Perineal tears during childbirth and other obstetric injuries (obstetric trauma): clinical guidelines

List of Abbreviations

Terms and Definitions

Vulvar laceration – disruption of the integrity of the soft tissues of the vulva during fetal expulsion.

Vaginal laceration – disruption of the integrity of the vagina during fetal expulsion.

Hematoma of the soft tissues of the birth canal - a localized accumulation of blood in closed injuries accompanied by vessel rupture and the formation of a blood-filled cavity.

Perineal laceration – disruption of the integrity of the perineal tissues during the birth of the fetus.

Cervical laceration – disruption of the integrity of the cervix resulting from trauma during the passage of the fetal presenting part.

Uterine inversion – displacement of the uterus in which it partially or completely turns inside out with the mucous membrane facing outward.

Complete uterine rupture – a uterine rupture extending into the abdominal cavity (myometrial and visceral peritoneal injury) or disruption of myometrial integrity with extension of the tear into the urinary bladder, with or without displacement of fetal parts into the maternal abdominal cavity.

Incomplete uterine rupture – disruption of myometrial integrity that does not extend into the abdominal cavity, without disruption of the vesicouterine fold and leaves of the broad ligament, and without rupture of the amniotic sac.

Pubic symphysis – the joint connecting the right and left superior pubic rami with a normal gap of 4 to 5 mm on radiography.

Physiological diastasis of the pubic symphysis – an increase of 2–3 mm due to physiological processes during pregnancy.

Pathological diastasis of the pubic symphysis - separation of the right and left superior pubic rami by more than 10 mm.

Rupture of the pubic symphysis - separation by more than 25 mm with damage to the ligamentous apparatus [3].

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Obstetric trauma - injuries to the birth canal tissues occurring during pregnancy and labor.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

The causes of vulvar lacerations include limited tissue distensibility, delivery of a macrosomic, giant, and/or post-term fetus, rapid and precipitous labor, as well as prolonged labor, malpresentations, a narrow pelvis, breech presentation, tissue rigidity, connective tissue dysplasia, cicatricial or inflammatory changes in the tissues, the use of obstetric operations (application of obstetric forceps, vacuum extractor), or improperly performed perineal protection. Sometimes these traumatic injuries can occur in normal labor without any apparent external cause [2].

Vaginal lacerations occur due to insufficient distensibility of the vaginal walls, genital infantilism, infectious and inflammatory processes, operative delivery, deflexion presentations, a large fetal head, and prolonged labor [2]. As fetal body weight increases, the likelihood of birth injuries increases [4, 5]. Lacerations most commonly occur in the lower third of the vagina, usually concurrently with a perineal tear. The middle third of the vagina, being less fixed and more distensible, is rarely injured. Causes of injury to this part of the vagina during labor may include anatomical features of the wall (scar changes, infantilism, etc.) or obstetric operations (forceps application, vacuum extraction). Detachment of the vaginal fornices may occur spontaneously or, more commonly, as a result of obstetric interventions.

In cases of insufficient tissue elasticity or rapid stretching under the pressure of the fetal head, the perineum becomes thinned, which can lead to its rupture. The main causes of perineal lacerations include: previous alterations in the perineum and external genitalia (may occur on the background of infantilism, due to tissue rigidity in elderly primiparas, or from cicatricial changes following previous tears), rapid passage of the fetal head through the vulvar ring, obstetric operations involving rapid fetal extraction, and passage of the fetal head through the vulvar ring by a larger circumference [2].

During labor, rupture of blood vessels and hemorrhage into the cellular tissue of the external genitalia or beneath the vaginal mucosa may occur. The causes of hematomas are typically vascular wall alterations (increased vessel fragility, varicose veins), rapid labor, tissue compression by the fetal head, and obstetric operations (obstetric forceps, etc.) [2]. In addition, injury may occur during the administration of paracervical or pudendal anesthesia. Hematomas may also form along the wound edge during perineotomy/episiotomy or around tears.

Cervical lacerations are promoted by cervical rigidity, excessive stretching of the margins of the internal os (macrosomic fetus, deflexion presentations of the fetal head), rapid and precipitous labor, prolonged compression of the cervical lips in cephalopelvic disproportion, cicatricial deformity of the cervix, and operative delivery [2]. Tears typically occur on the lateral sides of the cervix, most frequently on the left. Tears are more often noted on the side where the parietal and occipital eminences are located during the flexed position of the fetal head, and the frontal eminences during the deflexed position.

Uterine rupture may be caused by the following: overdistension of the lower uterine segment due to a narrow pelvis, macrosomia, abnormal fetal lie (transverse, oblique) or presentation (frontal, facial), hydrocephalus, tumors of the birth canal (uterine myoma); prolonged labor; uterine scars from prior surgical interventions (uterine perforation, myomectomy, cesarean section, particularly classical). The group of pregnant women at risk for uterine rupture during pregnancy includes: pregnant women with a uterine scar following cesarean section, myomectomy with closure of the myometrial bed, myomectomy with electrosurgical coagulation of the bed after endoscopic intervention, uterine wall repair after perforation, and tubectomy for interstitial ectopic pregnancy; pregnancies following numerous abortions, particularly those complicated by uterine inflammatory processes; grand multiparous women. The group of pregnant women at risk for uterine rupture during labor includes: all the conditions listed in the previous section; pregnant women with a large or giant fetus; abnormal fetal lie (transverse, oblique); anatomically narrow pelvis; anatomical changes of the cervix due to scars after electrosurgical conization/diatermocoagulation, cryodestruction, plastic surgeries; and uterine tumors blocking the pelvic outlet [2].

Uterine rupture occurs with the simultaneous presence of pathological processes in the uterus and some obstacle to fetal expulsion. Pathological changes in the uterine wall are predisposing factors, while mechanical factors are directly acting ones. In the presence of obstacles to fetal expulsion, vigorous uterine activity develops; the upper uterine segment contracts increasingly, and the fetus is progressively displaced into the thin-walled, stretched lower uterine segment. With continuing labor activity, overdistension and thinning of the lower segment reach their utmost limit, resulting in its rupture.

The relationship between the management of the third stage of labor and uterine inversion has not been proven [6], but it is believed that connective tissue dysplasia, uterine atony, and mechanical pressure on the uterus may be risk factors [2].

During pregnancy, a moderate relaxation of the pelvic joints occurs, so the pressure of the fetal head on the bony pelvic ring can lead to separation of the pubic bones. This occurs more frequently in women with a narrow pelvis or in spontaneous births with a macrosomic fetus. In complicated labor and operative interventions (application of obstetric forceps, breech extraction, destructive operations), especially in women with a narrow pelvis, significant separation and rupture of the pubic symphysis may occur. Sometimes, rupture of the pubic symphysis is accompanied by concurrent injury to the urinary bladder and urethra [2].

1.3 Epidemiology of the Disease or Condition

The mother's birth canal undergoes significant stretching during labor, as a result of which it may be injured. Although the frequency of lacerations varies depending on the patient's characteristics and labor management conditions, 53% to 79% of women sustain some type of tear during vaginal delivery [7–9].

The incidence of perineal lacerations currently ranges from 10 to 12%. Episiotomy is not recommended for the prevention of perineal tears. Restricting the use of routine episiotomy reduces third- and fourth-degree tears. Episiotomy has no short- or long-term benefit in preventing the severity of perineal trauma, pelvic floor dysfunction, or pelvic organ prolapse.

Episiotomy is associated with an increased risk of postpartum anal incontinence compared to no episiotomy [10–12], [40], [67].

The incidence of third- and fourth-degree perineal tears in the Russian Federation has decreased by more than 2-fold over the past 15 years (0.34 per 1,000 births in 2005 vs. 0.15 per 1,000 births in 2019). In a number of regions, the incidence of third- and fourth-degree perineal tears has remained high over the past 15 years, reaching a maximum value of 1.78 per 1,000 births.

Cervical lacerations occur in 6–15% of deliveries.

The incidence of uterine rupture in the general patient population is approximately 0.02% [1, 13]. Uterine ruptures account for 0.05–0.1% of all births and are more common in multiparous women. During pregnancy, uterine ruptures occur much less frequently than during labor, accounting for 9.1% (of all uterine ruptures). According to WHO data, the average global incidence of uterine rupture is 0.053–0.07%, or 5.3–7 per 10,000 births, with fairly low rates in developed countries: Australia – 8.6, Canada – 3, Ireland – 2.3, Singapore – 1.6, USA – 0.67–1.3 per 10,000 births, and high rates in developing countries: Nigeria, Ethiopia, Pakistan, Yemen – 50–263 per 10,000 births [14–16].

The incidence of uterine rupture in the Russian Federation has shown an upward trend over the past 15 years (0.14 per 1,000 births in 2005 vs. 0.18 per 1,000 births in 2019). At the same time, attention is drawn to the increasing incidence of out-of-hospital uterine ruptures (25.4% of all uterine ruptures in 2005 vs. 33.2% in 2019). In a number of regions, the incidence of uterine rupture has remained high over the past 15 years, reaching a maximum value of 1.13 per 1,000 births. In Moscow, according to the Organizational and Methodological Department of the Moscow Healthcare Department, the incidence of uterine rupture in 2018 was 3.2 per 10,000 births [12, 13].

1.4 Features of Coding the Disease or Condition

O70 Perineal laceration during delivery

O70.0 First degree perineal laceration during delivery

O70.1 Second degree perineal laceration during delivery

O70.2 Third degree perineal laceration during delivery

O70.3 Fourth degree perineal laceration during delivery

O70.9 Perineal laceration during delivery, unspecified

O71 Other obstetric trauma

O71.0 Rupture of uterus before onset of labour

O71.1 Rupture of uterus during labour

O71.2 Postpartum inversion of uterus

O71.3 Obstetric laceration of cervix

O71.4 Obstetric high vaginal laceration only

O71.5 Other obstetric trauma to pelvic organs

O71.6 Obstetric damage to pelvic joints and ligaments

O71.7 Obstetric pelvic haematoma

O71.8 Other specified obstetric trauma

O71.9 Obstetric trauma, unspecified

O26.7 Subluxation of pubic bone during pregnancy, childbirth and the puerperium

1.5 Classification of the disease or condition

Obstetric uterine traumas are classified into spontaneous and violent ones resulting from obstetric interventions. They are divided into mechanical (associated with tissue overdistension), morphological (caused by histochemical changes in tissues), and mixed (mechanohistopathic) [2].

Types of maternal birth trauma: vulvar tears, vaginal tears, soft tissue hematomas of the birth canal, perineal tears, cervical tears, uterine rupture, uterine inversion, injuries to the pubic symphysis.

I. Classification of vulvar tears:

1.1 By extent:

• superficial;

• deep.

1.2 By location:

• tear of the labia minora;

• tear in the vaginal vestibule area;

• tear in the clitoral area;

• tear of the labia majora.

II. Classification of vaginal tears:

2.1 By extent:

• superficial;

• deep.

2.2 By location:

• tears of the upper third of the vagina;

• tears of the middle third of the vagina;

• tears of the lower third of the vagina.

III. Classification of soft tissue hematomas of the birth canal:

3.1 By location:

• in the labia majora region;

• in the perineal region;

• in the vaginal wall region;

• in the paravaginal tissue region;

• in the gluteal muscle region.

Depending on their location, hematomas are classified as lying above or below the levator ani muscle.

IV. Perineal tears:

4.1 By degree of injury [2]:

• first-degree tear – injury to the skin only;

• second-degree tear – injury to the perineum involving the muscles, but not involving the anal sphincter;

• third-degree tear – injury to the perineum involving the anal sphincter complex:

IIIa – less than 50% of the external anal sphincter.

IIIb – more than 50% of the external anal sphincter.

IIIc – injury to both the external and internal anal sphincters.

• fourth-degree tear – injury to the perineum involving the anal sphincter complex (external and internal) and the rectal mucosa.

V. Cervical lacerations:

• Grade I — cervical laceration on 1 or 2 sides, no more than 2 cm in length.

• Grade II — cervical laceration on 1 or 2 sides, more than 2 cm in length, but not reaching the vaginal vault by 1 cm.

• Grade III — cervical laceration on 1 or 2 sides, reaching the vaginal vault or extending onto it.

VI. Uterine ruptures [13]:

6.1 By etiology and pathogenesis:

• spontaneous (occurring without any external influences):

- mechanical;

- histopathic;

- mixed.

• violent (associated with improperly applied interventions or trauma):

- traumatic;

- mixed.

6.2 By localization:

• in the uterine fundus;

• in the uterine body;

• in the lower uterine segment;

• detachment of the uterus from the vaginal fornices.

6.3 By the nature of the damage:

• complete rupture;

• incomplete rupture.

VII. Uterine inversion:

7.1 Partial (inversion of only the uterine body or its upper third);

7.2 Complete (the entire uterus is inverted outward).

According to the classification of Academician G.M. Savelieva (2020), the following are distinguished [22]:

1. Violent uterine rupture

2. Spontaneous uterine rupture

a. Mechanical

i. Rupture during labor

b. Histopathic

i. Rupture of a scarred uterus

1. Rupture during pregnancy

2. Rupture during labor

ii. Rupture of an unscarred uterus

1. Rupture during pregnancy

2. Rupture during labor

c. Mechano-histopathic

i. Rupture during labor

Violent uterine ruptures differ in pathogenesis from spontaneous ones. Violent ruptures include traumatic ones caused by external trauma, and iatrogenic ones resulting from obstetric procedures performed without proper conditions: applying obstetric forceps to the fetal head positioned higher than the narrow part of the pelvic cavity, or performing vacuum extraction of the fetus [22].

1.6 Clinical presentation of the disease or condition

Upon examination, disruption of the integrity of the soft tissues of the birth canal is detected, with or without bleeding. A sign of vaginal lacerations may be bleeding immediately after delivery [2].

When a hematoma is localized in the vagina, due to a large accumulation of blood, it protrudes into its lumen and fluctuates. A large accumulation of blood causes tissue tension and pain. Clinical symptoms such as pain, a sensation of pressure on the rectum or urinary bladder, and tenesmus are noted. Small hematomas do not cause dysfunction of neighboring organs [2, 13].

Pelvic injuries cause pain in the pubic symphysis, sacrum, and coccyx in the first 3 days of the postpartum period, which intensifies with leg abduction and walking. Gait is impaired.

The main clinical signs of threatened perineal rupture during labor include: perineal bulging, cyanosis, edema, and pallor of the skin. The main clinical sign of perineal rupture is bleeding immediately after the birth of the child. Clinically, a rare type of perineal rupture is distinguished – central perineal rupture, when neither the posterior commissure nor the external anal sphincter is damaged; only the perineal tissues lying between these two boundaries rupture. With this type of perineal injury, the rupture is not always complete – the vaginal tissue and underlying tissues rupture, but the skin remains undamaged. In some cases, the rupture begins from the skin integument, extending to the underlying tissues, but does not reach the vaginal mucosa [13].

Shallow cervical lacerations 0.5–1.0 cm in length are usually asymptomatic, therefore speculum examination of the cervix is mandatory for all postpartum women. Deeper lacerations are accompanied by bleeding of varying intensity. When the descending cervical branch of the uterine artery is damaged, the bleeding is profuse and begins immediately after the birth of the child. The blood flows in a bright red stream, and the bleeding persists even after the delivery of the placenta and with a well-contracted uterus [2].

Characteristic symptoms of uterine inversion: sudden severe lower abdominal pain, signs of shock, uterine bleeding. The inverted uterus protrudes from the vaginal opening. Palpation above the pubic bone in the area of its usual location reveals a funnel. Bleeding may begin before uterine inversion due to uterine hypotonia and continue after the inversion is complete [2].

In threatened mechanical uterine rupture, examination and objective assessment reveal vigorous labor activity; contractions are sharply painful, sometimes becoming spasmodic in nature; the uterus does not relax sufficiently between contractions, is elongated with the fundus deviated from the midline; the lower uterine segment is sharply stretched and thinned; the retraction (boundary) ring rises high, reaching the level of the umbilicus and lying obliquely (the uterus acquires an "hourglass" shape); the condition of the intrauterine fetus suffers, signs of fetal distress appear; spontaneous urination is difficult; on vaginal examination, the edges of the cervix are edematous [13].

Symptoms of threatened uterine rupture are determined by overdistension of the lower uterine segment [22]:

• complaints of painful contractions, if epidural anesthesia has not been performed, and difficulty urinating;

• objectively: high, oblique position of the contraction ring, asymmetrical height of the round ligaments, overdistended bladder palpable above the pubic bone;

• on vaginal examination, the edges of the cervix are edematous, cervical dilation is complete or nearly complete, and there is a significant caput succedaneum on the fetal head.

Symptoms of incipient uterine rupture are associated with the disruption of the integrity of the uterine wall and the formation of a hematoma within it, which brings the signs of rupture close to those of placental abruption (uterine hypertonus, impaired fetal cardiac activity, appearance of bloody discharge from the genital tract). The combination of pressure from a pronounced fetal caput succedaneum on the sacrum and pelvic diaphragm leads to contractions acquiring a "pushing" (expulsive) character. With incipient uterine rupture, blood may not flow from the genital tract (an optional symptom), but its appearance always indicates incipient uterine rupture [22]. In incipient uterine rupture, symptoms of painful shock and external bleeding join the symptoms of threatened rupture, and blood may appear in the urine. The fetus develops tachycardia or bradycardia, motor activity increases, and meconium appears in the amniotic fluid [13].

In complete uterine rupture, the parturient woman typically experiences severe cutting abdominal pain, labor activity ceases, and signs of shock are observed. During uterine rupture, the fetus completely or partially enters the abdominal cavity, and fetal parts are clearly palpable directly beneath the abdominal wall. External bleeding is usually insignificant; blood pours into the abdominal cavity. Intrauterine fetal death is possible [13].

A penetrating complete uterine rupture presents no diagnostic difficulties [22]:

• labor activity ceases, a "quiet phase" sets in;

• signs of painful shock combined with hemorrhagic shock appear, which were present to varying degrees in all parturient women;

• symptoms of fetal hypoxia (most often bradycardia) up to fetal death.

In a non-penetrating rupture, a hematoma forms either beneath the vesicouterine fold (plica vesico-uterina) or between the leaves of the broad ligament of the uterus. Clinical symptoms of a non-penetrating uterine rupture include [22]:

• pain sensations in the lower abdomen in the 3rd stage and/or early postpartum period;

• deterioration of the general condition: weakness, dizziness, tachycardia, hypotension;

• bleeding from the genital tract;

• the diagnosis can be confirmed by palpation and/or ultrasound.

Ruptures of the scarred uterus are becoming dominant in many countries worldwide. There is an obvious direct correlation between the increasing frequency of scar rupture and the ubiquitous progressive growth in the rate of cesarean sections, performed in over 30% of women in Russia, Europe, and the USA. In China and some South American countries, this figure reaches 50–70%. Histopathic uterine rupture is characterized by the absence of clear symptoms and a "blunted" clinical course. Symptoms of histopathic scar rupture during pregnancy [22]:

Threatened uterine rupture along a scar during pregnancy is characterized by complaints of nausea, vomiting, epigastric pain, and lower abdominal pain.

An incipient uterine rupture is defined by a tear of the uterine wall along the scar, with the formation of a hematoma at the rupture site, leading to uterine hypertonus and fetal hypoxia (bradycardia). Bloody discharge may occur, which confirms the diagnosis of incipient uterine rupture in 100% of cases. Characteristic symptoms include abdominal pain without a clear localization, as well as pain in the scar area.

Signs of a completed uterine rupture depend on the localization of the scar and the nature of the uterine integrity disruption: penetrating or non-penetrating; the clinical presentation does not differ from that of mechanical ruptures.

Symptoms of a histopathic uterine rupture along the scar during labor [22]:

Symptoms of a threatened uterine rupture along the scar during labor are similar to those during pregnancy and consist of nausea, vomiting, abdominal pain, and pain in the scar. A specific sign of a threatened uterine rupture along the scar is uterine inertia or uncoordinated labor.

During an incipient uterine rupture along the scar in labor, abdominal pain intensifies, the uterus is in a state of hypertonus, which is accompanied by impaired placental blood flow and fetal hypoxia manifested as bradycardia. A completed uterine rupture along the scar during pregnancy and labor can be either complete (penetrating) or incomplete (non-penetrating).

A completed non-penetrating uterine rupture along the scar is characterized by the formation of a hematoma beneath the uterovesical fold or between the leaves of the broad ligament of the uterus. If this occurs during pregnancy, abdominal pain and pain in the scar area appear against the background of uterine hypertonus and fetal hypoxia. During labor, cessation of labor activity joins the aforementioned symptoms. The volume of the hematoma and the rate of its progression determine the severity of symptoms: weakness, lower abdominal pain, pallor of the skin, and a drop in blood pressure. In a penetrating rupture, the severity of the clinical presentation is determined by the volume of blood loss [22].

Scar dehiscence / aneurysm has a distinct presentation: separation of the scar and translucent bulging, against which fetal parts are presenting. Scar dehiscence / aneurysm can be detected starting from 17 weeks of gestation. Pregnancy is prolonged in such cases. The basis for prenatal diagnostics of this pathology is a lower uterine segment thickness in the area of the suspected scar of less than 1 mm, according to ultrasound examination [23].

Symptoms of uterine rupture diagnosed in the postpartum period: genital bleeding, pronounced pain in all abdominal quadrants, severe pain upon uterine palpation, sometimes absence of placental delivery, possible abdominal distension, nausea, vomiting, the uterine fundus is not clearly contoured (the "masked" uterine fundus sign), a painful mass (hematoma) is palpated along the uterine margin, the appearance of hyperthermia, and symptoms of hemorrhagic and pain shock [13].

2. Diagnostics, medical indications and contraindications for diagnostic methods

Diagnosis of vulvar lacerations is accessible via a visual inspection of the external genitalia.

Diagnosis of vaginal and cervical lacerations is based on the inspection of the birth canal using specula after the completion of the third stage of labor. Inspection reveals a disruption of the soft tissue integrity of the birth canal with or without bleeding [2].

The fact of rupture and the degree of perineal injury are also identified upon inspection of the birth canal. If a grade III-IV perineal tear is suspected, a finger must be inserted into the rectum. An intact sphincter provides resistance when a finger is inserted into the rectum. A tear of the rectal wall is easily identified by the specific appearance of the everted rectal mucosa [2].

When large hematomas form, a thorough rectal and vaginal examination, as well as abdominal palpation, is necessary [2].

The only sign of a cervical laceration is bleeding. If, in the presence of a well-contracted uterus and the absence of external injuries, blood is continuously discharged in a stream immediately after the birth of the child or in the form of a large number of blood clots, a cervical laceration should be suspected [2].

In uterine inversion, the bright red everted uterine mucosa protrudes from the vaginal introitus. Sometimes the uterus inverts with the placenta still attached. Complete uterine inversion may be accompanied by vaginal inversion. In this case, the uterus is located outside the vulva, and the diagnosis is straightforward. With isolated uterine inversion, the uterus is identified in the vagina upon speculum examination. In both cases, the uterus cannot be palpated above the pubic symphysis. With incomplete uterine inversion, the general condition is less severe and deteriorates significantly slower [2].

Diagnostics for threatened, incipient, and completed uterine rupture: see section 1.6.

2.1 Complaints and Anamnesis

Complaints: see section 1.6

2.2 Physical Examination

• In grade III-IV perineal tears, a transrectal digital examination after delivery is recommended to assess the integrity of the rectal wall and its external sphincter [2, 7, 24].

LoR CGoE 4Level of Recommendation C (Grade of Evidence - 4).

• In cases of uterine rupture and grade III cervical laceration, a manual postpartum examination of the uterus is recommended to confirm or exclude uterine rupture [2, 7, 24, 25].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

Comments: During a manual examination of the uterine cavity, special attention should be paid to the left margin of the uterus, as anatomical reasons make ruptures most common in this area.

• Palpation of the pubic symphysis is recommended for all women in labor and postpartum women to detect separation of the pubic bones and symphysitis [2].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

Comment: Attention is paid to the width of the pubic symphysis and its tenderness upon examination. Signs of pubic symphysis injury include edema and tenderness, and a depression between the separated ends of the pubic bones [2, 13]. Pronounced symphysitis may be one of the relative indications for planned delivery via Cesarean section.

2.3 Laboratory Diagnostics

[1]

• In cases of uterine rupture and uterine inversion during labor, a complete blood count (CBC) and platelet count are recommended to assess the presence of bleeding [13].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

Comments: Determining the hemoglobin level is necessary to detect and treat anemia, which helps reduce the risk of adverse outcomes [13].

[1] In case of bleeding in the 3rd stage of labor and the postpartum period, the diagnostic algorithm corresponds to the clinical guidelines "Postpartum Hemorrhage" https://roag-portal.ru/clinical_recommendations

2.4 Instrumental Diagnostics

• In cases of uterine rupture, fetal ultrasound is recommended if the rupture is detected during pregnancy or labor, or pelvic ultrasound if the rupture is detected postpartum, with the purpose of diagnosing uterine rupture [2, 13].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

• To diagnose pubic symphysis diastase, X-ray imaging of the pubic symphysis is recommended [2, 13].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

• In the presence of a soft tissue hematoma of the birth canal, contrast-enhanced magnetic resonance angiography is recommended if surgical methods for stopping bleeding during hematoma evacuation are ineffective [2, 13].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

Comment: Identifying the source of bleeding in the area of the hematoma allows for selective endovascular vessel embolization to achieve sustained hemostasis [13].

2.5 Other Procedures

Not applicable.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1 Non-pharmacological treatments

• In cases of pathological pubic symphysis diastase, bed rest in a side-lying position or in a hammock is recommended [26].

LoR CGoE 4Level of Recommendation C (Grade of Evidence - 4).

Comment: Treatment is prescribed by an orthopedic traumatologist. In case of rupture of the pubic symphysis or significant separation of the pelvic bones, surgical intervention is required [27].

• In cases of pathological pubic symphysis diastase, physiotherapy in the postpartum period is recommended to accelerate repair processes [27].

GCR BLEL 3Recommendation Grade B (Level of Evidence — 3).

Comment: Treatment is prescribed by a physiotherapist.

3.2 Pharmacological treatments

• For grade III–IV perineal tears, the use of laxatives and patient counseling on constipation prevention are recommended [28, 29].

LeveL of Recommendation AGrade of Evidence 2LeveL of Recommendation A (Grade of Evidence - 2).

Comment: Studies demonstrate that the use of laxatives in patients with grade III perineal tears is associated with a significantly earlier and less painful first bowel movement after surgery, and an earlier postpartum hospital discharge compared to delayed defecation. No significant differences were demonstrated in functional outcomes for the anal sphincter or the incidence of wound infections. Laxatives are recommended in the postoperative period. It is recommended to use lactulose** for 10 days post-surgery. Stool softeners and oral laxatives should be prescribed to women with obstetric anal sphincter injuries, and postpartum counseling should include recommendations on avoiding constipation [38].

• In the event of a threatened, incipient, or completed uterine rupture during labor, it is recommended to immediately stop the oxytocin** infusion if it is being administered [1].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

• In cases of pathological pubic symphysis diastase in the postpartum period, oral calcium supplements are recommended [13].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

• In case of pathological diastasis of the pubic symphysis in the postpartum period, the administration of ibuprofen** or paracetamol** as first-line therapy is recommended for pain relief and inflammation management [13, 26, 80].

GCR CLOE 4Grade of Recommendation C (Level of Evidence - 4).

Comment: Therapy is usually started with ibuprofen** 400 mg 3 times daily. Pain management should be combined with bed rest in a lateral position or in a hammock.

3.3 Surgical treatments

• In the presence of vulvar and vaginal lacerations, surgical repair of the lacerations in the early postpartum period is recommended [30].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

Comments: Superficial lesions not accompanied by bleeding do not require intervention. Laceration repair is performed under local infiltrative anesthesia. In deep lacerations of the clitoris with urethral involvement, sutures should be placed without capturing the cavernous tissue (under conditions of urinary bladder catheterization). In certain cases, consultation with a urologist may be required. Potential allergic reactions to local anesthetics must be kept in mind. Following the repair of deep lacerations of the posterior vaginal wall, it is advisable to perform a digital examination of the anterior wall of the anal opening and the ampulla of the rectum to rule out accidental inclusion of their walls in the sutures. If rectal wall involvement in the sutures is detected, all sutures must be removed, the surgical field and the surgeon's hands treated, and gloves changed. Re-establish the integrity of the vaginal tissues with the assistance of an aide. In cases where reliable hemostasis of a vaginal laceration is not achievable, temporary tight packing of the laceration is acceptable. Subsequent management strategy, timing of pack removal, and the need for resuturing are decided on an individual basis. The risk of underestimating blood loss volume when repairing vaginal lacerations must be kept in mind.

• In the presence of soft tissue hematomas of the birth canal in the early postpartum period, an individualized choice of treatment strategy is recommended [81].

LoR CGoE 4Level of Recommendation C (Grade of Evidence - 4).

Comments: For small hematomas, an expectant management strategy is recommended using local hypothermia in the area of the hematoma. If there are no signs of hematoma enlargement and its size is small, conservative treatment is possible. If the hematoma is expanding, surgical treatment is indicated, consisting of opening and ligation of bleeding vessels. Drainage of the hematoma cavity is possible if there is uncertainty regarding the reliability of the achieved hemostasis. Infected hematomas must be opened and managed according to the principles of purulent surgery. The risk of underestimating blood loss must be kept in mind.

• For grade II–IV perineal tears, surgical restoration of the integrity of the vaginal wall and perineal muscles using synthetic absorbable suture material is recommended [30].

GCR ALeE 1Grade of Recommendation A (Level of Evidence - 1).

Comments: The anatomical relationships of the tissues must be restored as accurately as possible. Repair of the perineal tear should be performed immediately after delivery. In case of significant bleeding, placement of a clamp or packing of the tear area is recommended until the delivery of the placenta.

• For grade II–IV perineal tears, surgical restoration of the integrity of the vaginal wall and perineal muscles using continuous sutures is recommended [31].

GCR ALeE 1Grade of Recommendation A (Level of Evidence - 1).

Comments: For grade I perineal tears, surgical restoration of the integrity of the perineal skin can be performed either using suture material or with the application of adhesive glue [32, 33]. Furthermore, in the absence of bleeding and with a small defect size (according to some authors), suturing is not strictly necessary [34]. According to other experts, repair should be performed if there is bleeding or disruption of the anatomy of the external genitalia [35, 36].

• For grade III-IV perineal tears, surgical restoration of the integrity of the anal sphincter and rectum is recommended [35–37].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

Comments: When repairing the rectal wall and anal sphincter, the participation of a coloproctologist or surgeon is optimal. If this is not feasible, the rectal mucosa is sutured first, followed by restoration of the anal sphincter. After performing the repair of a grade III–IV perineal tear, evaluation of anal sphincter function via transrectal digital examination immediately upon completion of the surgical intervention is mandatory. The use of laxatives in patients with grade III perineal tears is associated with a significantly earlier and less painful first postoperative defecation and earlier hospital discharge in the postpartum period compared to delayed defecation. However, no significant differences were demonstrated in anal sphincter function or the rate of wound infections. It is recommended to use lactulose** for 10 days postoperatively. Stool softeners, contact laxatives, and osmotic laxatives should be prescribed to women with obstetric anal sphincter injury, and postpartum counseling should include recommendations on avoiding constipation. Women should avoid excessive physical activity and heavy lifting for 4–6 weeks, after which a gradual increase in physical activity is possible [29, 38, 39].

• For grade II-III cervical tears, surgical repair of the tears is recommended [2, 37, 40].

LeveL of Recommendation AGrade of Evidence 2LeveL of Recommendation A (Grade of Evidence - 2).

Comments: For grade I cervical tears in the absence of signs of bleeding, repair is not always performed. A grade III cervical tear is an indication for manual exploration of the uterine cavity to rule out extension of the tear to the lower segment of the uterine body. In the presence of hematomas in the parametrial tissue associated with a cervical tear, the situation is classified as a uterine rupture, for which laparotomy and intraperitoneal suturing are performed. The extent of surgical intervention is determined on an individual basis by a medical board.

• In cases of threatened, ongoing, or complete uterine rupture, emergency delivery via Cesarean section is recommended [2, 41–43].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

• In cases of uterine rupture during labor and ongoing bleeding, catheterization of peripheral veins in both arms with 14-16G needles is recommended for infusion therapy and blood component transfusion [1].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

• In cases of uterine rupture during labor, urinary bladder catheterization is recommended to monitor urine output [1].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

Comment: When performing Cesarean section for uterine rupture, exteriorization of the uterus from the abdominal cavity and its thorough inspection after fetal extraction are mandatory to rule out uterine wall rupture. Possible surgical options include: suturing the uterine rupture, supracervical hysterectomy, or total hysterectomy with or without adnexa. The extent of the intervention depends on the size and location of the rupture, presence of signs of infection, time elapsed since the uterine rupture, volume of blood loss, and the patient's general condition. Hysterectomy worsens the prognosis and is performed strictly for life-saving indications. The scope of surgical intervention is determined intraoperatively by a medical board.

Comment: The decision to perform a hysterectomy is based on a combination of factors, which include: the patient's future reproductive plans, the degree of uterine damage, intraoperative hemodynamics, and the surgeon's skills in repairing complex ruptures. In all cases of complete uterine rupture, a thorough inspection of the urinary bladder, ureters, and intestines is performed during surgery, along with drainage of the abdominal cavity.

Comment: If manual reposition of uterine inversion is difficult, the use of muscle relaxants is recommended. Following reposition, the physician's hand should not be withdrawn from the cavity of the repositioned uterus until the tone of the uterine walls is restored (but for no more than 15 minutes). Following uterine inversion reposition, the administration of uterotonic agents is required [82].

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Comments: Rehabilitation measures for this group of patients should begin as early as possible, while still in the obstetric inpatient facility, and continue in the outpatient setting after discharge. The duration of the rehabilitation program is individualized and determined by an obstetrician-gynecologist and a medical rehabilitation physician. The complex of rehabilitation measures may include physiotherapy, exercise therapy, and sanatorium-resort treatment [49].

5. Prevention and Dispensary Observation

There is no specific prevention for maternal birth trauma.

Comment: see Clinical Guidelines "Normal Labor" (RUOG, 2021).[1]

Comment: The patient should be able to independently determine the most comfortable position for her in the first and second stages of labor [49].

Comment: Both continuous and intermittent catheterization can be used [49].

Comment: Indications for episiotomy may include: fetal distress, vacuum extraction of the fetus, application of obstetric forceps, shoulder dystocia. Mediolateral episiotomy is preferred over midline episiotomy because midline episiotomy is associated with an increased risk of anal sphincter complex injury; however, existing data suggest that mediolateral episiotomy may lead to perineal pain and dyspareunia [67].

• In cases of grade III–IV perineal tears, antibiotic prophylaxis in the postpartum period is recommended [68–71].

LeveL of Recommendation AGrade of Evidence 2LeveL of Recommendation A (Grade of Evidence - 2).

• In cases of uterine inversion, antibiotic prophylaxis in the postpartum period is recommended [2, 72].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

• For patients with a term singleton pregnancy and a history of uterine rupture during labor, repeat elective CS is recommended no later than 38 weeks [2, 50, 51, 73–79].[2]

LoR CGoE 4Level of Recommendation C (Grade of Evidence - 4).

[1] https://roag-portal.ru/clinical_recommendations

[2] https://roag-portal.ru/clinical_recommendations

6. Organization of Medical Care

As a rule, cases of obstetric trauma are diagnosed while the patient is still in the inpatient facility, in the labor and delivery department or, in rare cases, in the postpartum department.

Indications for hospitalization in an obstetric medical organization:

1) appearance of signs of threatened uterine rupture during pregnancy (emergency hospitalization to the nearest obstetric medical organization);

2) appearance of signs of pubic symphysis injury during pregnancy — for evaluation and selection of a treatment regimen.

Medical care for patients with obstetric trauma during labor is provided on an emergency basis in the medical organization where the delivery took place. Transportation of patients with ongoing bleeding is contraindicated.

The appearance of signs of threatened uterine rupture during pregnancy is an indication for hospitalization in the nearest obstetric medical organization, regardless of the level of medical care provided. In cases of threatened or complete uterine rupture during pregnancy or labor, emergency delivery via cesarean section is indicated in the medical organization where the patient is hospitalized. When providing medical care to a patient with a uterine rupture during pregnancy or labor in group I and II obstetric inpatient facilities, it is indicated to call an obstetric anesthetic and resuscitation team with the mandatory inclusion of an experienced obstetrician-gynecologist skilled in the necessary scope of surgical interventions. The inclusion of other related specialists (vascular surgeon, urologist, etc.) in the mobile team is decided on an individual basis.

Indications for discharging a patient from a medical organization: discharge of postpartum women from the obstetric inpatient facility is carried out according to general rules under the following conditions:

1) absence of hyperthermia (above 37.2°C) and an uncomplicated postoperative course;

2) absence of pathological changes on transabdominal or transvaginal ultrasound of the uterus and appendages;

3) absence of signs of mastitis and lactostasis;

4) absence of signs of inflammation in the suture area.

Discharge is possible with non-absorbable suture material followed by suture removal at the place of residence.

7. Additional Information

With timely and adequate surgical repair of birth canal injuries and appropriate management of the postpartum period, the prognosis is favorable.

In cases of vaginal tears and a complicated postpartum course (secondary healing of sutures), cicatricial deformations of the vaginal walls may develop, increasing the risk of traumatic complications in subsequent deliveries, as well as pelvic floor dysfunction in the long term.

In cases of cervical tears, delayed diagnosis and lack of repair, and a complicated postpartum course (secondary healing of sutures), cicatricial deformations of the cervix and ectropion may form, increasing the risk of traumatic complications in subsequent deliveries.

Uterine rupture is a life-threatening condition for both mother and fetus. Delayed diagnosis and treatment of threatened or complete uterine rupture leads to shock, hemorrhage, and ante- or intrapartum fetal death.

With timely diagnosis and correct treatment of uterine inversion, the prognosis is favorable. If emergency medical care is not provided, a fatal outcome is possible due to shock and hemorrhage, and in the later period, due to purulent-septic complications (peritonitis, sepsis) [2].

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Oleg G. Pekarev – MD, Professor, Deputy Director of the Institute of Obstetrics, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health (Moscow). No conflict of interest.

2. Natalia V. Artymuk – MD, Professor, Head of the Department of Obstetrics and Gynecology named after Professor G.A. Ushakova, Kemerovo State Medical University of the Russian Ministry of Health, Chief Freelance Specialist in Obstetrics and Gynecology of the Russian Ministry of Health in the Siberian Federal District (Kemerovo). There is no conflict of interest.

3. Igor I. Baranov - MD, Professor, Head of the Department of Scientific and Educational Programs, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health (Moscow). No conflict of interest.

4. Nadezhda V. Bashmakova - MD, Professor, Chief Researcher, Research Institute of Maternity and Infancy of the Russian Ministry of Health, Honored Doctor of the Russian Federation, Chief freelance specialist in obstetrics and gynecology of the Russian Ministry of Health in the Ural Federal District (Yekaterinburg). No conflict of interest.

5. Vitaly F. Bezhenar - MD, Professor, Head of the Department of Obstetrics, Gynecology and Reproductology, First Saint Petersburg State Medical University named after Academician I.P. Pavlov of the Russian Ministry of Health, Chief freelance specialist in obstetrics and gynecology of the Russian Ministry of Health in the Northwestern Federal District (Saint Petersburg). No conflict of interest.

6. Tatiana E. Belokrinitskaya - MD, Professor, Head of the Department of Obstetrics and Gynecology of the Faculty of Advanced Training and Professional Retraining, Chita State Medical Academy of the Russian Ministry of Health, Honored Doctor of the Russian Federation, Chief freelance specialist in obstetrics and gynecology of the Russian Ministry of Health in the Far Eastern Federal District (Chita). No conflict of interest.

7. Kirill A. Desyatnik – Obstetrician-gynecologist, Organizational and Methodological Department, Yekaterinburg Clinical Perinatal Center (Yekaterinburg). No conflict of interest.

8. Natalia V. Dolgushina – MD, Professor, Deputy Director – Head of the Department for Organization of Scientific Activities, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health, Chief freelance specialist in women's reproductive health of the Russian Ministry of Health (Moscow). No conflict of interest.

9. Vladimir A. Klimov – PhD, Head of the Medical Care Organization and Information Service, Head of the Department of Medical Care Organization, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health (Moscow). No conflict of interest.

10. Victoria A. Krutova – MD, Professor, Chief Physician of the Clinic, Vice-Rector for Clinical Work, Kuban State University of the Russian Ministry of Health, Chief freelance specialist in obstetrics and gynecology of the Russian Ministry of Health in the Southern Federal District (Krasnodar). No conflict of interest.

11. Anna I. Malyshkina - MD, Professor, Director of the Gorodkov Ivanovo Research Institute of Maternity and Childhood, Head of the Department of Obstetrics and Gynecology, Medical Genetics of the Faculty of Medicine, Ivanovo State Medical Academy of the Russian Ministry of Health, Chief freelance specialist in obstetrics and gynecology of the Russian Ministry of Health in the Central Federal District (Ivanovo). No conflict of interest.

12. Sergey V. Martirosyan – Ph.D. (Medicine), Chief Physician of the Yekaterinburg Clinical Perinatal Center, Associate Professor at the Department of Obstetrics and Gynecology, Faculty of Medicine and Prevention, Ural State Medical University (Yekaterinburg). No conflict of interest.

13. Anton V. Mikhailov - MD, Professor, Chief Physician of Maternity Hospital No. 17, Professor of the Department of Obstetrics and Gynecology, North-Western State Medical University named after I.I. Mechnikov of the Russian Ministry of Health, and the Department of Obstetrics, Gynecology and Perinatology, First Saint Petersburg State Medical University named after Academician I.P. Pavlov of the Russian Ministry of Health, Chief freelance specialist in obstetrics and gynecology of the Russian Ministry of Health in the Northwestern Federal District (Saint Petersburg). No conflict of interest.

14. Anastasia V. Nikolaeva – PhD, Chief Physician, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health (Moscow). No conflict of interest.

15. Anton S. Olenev – PhD, Chief freelance specialist in obstetrics and gynecology of the Moscow Healthcare Department, Head of the Perinatal Center branch of City Clinical Hospital No. 24, Associate Professor of the Department of Obstetrics and Gynecology with a Course in Perinatology, Medical Institute of RUDN University. No conflict of interest.

16. Olga V. Perevozokina – Ph.D. (Medicine), Head of the Organizational and Methodological Department, Yekaterinburg Clinical Perinatal Center (Yekaterinburg). No conflict of interest.

17. Uliana L. Petrova – Postgraduate student, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health (Moscow). No conflict of interest.

18. Vasily A. Petrukhin – MD, Professor, Honored Doctor of the RF, Director of the Moscow Regional Research Institute of Obstetrics and Gynecology (MONIIAG) (Moscow). No conflict of interest.

19. Ivan A. Pryalukhin – PhD, Deputy Head of the Department for Organization of Project Activities, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health (Moscow). No conflict of interest.

20. Viktor E. Radzinsky – Honored Worker of Science of the Russian Federation, MD, Professor, Corresponding Member of the RAS, Head of the Department of Obstetrics and Gynecology with a Course in Perinatology, Peoples' Friendship University of Russia (Moscow). No conflict of interest.

21. Andrey Yu. Romanov – Researcher, Scientometrics Department, Department for Organization of Scientific Activities, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health (Moscow). No conflict of interest.

22. Galina M. Savelieva - Academician of the RAS, MD, Professor, Honored Worker of Science of the RF, Hero of Labour of the Russian Federation (Moscow). No conflict of interest.

23. Vladimir N. Serov - Academician of the RAS, MD, Professor, Honored Worker of Science of the RF, President of the Russian Society of Obstetricians and Gynecologists, Chief Researcher, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health (Moscow). No conflict of interest.

24. Ildar F. Fatkullin - MD, Professor, Honored Worker of Science of the Republic of Tatarstan, Honored Doctor of the Republic of Tatarstan, Head of the Prof. V.S. Gruzdev Department of Obstetrics and Gynecology, Kazan State Medical University of the Russian Ministry of Health, Chief freelance specialist in obstetrics and gynecology of the Russian Ministry of Health in the Volga Federal District (Kazan). No conflict of interest.

25. Elena L. Sheshko - PhD, Head of the Department for Organization of Project Activities, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health (Moscow). No conflict of interest.

26. Roman G. Shmakov - MD, Professor of the RAS, Director of the Institute of Obstetrics, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health, Chief freelance specialist in obstetrics of the Russian Ministry of Health (Moscow). No conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. obstetrician-gynecologists

2. obstetrics and gynecology residents

3. faculty members, researchers.

Table 1. Level of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

Table 2. Scale for assessing levels of reliable evidence (LRE) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, rehabilitation interventions)

Table 3. Grade of Recommendation (GoR) scale for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Appendix A3. Reference Materials

• Federal Law No. 323-FZ of November 21, 2011, «On the Fundamentals of Protecting Citizens' Health in the Russian Federation».

• Collection of the Federal Research Institute for Health Organization and Informatics of the Russian Ministry of Health, "Main indicators of maternal and child health, the activities of the child and maternity welfare services in the Russian Federation", Moscow, 2019.

• Order of the Ministry of Health of the Russian Federation No. 1130n dated October 20, 2020, "On approval of the Procedure for providing medical care in the field of obstetrics and gynecology".

• Order of the Russian Ministry of Health No. 804n dated October 13, 2017 (as amended on April 16, 2019) "On approval of the nomenclature of medical services".

• Letter of the Ministry of Health of the Russian Federation No. 15-4/i/2-2535 dated March 26, 2019, "Prevention, management algorithm, anesthesia, and intensive care in postpartum hemorrhage".

• Clinical guidelines "Singleton childbirth, delivery by caesarean section", Moscow, 2021

• Obstetrics: National Guidelines / ed. by G.M. Savelieva, G.T. Sukhikh, V.N. Serov, V.E. Radzinsky. – 2nd ed. – M.: GEOTAR-Media, 2018.

• Macrosomia: ACOG Practice Bulletin, Number 216. Obstet Gynecol. 2020; 135(1):e18–35.

• Practice Bulletin No. 173 Summary: Fetal Macrosomia. Obstet Gynecol. 2016; 128(5):1191–2.

• Ducarme G., Pizzoferrato A.C., de Tayrac R., Schantz C., Thubert T., Le Ray C., et al. Perineal prevention and protection in obstetrics: CNGOF clinical practice guidelines. J Gynecol Obstet Hum Reprod. 2019; 48(7):455–60.

• Cunnigham F., Leveno K., Bloom S., Spong C., Dashe J., Hoffman B. Williams obstetrics. 24th ed. NY: McGraw-Hill; 2014.

• ACOG committee opinion No. 433: optimal goals for anesthesia care in obstetrics. ACOG Committee on Obstetric Practice.

• Commissioned by the National Institute for Health and Clinical Excellence «Caesarean section» National Collaborating Centre for Women’s and Children’s Health. Commissioned by the National Institute for Health and Clinical Excellence. November 2011

• ACOG Committee Opinion No. 382: Fetal Monitoring Prior to Scheduled Cesarean Delivery. Committee on Obstetric Practice.

• NICE Caesarean section Clinical guideline Published: 23 November 2011Last updated August 2019

• RCOG. Placenta Praevia and Placenta Accreta: Diagnosis and Management: Green-top Guideline No. 27a.

• RCOG. Classification of urgency of caesarean section: a continuum of risk. Good Practice No. 11, April 2010

• The Cochrane Collaboration. Techniques for assisting difficult delivery at caesarean section (Review) 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

• WHO recommendations: uterotonics for the prevention of postpartum haemorrhage. World Health Organization. 2018;53 p.

• Guidelines for Perinatal Care. 8th Edition. ACOG&AAP, 2017

• Antenatal Care. Routine care for the Healthy Pregnant Woman. NICE&NCCWCH, RCOG Press 2008.

Appendix B. Physician Action Algorithms

Management algorithm for a patient with threatened and completed uterine rupture

* in completed vaginal delivery, manual exploration of the uterine cavity should be performed to check the integrity of the uterine walls.

Appendix C. Patient Information

What are the types of sutures?

Sutures are divided into internal and external. There is another type of suture placed on the anterior abdominal wall after a caesarean section.

Internal sutures

This type of suture is applied in case of ruptures of the walls of the vagina, uterus, or its cervix. The procedure is performed immediately after childbirth. Anesthesia is used when repairing vaginal wall tears. Only self-absorbing threads that do not need to be removed are used for internal sutures.

External sutures

This type of suture is applied for perineal tears or incisions. The perineum is sutured under anesthesia.

External sutures can be applied using either self-absorbing threads or those that need to be removed 5 days after placement.

Sutures after caesarean section

Caesarean section is far from rare in medical practice. The surgery can be scheduled electively or performed as an emergency. There are many indications for a caesarean section, ranging from a pathological course of pregnancy to maternal health problems. Emergency caesarean is prescribed in cases where vaginal delivery gets out of control and there is a threat to the life and health of the mother or baby. Cosmetic self-absorbing sutures are often used during caesarean sections. They completely disappear 60 days after placement.

When are sutures applied and what are the causes of tears during childbirth?

Tears during childbirth can be internal—tears of the cervix and vagina, and external—tears and incisions of the perineum.

After a vaginal delivery, an obstetriciangynecologist always checks for tears and performs suturing if necessary.

The causes of tears can vary: failure to follow the obstetrician's advice during the active pushing stage, presence of scar tissue from sutures placed in previous deliveries, precipitate, prolonged, delayed, or operative vaginal delivery, anatomical pelvic features, large fetal head, breech presentation, low skin elasticity by the time of delivery.

In which cases should you consult a doctor immediately?

• If the pain in the suture area becomes sharp and does not stop within an hour. This may indicate that the suture has dehissed.

• If there is unnatural-looking or foul-smelling discharge from the external suture.

• If the abdomen after a caesarean section starts to increase rapidly in size (within a day, for example)—this may indicate fluid accumulation in the abdominal cavity.

• If body temperature exceeds 38 degrees.

• If nausea, weakness, dizziness, and dull severe lower abdominal pain appear.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Not applicable.