-degree perineal tears following vaginal delivery’. RCOG Guideline No. 29, 2001: p 1-8.
7. Thakar R, Sultan AH: ‘Management of obstetric anal sphincter injury’. The 0 bst et ri ci a n & Gynaecologist, 2003; 5:72-8.