19.1

Gynecologic Trauma and Emergencies

Chapter 19

Gynecologic Trauma and Emergencies

Introduction

The current active duty population consists of 14% women,

many of whom are subject to the same risks of combat injury as

their male colleagues. This chapter deals with OB/GYN

emergencies that may present to a deployed medical treatment

facility (MTF), particularly in military operations other than war

(MOOTW).

Gynecologic Trauma

Vulva

 Vulvar injuries include lacerations and hematomas.

ο Lacerations that are superficial, clean, and less than 6 hours

old can be primarily closed with absorbable suture.

Debridement of obviously devitalized tissue is

recommended.

♦ Deep lacerations should be examined and explored to

rule out urethral, anal, rectal mucosa, or periclitoral

injuries.

♦ Placing a urethral catheter will assist in determining

injury. If found, single-layer closure with fine (4-0 or

smaller), absorbable suture, leaving the catheter in place,

is recommended. Rectal and periclitoral injuries are

closed in a similar fashion.

♦ Anal lacerations should be repaired by approximating

the cut ends of the anal sphincter with size 0 or 1

absorbable suture.

♦ Antibiotics (2nd generation cephalosporin) are

recommended with contaminated wounds.
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Emergency War Surgery

 Vulvar trauma may cause infrafascial (below the pelvic

diaphragm) hematoma.

ο Because the deeper layer of subcutaneous vulvar fascia is

not attached anteriorly to the pubic rami, hematoma can

spread freely into the anterior abdominal wall.

ο Most vulvar hematomas are treated conservatively.

ο External compression and ice packs should be applied

until hemostasis is ensured by serial examination of the

vulva, vagina, and rectum.

ο Signs of shock in association with a decreasing

hematocrit should prompt consideration of extraperitoneal expansion. Ultrasound or computed tomography

is useful for detecting expansion not diagnosed by clinical

exam.

A vulvar hematoma continuing to expand despite

external pressure, or presenting acutely with a size

greater than 10 cm, should be incised and evacuated, with

ligation of bleeding vessels and packing placed to secure

hemostasis.

Vagina

 Trauma to the vagina can cause lacerations, and less

commonly, suprafascial (above the pelvic diaphragm)

hematoma.

 Vaginal trauma has been reported in approximately 3.5% of

women with traumatic pelvic fractures. Concomitant

urologic trauma, most often involving the bladder and/or

urethra, has been described in about 30% of patients with

vaginal trauma.

 Thorough inspection and palpation of the vagina and

rectovaginal exam are necessary for detection of vaginal

trauma and to determine the need for further urologic

evaluation/imaging. Due to pelvic instability (in fracture

cases) or pain, examination under sedation or anesthesia

may be necessary.

 Patients with vaginal lacerations typically present with

bleeding, sometimes profusely, from the well-vascularized

vagina.
19.3

Gynecologic Trauma and Emergencies

 Lacerations are repaired using the guidelines given above

for vulvar lacerations.

 Vaginal hematoma is usually accompanied by severe rectal

pressure and is diagnosed by palpation of a firm, tender mass

bulging into the lateral vagina. Vaginal hematoma should

be treated by incision, evacuation, ligation, and packing.

 Unrecognized vaginal trauma can result in dyspareunia,

pelvic abscess, and fistula formation.

Uterus/Cervix

 Trauma to the uterus and cervix is most commonly found in

association with pregnancy, but may be seen as a result of

penetrating vaginal or abdominal trauma.

 Noninfected simple cervical lacerations should be repaired

to optimize restoration of normal anatomy (and possibly

decrease the risk of cervical incompetence or stenosis with

dysmenorrhea from poor healing). Absorbable 0 grade suture

can be used.

 Acute penetrating trauma involving the uterine fundus

usually causes little bleeding and can be managed expectantly

without repair. Damage to the uterine wall with bleeding can

be repaired with size 0 absorbable suture.

 Trauma involving the lateral wall of the uterus may cause

significant bleeding, but can usually be controlled by

successive ligation of the ascending and descending branches

of the uterine artery as described below in the obstetrical

section “uterine atony.”

Hemorrhage not responding to ligation, or extensive

mutilating damage to the cervix or uterus, is best treated

by hysterectomy.

 Prophylactic antibiotics should be given. Adnexa should be

retained unless there is an indication for removal (see next

page).
19.4

Emergency War Surgery

Basic steps for performing an emergent total

abdominal hysterectomy.

 Ligate/cauterize round ligaments (Fig. 19-1).

 Incise anterior leaves of broad ligaments bilaterally, then

continue across midline to incise vesicouterine fold.

 Mobilize bladder downward by blunt dissection (and

sharp dissection if necessary) from lower uterine

segment and cervix.*

 To retain adnexa, clamp/cut/ligate utero-ovarian

ligaments and fallopian tubes near their connections to

uterine fundus (Fig. 19-2).

 To remove adnexa with uterus, clamp/cut/ligate

infundibulopelvic ligaments after making windows in

posterior leaves of broad ligaments above ureters.

 Incise posterior peritoneum to mobilize adnexa either

away from (if being retained) or toward (if being

removed) uterus.

 Incise peritoneum overlying rectovaginal space, then

mobilize rectum downward and away from posterior

vagina by blunt dissection (Fig. 19-3).*

 Clamp/cut/ligate uterine arteries along lateral surface

of uterus at uterocervical junction, staying within 1 cm

of uterus to avoid damaging ureters.

 Clamp/cut/ ligate remainder of cardinal ligaments,

paracervical tissue, and uterosacral ligaments by taking

successive inferior bites until cervicovaginal junction

is reached; each bite should be placed medial to previous

bite to avoid injuring ureter and bladder.

 Crossclamp vagina below cervix.

 Transect vagina, removing uterus (and attached adnexa,

if applicable).

 Suture vaginal cuff closed, ensuring bladder is not

incorporated.

*In case of dense adhesions between cervix and bladder or rectum in

emergent setting, or ongoing hemorrhage with poor visualization,

supracervical hysterectomy can be performed. After mobilizing bladder

and rectum from uterus and ligating uterine arteries, uterine fundus is

transected from cervix with a knife. Cervix is then oversewn with a baseball

stitch, staying medial to ligated uterine arteries.
19.5

Gynecologic Trauma and Emergencies

Fig. 19-1. Abdominal hysterectomy anterior view.

X Broad Ligament

Round Ligament

Ovary

Fallopian Tube Utero-Ovarian

Ligament

X: Location to Incise

Peritoneum and Enter Vesicocervical

Uterine Space

Anterior View

X

Bladder

Utero-Ovarian Ligament

Round

Ligament,

Ligated

Adnexal View

Fallopian Tube

Location for Ligation if Adnexum Retained

Infundibulopelvic

Ligament

Location for Ligation

if Adnexum

Removed

Window in Posterior Leaf of Broad Ligament

Ovary

Ureter

Fig. 19-2. Abdominal hysterectomy adnexal view.

Adnexa

 Fallopian Tubes.

ο Damage to the wall of the fallopian tube by ruptured

ectopic pregnancy or penetrating abdominal trauma

should be treated by salpingectomy if there is significant

damage to the tube, due to the risk of subsequent or recurrent ectopic pregnancy if left in situ. If the damage is
19.6

Emergency War Surgery

equivalent to a linear salpingotomy (see below), achieve

hemostasis, then allow healing by secondary intention.

ο The mesosalpinx is ligated or cauterized, then the tube

ligated and cut at its connection with the uterine fundus.

ο Unruptured ampullary/isthmic ectopic pregnancy can be

treated by linear salpingotomy, with extraction of the

ectopic gestation. The tubal incision is left open to heal by

secondary intention.

ο An unruptured or ruptured corneal/interstitial ectopic

pregnancy requires wedge resection of the uterine

cornuum with salpingectomy.

ο An ectopic pregnancy spontaneously aborted into the

abdominal cavity through the end of the tube should be

removed, but the tube may be left in situ if hemostasis is

attained.

 Ovaries.

ο A ruptured ovarian cyst should be treated via cystectomy

by shelling the cyst wall out of the ovary, then cauterizing

or ligating any bleeding vessels, usually at the base of the

cyst.

Fig. 19-3. Abdominal hysterectomy posterior view.

X

Posterior View

Cardinal Ligament

Infundibulopelvic

Ligament

Ureter

Uterosacral Ligament

X: Location to Incise Peritoneum

and Enter Rectovaginal Space

Rectosigmoid Colon

Uterus
19.7

Gynecologic Trauma and Emergencies

ο Torsion of an ovarian mass is first treated by assessing

the ovary. Untwist the ovary and or fallopian tube. If it

appears healthy with some continuing blood supply, it can

be left in situ. If the ovary contains a large (> 4 cm) simple

appearing cyst, the cyst can be drained and the cyst wall

removed. Interrupted sutures using a fine monofilament

or electrocautery can be used to obtain hemostasis. If the

ovary appears dark and dusky after untwisting, perform

a salpingo-oophorectomy by ligating the infundibulopelvic ligament first (after identifying the ureter), then

the utero-ovarian ligament and fallopian tube.

ο Hemorrhage from an infundibulopelvic ligament, as a

result of penetrating abdominal trauma, is best treated by

ligation with salpingo-oophorectomy.

Retroperitoneal Hematoma

 Laceration of an arterial branch of the hypogastric artery

can cause a retroperitoneal hematoma.

 A large amount of blood may collect in the broad ligament

with few symptoms. Dissection of the hematoma can extend

up to the level of the renal vessels. The hematoma may be

discovered during emergency surgery for trauma or during

re-operation or post pelvic surgery, or can be prompted by

signs of shock suggesting internal bleeding.

 Retroperitoneal hematoma can be treated by hypogastric

artery ligation on the affected side. Bilateral hypogastric

artery ligation may be necessary for hemostasis. The uterus,

tubes and ovaries may be left in situ if viable and without

other indication for removal.

Gynecologic/Obstetric Emergencies

 Acute Vaginal Hemorrhage Unrelated to Trauma.

ο Bright red vaginal bleeding filling more than one large

perineal pad per hour is considered vaginal hemorrhage.

A pregnancy test and pelvic exam direct initial therapy.

♦ If the patient is not pregnant, hormonal management

with 25 mg IV Premarin or 50 mcg estrogen-containing

oral birth control pills (OCPs) should be given every 6

hours.
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Emergency War Surgery

◊ If the bleeding responds to hormonal management,

OCPs should be continued qid for 5–7 days while

more definitive diagnosis and management plans are

made.

◊ If the bleeding has not decreased significantly within

24 hours, dilatation and curettage is reasonable. If

the heavy bleeding continues, imaging studies and

possibly coagulation studies will be needed to help

direct further therapy.

♦ In the pregnant patient, heavy bleeding from the

cervical os with uterine size < 20 weeks (fundus at/or

below the level of patient’s umbilicus) suggests

spontaneous abortion. Dilatation and suction curettage

should be performed.

◊ Ectopic pregnancy uncommonly presents with acute

hemorrhage, but should be considered if the patient

has an acute abdomen or if scant tissue is obtained

on curettage.

◊ In a pregnant patient with uterine size consistent with

a third trimester gestation (> 4 cm above the

umbilicus in a singleton pregnancy), vaginal

hemorrhage is usually an indication of placental

abruption or placenta previa.

◊ Emergent cesarean section will be necessary if the

uterine hemorrhage does not spontaneously resolve

within several minutes.

◊ After delivery of the fetus and placenta, persistent

hemorrhage unresponsive to more conservative

measures may require hysterectomy (see emergent

cesarean and uterine atony below).

◊ Pregnant patients (mothers) with acute vaginal

hemorrhage who have Rh negative bloodtype, or if

their Rh status is unknown, should be given

RhoGAM 300 mcg IM.

ο A hemorrhaging mass in the vagina is most likely cervical

cancer. The vagina should be packed to tamponade the

bleeding after placing a urethral catheter. Placing sutures

is generally futile and may make the bleeding worse.
19.9

Gynecologic Trauma and Emergencies

Precipitous Vaginal Delivery

 Preparation.

ο Supplies needed for the delivery, include povidone-iodine

sponges, a 10 cc syringe, lidocaine, 2 Kelly clamps, ring

forceps, dry towels, a bulb syringe, and scissors.

ο The mother should be placed on her left side for labor.

ο The fetal heart rate should be determined every 15 minutes

prior to pushing, and following each contraction during

the pushing phase using a vascular Doppler. Normal heart

rate is between 120–160 bpm. The heart rate often drops

with the contraction, but should recover to normal prior

to the next contraction.

If the heart rate drops below 100 and stays low for more

than 2 minutes, a cesarean section should be considered.

ο When the patient presents, the cervix should be examined

to determine dilation and fetal position. For the woman to

begin pushing, the cervix should be completely dilated

(10 cm) and no cervix should be felt on either side of the

fetal head. If the baby’s head is not presenting, move to

cesarean section immediately. If there is any question, and

ultrasound is available, it should be used to determine the

presentation.

 Delivery.

ο Once the patient begins pushing, flex the hips to optimally

open the pelvis. The patient may be on her back, or tilted

slightly to the left. Assistants should support the legs

during pushing and relax them between contractions.

ο Clean the perineum with sterile Betadine solution. If this

is the patient’s first delivery, the perineum should be

anesthetized with lidocaine in case an episiotomy is

needed. There is little support for prophylactic episiotomy,

but may be necessary if the fetus is large, or tearing is

anticipated.

ο The fetal head delivers by extension. Pushing upward on

the fetal chin through the perineum can assist this process.
19.10

Emergency War Surgery

Additionally, it is extremely important to control the rate

of delivery of the head with the opposite hand.

ο If an episiotomy is needed, it should be cut in the posterior

midline from the vaginal opening approximately 1

/2 the

length of the perineum, and extend about 2–3 cm into the

vagina.

ο After delivery of the head, the mouth and nose should be

suctioned and the neck palpated for evidence of a nuchal

cord. If present, this should be reduced by looping it over

the fetal head, or by clamping twice and cutting if it will

not reduce.

ο Next, the operator’s hands are placed along the parietal

bones and the patient is asked to push again to allow

delivery of the anterior shoulder. Gentle downward

traction should allow the shoulder to clear the pubis, and

the fetus should be directed anteriorly to allow delivery

of the posterior shoulder. The remainder of the body will

normally follow rapidly. Wrap infant in dry towels.

ο Once the fetus delivers, the cord should be doubly clamped

and cut. The placenta usually delivers within 15 minutes

of delivery, but may take up to 60 minutes. Delivery of the

placenta is heralded by uterine fundal elevation,

lengthening of the cord, and a gush of blood. While

waiting, gentle pressure may be placed on the cord,

however, vigorous uterine massage and excessive traction

can lead to complications.

ο Following delivery of the placenta, the patient should be

started on an infusion of lactated Ringer’s with 20 units of

oxytocin (Pitocin). Oxytocin can also be given IM if there

is no IV access. If there is no oxytocin available, alternatives

are methylergonovine maleate (Methergine) 0.2 mg

intramuscular (IM) or allowing the patient to breastfeed.

The placenta should be inspected for evidence of

fragmentation that can indicate retained products of

conception.

 Inspection and repair.

ο Following delivery of the placenta, the vagina and cervix

should be inspected for lacerations. Downward digital

pressure on the posterior vagina and fundal pressure (by
19.11

Gynecologic Trauma and Emergencies

an assistant, if available) will facilitate visualization of the

cervix. A ring forceps is then used to grasp and visualize

the entire cervix.

ο The vagina should be inspected with special attention to

the posterior fornix. The perineum and periurethral areas

should also be inspected. Vaginal and cervical lacerations

may be repaired with 3-0 vicryl or an equivalent suture in

running or interrupted layers.

ο If the anal sphincter is lacerated, it should be reapproximated with 2-0 absorbable interrupted single or figureof-eight sutures.

ο If the patient has torn into the rectum, the rectal-vaginal

septum should be repaired with interrupted sutures of 3-

0 vicryl. A second layer imbricating the underlying tissue

will decrease the risk of breakdown. Care should be taken

to preserve aseptic technique. If a large tear is noted, a

saddle block or spinal anesthetic may be necessary.

ο Patients with a periurethral tear may require urethral

catheterization. In addition to lacerations, hematoma in

the vulva, vagina, or retroperitoneum may occur. See above

gynecologic trauma for management.

Emergency Cesarean Section

 Indications.

ο Fetal heart rate drops below 100 and stays down for more

than 2 minutes.

ο Acute uterine hemorrhage persisting for more than a few

minutes (suggestive of placental abruption or previa).

ο Breech or transverse fetal presentation.

 The patient should be placed in the left tilt position with an

IV bag or towel displacing the uterus to the left. She should

undergo a quick prep from just below the breasts to the mid

thigh. A major abdominal equipment set should have most

of the instruments that you will need.

 Basic steps to performing an emergency C-section (Fig. 19-

4 a,b,c,d).

ο Enter the abdomen through lower midline.
19.12

Emergency War Surgery

Fig. 19-4. Emergency C-Section.

Uterine Incision

Uterus

Incision in Lower

Uterine Segment

Bladder Retracted After

Incising Vesicouterine Fold

a

Delivery of Fetus

Placenta

Operator's Hand

in Position to

Deliver Fetal Head

Fundal Pressure

Exerted

b

Delivered Infant on Abdomen

Nose and Mouth Suctioned

Umbilical Cord Doubly Clamped,

Then Cut

c

Uterine Fundus Exteriorized

d
19.13

Gynecologic Trauma and Emergencies

ο Identify and incise the peritoneal reflection of the bladder

transversely, and create a bladder flap to retract the bladder

out of the field.

ο Using a scalpel, carefully incise the uterus transversely

across the lower uterine segment (where the uterine wall

thins).

ο Once the amniotic membranes are visible or opened,

extend the incision laterally, either bluntly or by carefully

using bandage scissors. Avoid the uterine vessels laterally.

If necessary, the incision can be extended at one or both of

its lateral margins in a J-fashion by vertical incision.

ο Elevate the presenting fetal part into the incision, with an

assistant providing fundal pressure.

ο Upon delivery of the fetus, suction the nose and mouth

and clamp and cut the cord. Hand the infant off for care

(see below).

ο Direct anesthetist to administer 2 grams of cefazolin

(Ancef) once the cord is clamped.

ο Allow the placenta to deliver by providing gentle traction

on the cord and performing uterine massage.

ο Begin oxytocin, if available as above.

ο Using a sponge, clean the inside of the uterus, and

vigorously massage the fundus to help the uterus contract.

ο Quickly close the incision with 0-vicryl. A single layer

(running, locking) is adequate, if hemostatic, for transverse

incisions. Take care to avoid the lateral vessels. If the

incision has a vertical extension, close it in 2 or 3 layers.

ο Once hemostasis is assured, close the fascia and abdomen

in the usual fashion.

ο In the rare case of continued uterine hemorrhage, evaluate

and treat as outlined in the section below.

Uterine Atony

 The majority of postpartum hemorrhage is secondary to

uterine atony (failure of uterine contracture).

When the uterus fails to contract following delivery of

the placenta, bleeding may be torrential and fatal.
19.14

Emergency War Surgery

 Initial management should include manual uterine exploration for retained placenta. Without anesthesia, this procedure

is painful. An opened sponge is placed around the examiner’s

fingers. Place the opposite hand on the patient’s uterine

fundus and apply downward pressure. Gently guide your

fingers through the open cervix and palpate for retained

placenta. The inside of the uterus should feel smooth, and

retained placenta will feel like a soft mass of tissue. This may

be removed manually or by using a large curette if available.

 If no tissue is encountered, use both hands to apply vigorous

uterine massage to improve the uterine tone.

 Medications should also be used if available. Oxytocin may

be given by IV bolus using 40 units in 1000 cc, or up to 10

units IM, but never by IV push. Although unlikely to be

available, other medications that can be considered are

Methergine, dinoprostone (Prostin), and misoprostol

(Cytotec).

 If no medication is available, the patient should be

encouraged to breast feed or do nipple stimulation to increase

endogenous oxytocin release.

If conservative measures fail to arrest the postpartum

hemorrhage, laparotomy (if the hemorrhage is occurring

post vaginal delivery), should be performed.

 Intraoperative massage of the uterine fundus may be tried.

 If the massage fails to improve uterine tone, the uterine

arteries should be ligated in a stepwise fashion. Begin with

the ascending branch at the junction of the upper and lower

uterine segment. Using 0 or No. 1 chromic, place a stitch

through the myometrium medial to the artery from front to

back. The stitch is then brought out through the adjacent

broad ligament and tied. If bilateral ligation of the ascending

branch does not control bleeding, the descending branch

should be ligated at the level of the uterosacral ligament. If

this fails, consider bilateral hypogastric artery ligation (see

above). If this fails, proceed to hysterectomy as outlined in

the gynecologic portion of this chapter.
19.15

Gynecologic Trauma and Emergencies

Neonatal Resuscitation

 Immediately following delivery, every infant should be

assessed for need for resuscitation. Equipment that may be

needed includes warm towels, bulb syringe, stethoscope,

flow-inflating or self-inflating bag with oxygen source,

laryngoscope and blade, suction catheter, and endotracheal

tube. The two medications that may be needed are epinephrine 1:10,000 and naloxone (Narcan) 0.4 mg/ml.

 Nearly 90% of term babies are delivered without risk factors

and with clear fluid, requiring only to be dried, suctioned

and observed. If the baby is less than 36 weeks, or if there

is meconium in the fluid at delivery, the baby will need to

be observed more closely.

ο In the first 30 seconds after delivery, dry and stimulate the

baby, position it in order to open the airway, and give free

flow oxygen if the color is poor.

ο At 30 seconds, evaluate the heart rate. If it is < 100 begin

to provide positive pressure ventilation.After 30 seconds

of ventilation, recheck the heart rate. If it is < 60, then

chest compressions should be started. After 30 seconds

of chest compressions, again re-evaluate. If the heart rate

remains < 60 you should administer epinephrine.

Epinephrine can be given either through the umbilical vein

or the endotracheal tube. The level of experience of the

team present should dictate which route should be used.

The dose is 0.1–0.3 ml/kg of the 1:10,000 solution.

ο If heart rate rises over 100, stop the positive pressure

ventilations, but continue to provide free flow oxygen. If

the mother has been given a dose of narcotics in the 4 hours

prior to delivery, and positive pressure ventilation has

resulted in a normal heart rate and color but poor

respiratory effort, then naloxene is indicated. Administer

naloxene by IV, IM, or endotracheal route at a dosage of

0.1 mg/kg.

 If at any time during resuscitation the heart rate goes above

100, with good respiratory effort, tone and color, the baby

may be moved to an observation status.
19.16

Emergency War Surgery