Inversion of the Uterus. Separation of the Symphysis Pubis

The inversion of the uterus is its turning inside out; the mucosa then becomes the outer layer, while the serous coat becomes the internal layer (the uterus is turned inside out like a finger of a glove). It occurs as follows: the uterine fundus is first impressed into the uterine cavity, then it reaches the cervical os, and finally turns inside out to assume a new position in the vagina (or even outside the pudendal cleft).

The uterus inverts under the following conditions: a) the cervical os is open; b) the uterine walls are relaxed (e.g., in hypotony or atony); c) downward thrust on the uterus (e.g., during extrusion of the placenta) or traction, for example, by the cord. The inversion of the uterus is favoured by: 1) a combination of relaxation of the uterine wall and extrusion of the placenta by the Crede-Lazarevich manoeuvre without preliminary massage of the uterine bottom; (2) traction by the umbilical cord with insufficient contraction of the uterus and a wide open cervix.

Inversion of the uterus after delivery is usually accompanied by grave symptoms, such as acute pain in the abdomen and shock.

The skin and the mucosa become pallid, the pulse accelerates, the arterial pressure drops; nausea, vomiting and syncope develop. A bright red inverted uterus appears from the pudendal cleft. Sometimes the uterus is inverted together with the non-separated placenta. A funnel-shaped depression is formed in the lower abdomen. The inversion of the uterus may become the cause of woman’s death.

Treatment. The uterus should be carefully corrected in a heavily anaesthetized patient. The placenta, if any, should be separated from the uterus before restoring its position. The vagina should then be packed with a strip of sterile gauze. Measures to prevent shock and infection should be taken. In case of non-effective restoring the uterus should be extirpated.

Separation of the Symphysis Pubis. During pregnancy the pelvic junctions and ligaments become hydrous due to saturation with serous fluid. This especially holds true for the symphysis pubis. Pelvic junctions may soften considerably in some pregnant. A heavy thrust of the fetal head on the bony ring of the pelvis during labor may cause separation of the symphysis pubis. This is more likely to occur in women with contracted pelvis, giant fetus, and inoperative parturition. Sometimes separation of the symphysis pubis is accompanied by bleeding and injury of the urethra, bladder or clitoris.

The sacroiliac joint may also be affected in complicated (especially operative) labor and delivery.

If the symphysis pubis separates, the woman complains of pain in the region of the symphysis; pain becomes especially annoying on locomotion. The pain intensifies when the legs flexed on the abdomen are abducted. A depression can be palpated between the separated ends of the pubic bones. If necessary, the diagnosis may be confirmed by ultrasound or x-ray examination.

Treatment. Bed rest and tight bandaging of the pelvis are recommended. Bed rest is administered for three or five weeks (sometimes for longer time). The walk in some women is disordered (waddling gait), but this defect is usually corrected in a lapse of time.

Fistulae. Urogenital and rectovaginal fistulae may be formed in pathological labor. Urogenital fistulae are abnormal communications between the bladder and the vagina (vesicovaginal fistulae) or between the urethra and the vagina. An abnormal communication between the bladder and the endocervical canal may be formed in rare cases. In these pathological conditions the urine (or only part of it) is emptied into the vagina and is discharged through the pudendal cleft. Faeces enter the vagina in rectovaginal fistulae. The fistulae are grave complications of labor and cause severe distress in women.

Fistulae are formed due to prolonged compression of the soft tissues of the birth canal and the adjacent organs between the pelvic walls and the presenting part (in contracted pelvis, malpresentations, pathological asynclitism, giant fetus, etc.). The compression upsets a normal circulation of blood in tissues with their subsequent necrosis and rejection. When the necrotized tissues are rejected a communication between the vagina and the rectum or bladder (urethra) is formed and faeces or urine enter the vagina. This usually occurs on the 5^th or 7^th day after delivery.

Fistulae may be formed due to injuries of the soft tissues of reproductive tract and adjacent organs (bladder or rectum) inflicted on the women by the surgical tools used in obstetric operations (destructive operations on the fetus, forceps delivery, etc.). In these cases fistulae are formed immediately after parturition.

The formation of fistulae may be prevented by appropriate conduct of labor. After the loss of amniotic fluid the delay of fetal head moving in one of the pelvic planes for a long time should be excluded. If the head is retained in the inlet, cavity or outlet planes for over two hours, a vaginal examination should be made to establish the diagnosis and to decide which way of parturition is more favourable in a given case. The condition of the bladder should be constantly observed. If urine is retained, the bladder should be catheterized carefully. Even insignificant traces of blood in the urine indicate a threatened fistula and the labor should then be ended operatively.

Fistulae should be treated operatively. Only small fistulae may close spontaneously provided they are managed properly. The treatment then consists in keeping the external genitalia clean, and applying vaseline or other oil, antibiotic emulsion to the external genitalia and to vaginal mucosa (to preclude irritation).

When a urogenital fistula is diagnosed, a permanent catheter for 6-7 days should be inserted into the urethra (the catheter should systematically be removed and sterilized by boiling). Hexamethylenetetramine, antibiotics should be given per os for prophylactic purposes. If the fistula does not close spontaneously, an operation should be made in 4 or 6 months post partum.