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Intrauterine perineal tear: A rare birth injury
Intrauterine
Perineal
By B. Vishnu Bhat, S. Jagdish,
Tear: A Rare Birth Injury
S. Srinivasan,
K.K. Pandey, and H. Chatterjee
Pondicherry, India 0 A rare case of birth injury having intrauterine complete perineal tear is presented. Defunctioning sigmoid colostomy was undertaken because of bad perineal condition. The baby died of Pseudomonas septicemia on the 15th day before definitive surgical procedure could be undertaken. Copyright o 1992 by W.B. Saunders Company
anesthesia reduction of the eviscerated viscus and closure of the abdominal wound was done. The patient developed respiratory distress on the 15th day and died of septicemia. The blood culture grew Pseudomonas aeruginosa resistant to all antibiotics.
DISCUSSION INDEX WORDS: complete.
Birth trauma,
intrauterine;
perineal
tear,
T
HE INCIDENCE of birth injury varies from place to place depending on the obstetric care available.‘,* Although minor soft tissue injuries are more common, rarely one encounters severe injuries requiring immediate surgical intervention. The mortality, morbidity, and the duration of hospital stay are increased even with the occurrence of minor birth trauma.’ Isolated reports of unusual birth injuries are available in the literature.3-7 However, complete perineal tear of the baby as a result of birth trauma has not been reported earlier. CASE REPORT A full-term girl was delivered by cesarean section from a 22-year-old primigravida mother for breech presentation with obstructed labor. The mother did not have any antenatal checkup and was handled by an untrained traditional birth attendant (dai) in her village during labor. The mother was later referred to the nearby hospital from where she was sent to our institute as a case of cervical dystocia with fetal distress. The baby at birth was smeared with thick meconium and had an Apgar score of 2/10 at 1 minute and 7/10 at 10 minutes. She was resuscitated with endotracheal suction and positive-pressure ventilation. She was found to have complete perineal tear with multiple lacerations. There was also contusion and echymosis of the perineal region (Fig 1). The baby had no congenital anomalies. The baby was shifted to the neonatal intensive care service and was put on oxygen, intravenous fluids, injection Ampicillin, and Garamycin. Intravenous Metranidazole was added for anaerobic organisms. She underwent defunctioning sigmoid colostomy and debridment of the perineal wound. Definitive repair was deferred to a later date because of the extensive contamination. The child was put on oral feeds 48 hours after surgery. Unfortunately the skin necrosis in the perineum spread and she developed evisceration of the intestine through paracolostomy wound dehiscence on the 8th postoperative day. Under general
From the Departments of Pediatrics and Pediatrics Surgery, Jawaharlal Institute of Postgraduate Medical Education & Research, Pondicherry, India. Address reprint requests to Dr B. k%hnu Bhat, Associate Professor of Pediatrics and Incharge Neonatal Division, Department of Pediatrics, Jipmer, Pondicheny-605006, India. Copyright o 1992 by WYB. Saunders Company 0022-3468/92/2712-0050$03.00/0 1614
Birth injuries are more common and severe in developing countries due to lack of available trained personnel in the primary care level. Ignorance, illiteracy, and poverty compound the problem. Severe birth trauma are uncommon although case reports like injury to the spinal cord, abdominal viscera and skull bone are available in the literature.3-7 Although trained birth attendants are now increasingly available, the traditional dais, because of their easy accessibility, are more often called to conduct deliveries in rural areas of the developing country like ours. Minor injuries to the genitalia like hemotoma, abrasions, and cellulitis, healing in a few days time have been reported.8 The perineal tear in the mother during parturition is not uncommon. But intrauterine injury to the baby’s perineum causing complete tear has not been reported. The mother in this case said that she underwent repeated vaginal examinations by the dai in her home and later in the hospital, but persistantly denied the use of any instrument in her genital tract. Presumably the repeated vaginal examination had caused the perineal tear. The vagina and rectum in the present case were crushed into one opening without any sphincteric tone. In view of this local condition, it was decided that initial colostomy would be ideal step. However,
Fig 1.
Clinical photograph showing complete perineal tear.
JournalofPediatricSurgety,
Vol27, No 12 (December), 1992: pp 1614-1615
INTRAUTERINE PERINEAL TEAR
the baby died of septicemia a few days subsequent to the procedure. The occurrence of such serious injury can be avoided by adequate training of the traditional birth attendants and developing an effective referral system for the high-risk mothers. REFERENCES 1. Padmini R, Bhat BV, Puri RK: Birth injuries-Incidence, causative factors and outcome. Indian Pediatr 25770-774, 1988 2. Cyr RM, Usher RH, Mclean FH: Changing pattern of birth asphyxia and trauma over 20 years. Am J Obstet Gynecol 148:490498,1984
1615
3. Stern WE, Rand RW: Birth injuries to the spinal cord. Am J Obstet Gynecol78:498-512,1959 4. Erakhis AJ: Abdominal injury related to trauma of birth. Pediatrics 39:421-424,1967 5. Leape LL, Bordy MD: Neonatal rupture of spleen-Report of a case successfully treated after spontaneous cessation of haemorrhage. Pediatrics 47:101-104, 1971 6. Warter CE, Tedeschi LG: Spinal injury and neonatal deathReport of six cases. Am J Obstet Gynecol 106:272-278.1970 7. Bhat BV, Puri RK, Padmini R: Depressed skull fracture in a neonate delivered by Caesarean section. Indian Pediatr 25:485487.1988 (letter) 8. Behrmen RE, Mangurten HH: Birth injuries, in Behrmen RE (ed): Neonatal-Perinatal Medicine-Diseases of the Fetus and Infant. St Louis, MO, Mosby, 1977, pp 146170
Perineal
By B. Vishnu Bhat, S. Jagdish,
Tear: A Rare Birth Injury
S. Srinivasan,
K.K. Pandey, and H. Chatterjee
Pondicherry, India 0 A rare case of birth injury having intrauterine complete perineal tear is presented. Defunctioning sigmoid colostomy was undertaken because of bad perineal condition. The baby died of Pseudomonas septicemia on the 15th day before definitive surgical procedure could be undertaken. Copyright o 1992 by W.B. Saunders Company
anesthesia reduction of the eviscerated viscus and closure of the abdominal wound was done. The patient developed respiratory distress on the 15th day and died of septicemia. The blood culture grew Pseudomonas aeruginosa resistant to all antibiotics.
DISCUSSION INDEX WORDS: complete.
Birth trauma,
intrauterine;
perineal
tear,
T
HE INCIDENCE of birth injury varies from place to place depending on the obstetric care available.‘,* Although minor soft tissue injuries are more common, rarely one encounters severe injuries requiring immediate surgical intervention. The mortality, morbidity, and the duration of hospital stay are increased even with the occurrence of minor birth trauma.’ Isolated reports of unusual birth injuries are available in the literature.3-7 However, complete perineal tear of the baby as a result of birth trauma has not been reported earlier. CASE REPORT A full-term girl was delivered by cesarean section from a 22-year-old primigravida mother for breech presentation with obstructed labor. The mother did not have any antenatal checkup and was handled by an untrained traditional birth attendant (dai) in her village during labor. The mother was later referred to the nearby hospital from where she was sent to our institute as a case of cervical dystocia with fetal distress. The baby at birth was smeared with thick meconium and had an Apgar score of 2/10 at 1 minute and 7/10 at 10 minutes. She was resuscitated with endotracheal suction and positive-pressure ventilation. She was found to have complete perineal tear with multiple lacerations. There was also contusion and echymosis of the perineal region (Fig 1). The baby had no congenital anomalies. The baby was shifted to the neonatal intensive care service and was put on oxygen, intravenous fluids, injection Ampicillin, and Garamycin. Intravenous Metranidazole was added for anaerobic organisms. She underwent defunctioning sigmoid colostomy and debridment of the perineal wound. Definitive repair was deferred to a later date because of the extensive contamination. The child was put on oral feeds 48 hours after surgery. Unfortunately the skin necrosis in the perineum spread and she developed evisceration of the intestine through paracolostomy wound dehiscence on the 8th postoperative day. Under general
From the Departments of Pediatrics and Pediatrics Surgery, Jawaharlal Institute of Postgraduate Medical Education & Research, Pondicherry, India. Address reprint requests to Dr B. k%hnu Bhat, Associate Professor of Pediatrics and Incharge Neonatal Division, Department of Pediatrics, Jipmer, Pondicheny-605006, India. Copyright o 1992 by WYB. Saunders Company 0022-3468/92/2712-0050$03.00/0 1614
Birth injuries are more common and severe in developing countries due to lack of available trained personnel in the primary care level. Ignorance, illiteracy, and poverty compound the problem. Severe birth trauma are uncommon although case reports like injury to the spinal cord, abdominal viscera and skull bone are available in the literature.3-7 Although trained birth attendants are now increasingly available, the traditional dais, because of their easy accessibility, are more often called to conduct deliveries in rural areas of the developing country like ours. Minor injuries to the genitalia like hemotoma, abrasions, and cellulitis, healing in a few days time have been reported.8 The perineal tear in the mother during parturition is not uncommon. But intrauterine injury to the baby’s perineum causing complete tear has not been reported. The mother in this case said that she underwent repeated vaginal examinations by the dai in her home and later in the hospital, but persistantly denied the use of any instrument in her genital tract. Presumably the repeated vaginal examination had caused the perineal tear. The vagina and rectum in the present case were crushed into one opening without any sphincteric tone. In view of this local condition, it was decided that initial colostomy would be ideal step. However,
Fig 1.
Clinical photograph showing complete perineal tear.
JournalofPediatricSurgety,
Vol27, No 12 (December), 1992: pp 1614-1615
INTRAUTERINE PERINEAL TEAR
the baby died of septicemia a few days subsequent to the procedure. The occurrence of such serious injury can be avoided by adequate training of the traditional birth attendants and developing an effective referral system for the high-risk mothers. REFERENCES 1. Padmini R, Bhat BV, Puri RK: Birth injuries-Incidence, causative factors and outcome. Indian Pediatr 25770-774, 1988 2. Cyr RM, Usher RH, Mclean FH: Changing pattern of birth asphyxia and trauma over 20 years. Am J Obstet Gynecol 148:490498,1984
1615
3. Stern WE, Rand RW: Birth injuries to the spinal cord. Am J Obstet Gynecol78:498-512,1959 4. Erakhis AJ: Abdominal injury related to trauma of birth. Pediatrics 39:421-424,1967 5. Leape LL, Bordy MD: Neonatal rupture of spleen-Report of a case successfully treated after spontaneous cessation of haemorrhage. Pediatrics 47:101-104, 1971 6. Warter CE, Tedeschi LG: Spinal injury and neonatal deathReport of six cases. Am J Obstet Gynecol 106:272-278.1970 7. Bhat BV, Puri RK, Padmini R: Depressed skull fracture in a neonate delivered by Caesarean section. Indian Pediatr 25:485487.1988 (letter) 8. Behrmen RE, Mangurten HH: Birth injuries, in Behrmen RE (ed): Neonatal-Perinatal Medicine-Diseases of the Fetus and Infant. St Louis, MO, Mosby, 1977, pp 146170