THE CANADIAN MEDICAL ASSOCIATION

PARTURITION should be looked upon as aphysiological exercise. Ordinarily, when vaginal

delivery takes place for the first time, a permanentchange in the soft tissues of the birth canal isbrought about. Ideally, the narrowness and com-parable rigidity of the parts are overcome and acondition of more pliable and physiologic relaxationis established. This "multiparous state" should beone of asymptomatic change associated with com-fortable function.These self-evident facts have on occasion given

the erroneous impression to some of our less en-lightened brethren that the specialty of obstetricsand gynecology is quite simple and mundane.However, those who practise the obstetric art knowwell that in relation to every pregnancy the possi-bility exists of dangers and complications sufficientlyserious and spectacular to rank among the mostimportant in all phases of medicine in terms of thedemands they make for immediate and skilfulhandling.Most of these complications will be encountered

and must be taken care of at the delivery table orin the immediate postpartum stage. However, thispaper has to do with the consequences of obstetri-cal delivery which require gynecological treatmentat a later time. Generally speaking, these are dueto obstetrical injury. Some are preventable whileothers occur as a result of congenital weakness ofimportant supporting structures which stretch andtear with inordinate ease. The accumulation of thosedefects of tissue integrity results in uterine pro-lapse, which is seen occasionally even in the nulli-parous woman.Some of the more important of the lesions in this

category are as follows:A. Uterus

1. Cervical canal incompetence.2. Prolapse.

From the Department of Obstetrics and Gynecology, Uni-versity of Pittsburgh School of Medicine and the Magee-Womens Hospital, Pittsburgh 13. Pennsylvania. U.S.A.Presented at the 95th Annual Meeting of the canadianMedical Association, Winnipeg, Manitoba, June 20, 1962.

ABSTRACT

Parturition should be looked upon as aphysiological exercise, and ideally the multi-parous state should be one of asymptomaticchange associated with comfortable func-tion. However, because obstetrics is a fieldin which serious complications may suddenlyoccur, the ideal is not always possible.Among the delayed effects of delivery is agroup of gynecological complications whichmay affect the well-being of the woman soinvolved in later life. Such complicationsas uterine prolapse, cystocele, rectocele,enterocele, and genital fistula may be thegrim aftermath of poor obstetric practice.The article reviews some of the advances

in the prevention of maternal mortality andmorbidity and emphasizes the importantplace of intelligent conservative obstetricsin the hands of both general physicians andspecialists.

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178 McCAu.: GYNECOLOGICAL ASPECTS OF OI3s.rEmIcAx.. D.uviiiiy

The etiological background is often that of rapidand traumatic stretching of the cervix. This may bedue to overzealous dilation for curettement orabortion, or to precipitate delivery. The inexcusableprocedures of too rapid medical induction withoxytocic agents, or of forceps and version opera-tions through the incompletely dilated cervix, arepernicious examples of such etiological factors.The therapy for this complication is surgical,

the aim being to correct the defect at the internalos. This may be done in the non-pregnant state bymeans of the technique of Lash or during earlypregnancy by Shirodkar's procedure. The ideal timeto perform the latter is between the fourteenth andtwentieth weeks of gestation, after it has beenascertained that a normal pregnancy is indeedpresent. This approach has been used with greatsuccess in many clinics, including our own,especially when Mersiline* suture is utilized. Itshould be used only in those patients who havedemonstrated cervical incompetence by previousmid-trimester abortion, for which there is no otheretiology. It has no place in the management of earlyabortion and should never be attempted before 14weeks of gestation have passed. At term the babymay be delivered by Cesarean section or the suturecut and normal vaginal delivery allowed to proceed.

Prolapse of the uterus is the result of partialunfastening and stretching of its moorings. Thebladder is dragged downward as the relaxingcardinal ligaments allow the uterus and cervix todescend and allow the cul-de-sac of Douglas todeepen with the formation of an enterocele. Poorobstetric judgment in the timing of the deliveryand uncalled-for operative manipulation frequentlycontribute to this complication. As the variousdegrees of prolapse develop, the patient becomesincreasingly uncomfortable. Prolapse may beassociated on the one hand with an inordinatelyprolonged second stage of labour; and on the otherwith premature delivery, by an impatient or in-capable operator, of the incompletely descendedfetus through a partially dilated cervix.The question often arises how prolapse of the

uterus should be treated in the woman of child-bearing age. In the young woman who wishes tobear further children, every attempt should bemade to delay the definitive surgical procedureswhich are curative. Depending upon the severity ofsymptoms, these patients may be prepared psycho-logically by the physician to put up with the ab-normality and some may be fitted with a pessaryto be worn during the day. If the symptoms areunbearable, a procedure similar to the Manchesteroperation may be performed which corrects theprolapse by shortening the cardinal ligaments.Correction of cystocele and associated perinealrelaxation should be carried out as indicated.Ordinarily, the cervix is amputated in this pro-cedure, but in the very young woman desiring

*Ethlcon suture. Ethicon, Inc., Somerville, New Jersey.

Canad. Med. Ass. J.Jan. 26, 1963, vol. 88

further family, only a minimum of cervical tissueshould be removed so as not to disturb the internalos or render it incompetent. With these precautions,normal pregnancy usually takes place and sub-sequent recurrence of prolapse may be avoidedby the intelligent use of Cesarean section.On the other hand, the patient with severe

symptoms and a good-sized family, and especiallythe woman who is nearing the end of her reproduc-tive period, should be offered a more definitiveoperation. In my opinion, the best results are ob-tained by employing vaginal hysterectomy and theappropriate plastic procedures to overcome cysto-cele, rectocele, and enterocele (posterior culdo-plasty). Such an approach restores the normalgynecological milieu and allows the excision of theredundant uterus which so often is the site ofbenign or malignant disease later on.Of distal posterior vaginal wall and perineal

injuries, none is as d.bffitating and embarrassing asthe complete tear through the anal sphincter andlower rectum. This injury should be recognizedimmediately following delivery and repaired atonce. Traumatic forceps manipulation, poor choiceof the type of episiotomy used, and too rapid ex-pulsion of the baby are the common causes of thisinjury. Carefully controlled gradual delivery of thepresenting part is a sine qua non of good obstetrics.When such technique is utilized, it becomes ap-parent whether episiotomy is needed and, if so,how extensive the incision of the perineum shouldbe. In recent times quite a fetish has been madeof the midline episiotomy. We use it frequentlyon our service, and there can be no question thatit is the easiest to repair anatomically and oftenis associated with minimal discomfort in thepuerperium. On the other hand, when more roomis needed for graceful delivery than exists betweenthe posterior fourchette and the anus, a deep andadequate medio-lateral incision should be made.Every physician who does obstetrics should exercisejudgment in this respect and know how to repairthis type of episiotomy perfectly. The specialistwho deliberately invites the third-degree tear isnot the obstetrician he should be.

If immediate and adequate repair of the com-plete anal tear is not accomplished at the deliverytable, the patient is destined to live a life of dis-comfort, embarrassment and isolation until it isrepaired (Figs. 1-4).

Vaginal fistula, either between bladder andvagina or rectum and vagina, fortunately has be-come an infrequent complication of obstetricdelivery. In the day of J. Marion Sims, the greatSoutherner who became known as the "father ofmodern operative gynecology," vesicovaginalfistula developed not uncommonly after prolongedsecond stage of labour. His ingenious methods, re-ported in 1852, were among the earliest to cure thiscondition. Today, most vesicovaginal fistulas occurfollowing surgical procedures, and only where poorobstetrics is practised does more than an occasional

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Canad. Med. Ass. 3.Jan. 26, 1963, vol. 88

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180 McCall: Gynecological Aspects of Obstetrical Delivery Canad. Med. Ass. J.Jan. 26, 1963, vol. 88

Fig. 5..A small cuff is left around the flstula opening andthe bladder is dissected widely to alleviate tension whensutures are placed.

(b) Await the return of pliability of thesurrounding tissues by allowing sufBcienttime to pass, or produce it with the use

of cortisone substances.(c) Local estrogens may be used efficaciously

in older women with fistulas of long-standing.

(d) Treat vigorously any local bladder infec-tion.

2. Good exposure.(a) The Schuchardt incision may be helpful.(b) The bladder should be dissected widely.

3. Placement of sutures without tension.4. Inversion of a small cuff about the flstula

opening.5. Interposition of a soft vascular tissue between

the bladder closure and the vaginal mucosa.

(a) A bulbocavernosus fat-flap often is help¬ful.

Recto-vaginal fistula is also a problem of import-ance. Prolonged second stage labour may be, butis less likely to be, causative. Forceps trauma andoperative mistakes at the upper reaches of episi-otomy wounds are more common etiological factors.Ischemic areas may develop owing to sutures mal-placed in the rectum itself. As with the repair ofbladder fistula, careful mobilization after adequatepreoperative preparations and the use of bulbo¬cavernosus fat-flap plastic procedures are mostuseful. In the case of a very large rectovaginalfistula, where much of the posterior vaginal wallhas sloughed, the performance of colostomy pre-liminary to definitive repair is mandatory. The con-

tinuity of the bowel is then re-established aftercomplete vaginal healing has taken place.DiscussionAs we contemplate the gynecological complica¬

tions that stem from obstetrical delivery, it isrelieving to note that such injuries are becomingless and less common.

:^^t^Si0^PPig. $..After closure of the fistula, a bulbocavernosus fat-

flap is made with its blood supply intact. A tunnel is madebetween the two areas of dissection.

Fig. 7..The fat-flap is swung- over the suture line in thebladder. The vaginal mucosa will now be closed over all andthe incision over the right labium majus brought togetherwith interrupted sutures.

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Canad. Med. ABS. J.Jan. 26, 1963, vol. 88

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