Singh and Chaudhary: Neonatal perineal tear: An unusual birth injury with breech presentation


Introduction

Intrauterine perincal tear is a recognized but relatively uncommon, infrequent & life threatening complication of breech presentation. It is more common in babies of primiparous woman than in those of multiparous woman & can theoretically be prevented by caesarean section without a trial of labour.1 In our case report, a female fetus was born at 40 weeks of gestation to a 30 Year old multiparous woman after an uneventful caesarean section. She weighed 4.8 Kg, was 52 cm long & had a head circumference of 35cm. The findings on physical Examination were unremarkable except for a 2nd degree perineal tear & a longitudinal tear on medial side of right labia majora which was repaired immediately under GA. With this case report, we would like to make the reader aware that a perineal injury in a newborn is a potential but rare complication of breech presentation. If it is recognized & treated properly, uneventful recovery is very well possible.

Figure 1

Picture of Second Degree Perineal tear in Neonate on labia separation

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Case Report

A 30 Year old woman G3 P2 L2 with previous two normal deliveries, was admitted to the Labour room of SVBP Hospital, Meerut at 40 weeks of gestation on 03.02.2019 for delivery with breech presentation. S he was referred from District Hospital, Meerut because of breech presentation. She had a History of dai handling for normal vaginal delivery. Dai did her P/V examination & after an hour, she told the patient to go to hospital as the presentation was breech. Her medical history was uneventful & her routine investigations were within normal limit. On P/A examination it was term, good size baby with breech presentation, presenting par t was high up, with regular FHR of 140 bpm & uterine contraction of 1 in 10 of 15-20 seconds.

On P/S exam –No bleeding or leaking was seen

On P/V exam – cervix was 2.5-3 cm dilated, 30-40% effaced, presenting part was buttocks which were high up, not entered in brim, membrane absent, pelvis seemed to be inadequate for the big size baby hence decision for caesarean section was taken. After an uneventful caesarean section (there was no difficulty in extraction of baby or no extension of uterine incision was there), a female baby of weight 4.8 kg was extracted out as breech. Baby cried immediately after birth. Her apgar score was 6 & 8 at 1 & 5 min respectively but the only abnormality on physical examination was 2nd degree perineal tear extending just short of external anal sphincter & a longitudinal tear of about 1 cm on medial side of right labia majora. Both the external & internal sphincter appeared to be intact. Both the tear were not actively bleeding. The laceration was repaired under GA in OT. The vaginal mucosa & perineal muscles were sutured with vicryl 4-0 in a continuous & int errupted manner respectively. The longitudinal tear on right labia majora & perineal skin were sutured with vicryl 4-0 in a mattress fashion. Injection ceftriaxone & metrogyl was given IV as prophylaxis & continued for 7 days. Both the perineal tear & tear on skin healed primarily.

Figure 2

Pictureof Neonate without labiaseparation

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Figure 3

Picture of second degree perineal tear in neonate on labia separation

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Figure 4

Picture of perineal tear repair

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Figure 5

Picture of perineal tear repair

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Review of Literature

A review of literature revealed very few cases reporting a perineal tear during vaginal delivery or caesarean section in breech presentation. This may be because of rarity, but one of the possible explanation can be'underreporting of the problem. The occurance of a severe intrauterine perineal tear sustained by neonate in breech presentation has only been reported once with a lethal outcome.2 A similar case report-was done by 'Irom keshorjit singh' in journal of neonatal surgery in which there was 4th degree perineal tear. The tear was extending from the vagina/ vestibule to the rectum running deep to the perineum about 2cm with devitalised tissues of peri-anal margin & vulva. In this baby loop sigmoid colostomy with perineal tear repair was done.3 Other such case of neonatal rectovaginal tear during caesarean section was reported by 'David et al in boston in which promt administion of antibiotic followed by debridement & primary repair was performed with successful outcome.4

Discussion

Birth injuries are more prone to develop in vaginal delivery in breech presentation. Caesarean section remains the method of choice to avoid these problems.5 But in our case report, Patient was not given trial of labour & immediately was taken for caesarean section, still 2nd degree perineal tear was observed. Several factors which may play a role in the etiology of these lesions might be-Dai handling, repeated maternal vaginal examinations at different places,6 birth weight>4.5kg, manual attempt to rotate a fetus in unfavorable lie, during artificial rupture of membrane or during caesarean section as a result of blunt finger dissection of endometrium if finger penetrates the neonate's perineum or during breech extraction from the maternal pelvis.6

In our case report, the tear in the newborn was recognized in the acute period. It was possible to repair it immediately with no long term complications. So uneventful recovery of perineal tear was very well possible. Based on our experience & reports in literature, primary repair with antibiotics & meticulous wound care can be performed safely in a newborn who sustains a perineal laceration during delivery.6

Conclusion

Our case demonstrates that a serious injury of the genitalia in a female fetus with breech presentation still can occur in uneventful caesarean delivery & without a trial of labour. Hence while doing pervaginal examination in breech presentation or during breech vaginal/caesarean delivery, utmost gentleness should be the aim and if a tear is detected, primary repair has the best outcome. 7

Details of ethical approval

Not Required

Conflict of interest

None

Source of support

Nil

References

1 

B J Zitelli H W Davis Atlas of pediatric physical diagnosis1997St Louis: Mosby-Wolfe3rd ed.

2 

R E Behrman R M Kliegman H B Jenson Nelson textbook of pediatrics16thPhiladelphia: WB Saunders200016th ed. Philadelphia: WB Saunders; 2000.Google Scholar

3 

B Bhat S Jadgish S Srinivasaan Intrauterine perineal tear: Arare birth injuryJ Pediatr Surg19922716141615

4 

D A Lickstein K P Moriarty N R Feins Neonatal rectovaginal tear during cesarean sectionJ Pediatr Surg19983313151316

5 

L Spitz G M Steiner R B Zachary Color atlas of pediatric surgical diagnosis. Chicago: 1981Year Book Medical Publishers

6 

H H Mangurten Birth injuries, in Fanaroff AA, Martin RJ (eds): Neonatal-Perinatal Medicine: Diseases of the Fetus and Infant1987St Louis, MO, Mosby317342St Louis, MO, Mosby

7 

Williams obstetrics25th edition



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