it includes the prolapse after delivery and its unani management

1. Submitted by :
Nesar KHAN (INTERN)
2K10 BATCH
Under supervision :
Dr. Suboohi Mustafa
DEPARTMENT OF AMRAZ- E- NISWAN WA ATFAL

2. PUERPERIUM
Puerperium is the period following child birth during which the
body tissues specially the pelvic organs revert back
approximately to the pre-pregnant state both anatomically and
physiologically.
Or
Normal puerperium is post delivery six weeks period when
maternal systems return to pre-gravid state. Port abortal
puerperium occurs for 2 weeks.
Duration: puerperium begins as soon as the placenta is expelled
and lasts for approximately 6 weeks when the uterus becomes
regressed almost to the non-pregnant size.
The period is devided into:-
a) immediate- within 24 hours
b) Early- upto 7 days
c) Remote- upto 6 weeks.

3. Post partumuterine prolapse
Uterine prolapse occurs when pelvic floor muscles and
ligaments stretch and weaken, providing inadequate
support for the uterus . The uterus then slips down into
or protrudes out of the vagina.
Uterine prolapse can happen to women of any age, but it
affects post menopausal women who had one or more
vaginal deliveries.
Weakening of the pelvic muscles that leads to uterine
prolapse can be caused by:
1) Damage to supportive tissue during pregnancy and
child birth
2) Effects of gravity
3) Loss of oestrogen

4. The incidence of prolapse is about one in 250
pregnancies.
Prolapse can not occur during pregnancy unless there
is relaxation and tearing of the structures which
support the uterus, together with softening and
elongation of ligament and tissues, the fascia of the
pelvic floor, vaginal and perineal tissues and the
round ligaments.
As pregnancy advances the enlarged uterus enter the
abdominal cavity and prolapsed cervix recede into the
vagina.

5. Causes
1)Birth injury : it is a important cause. A perineal tear
is less harmful than the excessive stretching of the
pelvic floor muscles and ligaments that occur during
child birth because over stretching causes atonicity
where as torn muscle could be stitched or toned up.
2) Peripheral nerve injury: such as pudendal nerve
injury during child birth causes prolapse which is
reversible in 60% and it may be responsible for stress
in continence also.

6. 3) Bear down before full dilatation of the cervix and when
the bladder is not empty.
4) Heavy work just after delivery without any rest or
pelvic floor exercises
5) Ventouse extraction of the fetus before the cervix is
fully dilated can results over stretching of both the
Macken-rodt’s ligaments and the utero sacral ligament
and cause prolapse.
6) Delivery of a big baby also stretches the perineal
muscles and leads to patulous introitus and prolapse.
Precipitate labour and fundal pressure may be
responsible for prolapse.
7) Rapid succession of pregnancies.
8) Loss of pelvic support which results in uterine prolapse
9) Post partum cough

7. Other causes
1) Congenital weakness: congenital weakness of the uterus and vagina is the
most important causative factor of the utero-vaginal prolapse in is
nulliparous women.
2) Acquired defects: in multiparous women overstretching of the ligaments.
3) Menopausal atrophy: After menopause due to withdrawl of oestrogen
there is atrophy of the genital tract and its supports.
In women due to atrophy of the ligamentous supports of the uterus and vagina
prolapse develop.
4) Activating factors: the utero vaginal prolapse is aggravated by-
a) Small fibroids or traction on the uterus.
b) Pelvic tumours.
5) Body type: some women have softer connective tissue than others which
means the ligaments that support your pelvic organs loosen more easily, they
are more prone to stretch during pregnancy and child birth so there may be a
higher risk for developing a prolapse.
6) obesity.

8. Pathology
In case of utero vaginal prolapse due to descent of the
uterus and prolapse of the vaginal walls following
changes may occur-
1) Elongation and hypertrophy of the cervix.
Supra vaginal part of cervix become elongated.
2) Keratinisation of the vaginal epithelium
3) Decubitus ulceration.
4) Incarceration
5) Complication of the urinary tract

9. TYPES OF PROLAPSE
1) Uterine prolapse: it involves prolapse of cervix and
uterus down into the vagina.
2) Vaginal prolapse: it is further divided into-
a) Anterior vaginal wall prolapse
• Upper 2/3rd  cystocele
• Lower 1/3rd  urethrocele CYSTOURETHROCELE
b) Posterior vaginal wall prolapse:
Upper 1/3rd  enterocele
Lower 2/3rd  rectocele

13. DEGREES OF PROLAPSE
Stage I:
The uterus is in the upper half of the vagina.
Stage II:
The uterus has descended nearly to the opening of
the vagina.
Stage III:
Uterus protrudes out of the vagina.
(complete procedentia)- popularly called as
procedentia. In this the vagina is completely inverted.
Stage IV:
Uterus completely out of the vagina.

15. Symptoms
Prolapse can present with or without symptoms after child birth.
Minor degree of genital prolapse may cause severe symptoms.
1) Something coming out of the vagina:
This is the commnest symptoms of genital prolapse and is associated
with feeling of heaviness,weakness.
2)Lower abdominal pain:
Patient may complaints of dull and dragging lower abdominal pain.
3) Backache:
Patient may also complain of low backache which is worse in the
evening.
4) Visible bulge from the vagina
5) Vaginal discharge:
Patients may complain of leucorrhoea.some time discharge may be
blood stained or purulent especially in case of decubitus ulceration.

16. 6) Urinary symptoms:
a) Frequency of micturation- In case of cystocele this is
due to mechanical irritation of trigone of bladder.
b) Difficulty in micturation-In case of a large cystocele
when most of the bladder lies below the level of
urethrovesical junction,then the patient expriences
difficulty in micturation.
c) Stress incontinence.
7)Difficulty of emptying of bowels:
In case of large rectocele the patient complaints of
difficulty to evacuate her bowel unless she manually
puches up the rectocele.
8)Coital difficulties:
In case of 2nd and 3rd degree prolapse due to protrusion of
the prolapse from the introitus penetration may be
become difficult during coitus.

17. SIGNS
utero-vaginal prolapse may be visible during
inspection of the vulva.
In case of minor prolapse it may become visible on
straining.
Rectal examination also differentiate between
rectocele and enterocele.
EFFECTS.
During puerperium
a) Subinvolution
b) Uterine sepsis

18. DIFFERENTIAL DIAGNOSIS
1. Vulval cyst or tumour can be differentiated from
prolapse.
2. Cyst of anterior vaginal wall is usually tense with
well defined margins and can not be reduced on
pressure.
3. Urethral diverticula are rare and situated low down
in the anterior vaginal wall. Urethroscopy help in
the diagnosis.
4. Polypoidal growths.
5. Hypertrophy of the cervix.
6. Vaginitis: congestion of the vagina in case of severe
vaginitis may give the feeling of fullness of vagina.

19. INVESTIGATIONS:
• Haemogram
• Urine examination (routine and microscopic)
• Blood urea
• Blood sugar
• X ray
• ECG
• Urine culture
• High vaginal swab in case of vaginitis

20. PREVENTION
The following measures include:
• PREGNANCY:
a) Women should be adviced to avoid pregnancies in quick succession
b) Pelvic floor exercices throughout the duration of pregnancy
• LABOUR
1ST Stage
a) Bearing down the first stage of labour should be avoided
b) Breech or forceps delivery before full dilatation of cervix should not be attempted
2nd Stage
a) Prolongation of the second stage should be avoided.
b) Episiotomy should be performed when tear or overstretching of perineum
are feared.
3rd Stage
a) Delivery of placenta by compression (crede’s method) should be avoided.
• PUERPERIUM
a) Chronic cough and constipation should be avoided.
b) Pelvic floor exercise should be advised.
c) Strenuous physical activity and standing for prolong period should be avoided at least for
3-6 months after delivery.

21. PROPHYLAXIS OF PROLAPSE:
1. The proper supervision and management of
second stage of labour
2. Low forcep delivery should be restored to if there
is delay in the second stage.
3. A perineal tear must be immediately and
accurately sutured after delivery
4. Postnatal exercises and physiotherapy are
beneficial.

22. TREATMENT
The treatment for uterine prolapse include:
• Surgical
• Non surgical
It depends upon general health, severity of condition and
plans for a future pregnancy.
A. NON SURGICAL TREATMENT:
1. Rest: to advice rest and avoid prolonged standing or
sitting.
2. Ice: used for reducing swelling
3. Elevation: is useful to reduce swelling and alleviate
vaginal discomfort.
4. If mass remains outside it should be covered with
gauze soaked in glycerine and acriflavine.

23. PELVIC FLOOR EXERCISES
Are helpful in promoting pelvic floor recovery after
child birth.pelvic floor exercises are also reduce
prolapse symptoms in mild to moderate
prolapse.pelvic exercises also lift the pelvic floor
muscles to sit higher within the pelvis.
THE KNACK
Is a technique to use to protect the pelvic floor and
prolapseafter childbirth. This technique which involve
a strong lift and squeeze of the pelvic floor muscles
before and during increases in downward pressure on
the pelvic floor(eg-cough ,sneeze). The knack may be
prevent further downward stretch and strain on the
pelvic floor.

24. PESSARY TREATMENT
A pessary is a mechanical device for correcting and controlling
uterovaginal prolapse
TYPES:
There are two types of pessaries which may be used for palliative
treatment of the uterovaginal prolapse.
1.Ring pessaries
Minor degree of prolapse require treatment until the uterus has risen
above the inlet and insertion of a suitable ring pessary is usually
sufficient. vaginal prolapse more marked during pregnancy and may
be treated by a ring pessary.
2.Hodge pessary
This is non paliable S –shaped pessary made of vulcanite or plastic
material.
The pessaries should be sterilised and lubricated before its insertion.

26. B).SURGICAL TREATMENT
This is the only curative treatment of uterovaginal prolapse.unless
there is any contraindication for operative treatment.
OPERATIONS:
1.Anterior colporrhaphy-
This is vaginal repair operation done for cystocele.
2.Posterior colporrhaphy and perineorrhaphy(colpo-
perineorrhaphy)-
Indications-
Rectocele
3.Manchester repair(fothergill’s operation)-
This operation is for repair of uterovaginal prolapse.
Following parts of this operation are-
a)Amputation of the cervix and tightening of the cardinal ligaments.
b)Anterior colporrhaphy
c)colpo-perineorrhaphy.

27. 4.Vaginal hysterectomy,anterior colporrhaphy and
colpo-perineorrhaphy:
This is the most popular for uterovaginal prolapse.
5.Sling operation:
Sling operation are of following types:
a)Shirodkar’s sling operation
b)purandare’s cervicopexy.
c)Sling operation for vaginal vault prolapsed.
6.colpocleisis,le fort’s operation:
This operation was design by Le fort in 1877 from
france.
Indication-the operation is indicated in procedentia with
atrophied but healthy uterus.