Obstetrics Flashcards
What are the 3 types postnatal depression?
- Baby blue: is seen in the majority of women in the first week after birth
- Postnatal depression: is seen in about 1 in 10 women, with a peak around ** 3 months after
- Puerperal psychosis: is seen in about one in a thousand women starting a few weeks after birth
What are the baby blues?
Baby blues affect more than 50% of women in the first week or so after birth (particularly in first time mothers)
What are the symptoms of the baby blues?
- Mood swings
- Low mood
- Anxiety
- Irritability
- Tearfulness
What causes baby blues?
- Hormonal changes
- Recovery from birth
- Fatigue and sleep deprivation
- The responsibility of caring for the neonate
- Establishing feeding
What is the classic triad of postnatal depression?
- Low mood
- Anhedonia (lack of pleasure in activities)
- Low energy
When do symptoms usually appear in postnatal depression?
Usually 3 months after birth and last for longer than 2 weeks
What is the treatment for postnatal depression?
Mild cases may be managed with additional support, self-help and follow up with their GP
Moderate cases may be managed with antidepressant medications (e.g. SSRIs) and cognitive behavioural therapy
Severe cases may need input from specialist psychiatry services, and rarely inpatient care on the mother and baby unit
What is the screening tool for postnatal depression?
Edinburgh Postnatal Depression Scale
What is included in the Edinburgh Postnatal Depression Scale?
I have been able to laugh and see the funny side of things.
I have looked forward with enjoyment to things.
I have blamed myself unnecessarily when things went wrong.
I have been anxious or worried for no good reason.
I have felt scared or panicky for no very good reason.
Things have been getting on top of me.
I have been so unhappy that I have had difficulty sleeping.
I have felt sad or miserable.
I have been so unhappy that I have been crying.
The thought of harming myself has occurred to me.
The subject is asked to consider the feelings they have experienced in the past 7 days and all items must be answered by the mother alone without prompting.
What is puerperal psychosis?
It is a rare but severe illness that has an onset 2-3 weeks after delivery
What are the symptoms of puerperal psychosis?
- Delusions
- Hallucinations
- Depression
- Mania
- Confusion
- Thought disorder
What is the treatment of puerperal psychosis?
- Admission to the mother and baby unit
- Cognitive behavioural therapy
- Medications
- Electroconvulsive therapy (ECT)
What is the problem with SSRIs in pregnancy?
Can lead to neonatal abstinence syndrome (also known as neonatal adaptation syndrome).
It presents in the first few days after birth with symptoms such as irritability and poor feeding.
What is an ectopic pregnancy?
Is when a pregnancy is is implanted outside the uterus, the most common site fallopian tube.
Can also occur at the entrance to the fallopian tube, ovary, cervix or abdomen
What are the risk factors for an ectopic pregnancy?
- Previous ectopic pregnancy
- Previous PID
- Previous surgery to the fallopian tubes
- Intrauterine devices
- Older age
- Smoking
What is the typical presentation of an ectopic presentation?
- Have a low threshold for suspecting an ectopic pregnancy, even in atypical presentations
- Always suspect with missed periods and lower abdominal pain
What are the classic features of an ectopic pregnancy?
- Missed period
- Constant lower abdominal pain in the right or left iliac fossa
- Vaginal bleeding
- Lower abdominal or pelvic tenderness
- Cervical motion tenderness (pain when moving the cervix during a bimanual examination)
What are some other symptoms of an ectopic pregnancy?
Dizziness or syncope (blood loss)
Shoulder tip pain (peritonitis)
What are the ultrasound findings in an ectopic pregnancy?
- A gestational sac containing a yolk sac or foetal pole in the fallopian tube
- Sometimes a non-specific mass may be seen in the tube. When a mass containing an empty gestational sac is seen, this may be referred to as the “blob sign”, “bagel sign” or “tubal ring sign” (all referring to the same appearance).
A mass representing a tubal ectopic pregnancy moves separately to the ovary.
Features that may also indicate an ectopic pregnancy are:
An empty uterus
Fluid in the uterus, which may be mistaken as a gestational sac (“pseudogestational sac”)
What is a pregnancy of unknown location?
- When a women has a positive pregnancy test and there is no evidence of pregnancy on an ultrasound scan
How do you monitor a PUL?
- Track hCG over time (every 48 hours)
- In an intrauterine pregnancy hCG will double every 48 hours, it won’t in an miscarriage or ectopic pregnancy . Once levels are above 1500 should be able to see on USS
- A fall of more than 50% is likely to indicate a miscarriage
What is the management for women with a suspected ectopic pregnacy?
- They need to be referred to an early pregnancy assessment unit
All ectopic pregnancies need to be terminated: there are 3 options:
- Expectant management (awaiting natural termination)
- Medical management (methotrexate)
- Surgical management (salpingectomy)
What is the criteria for expectant management?
Follow up needs to be possible to ensure successful termination
The ectopic needs to be unruptured
Adnexal mass < 35mm
No visible heartbeat
No significant pain
HCG level < 1500 IU / l
What is the criteria for methotrexate use?
Same as expectant management apart from:
- HCG level must be <5000 IU / l
Confirmed absence of intrauterine pregnancy on ultrasound
Must be below 5000 but is mainly recommended less than 1500.
HcG needs to be monitored on days 4 and 7 after use and check levels are falling. Then re-assess if this has not occurred
How does methotrexate work and what are the side effects of it?
- It is highly teratogenic and is given as an intramuscular injection into a buttock
Common side effects include:
- Vaginal bleeding
- Nausea and vomiting
- Abdominal pain
- Stomatitis
What are the indications for surgical management of an ectopic pregnancy?
Pain
Adnexal mass > 35mm
Visible heartbeat
HCG levels > 5000 IU / l
Is laparoscopic, it should be a salpingectomy removal of all the tube.
Salpingotomy is an alternative with women for risk factors of infertility
What is a miscarriage?
A spontaneous termination of a pregnancy. Early miscarriage is before 12 weeks. Late miscarriage is between 12-24
What are some key definitions for miscarriage?
- Missed miscarriage: the foetus is no longer alive but no symptoms have occurred
- Threatened miscarriage: vaginal bleeding with a closed cervix and a foetus that is alive
- Inevitable miscarriage: vaginal bleeding with an open cervix
- Incomplete miscarriage: retained products of conception remain in the uterus after the miscarriage
- Complete miscarriage: a full miscarriage has occurred, and there are no products of conception left in the uterus
- Anembryonic pregnancy: a gestational sac is present but contains no embryo
What are the ultrasound findings that a sonographer looks for in an early pregnancy?
- When a foetal heartbeat is visible the pregnancy is considered viable: a foetal heartbeat is expected once crown-rump length is 7mm
- When there is no foetal heartbeat and CRL is less than 7mm scan repeated in 1 week
- A foetal pole is expected once the mean gestational sac is more than 25mm
- When there is a mean gestational sac diameter of 25mm without a foetal pole an anembryonic pregnancy is expected
What is the management for women with vaginal bleeding that are less than 6 weeks gestation?
- If there is no pain and no risk factors then use Expectant management
- A repeat urine pregnancy test is performed 7-10 days and if negative, a miscarriage can be confirmed
- When bleeding continues then do further investigation
What is the management for women with vaginal bleeding that are more than 6 weeks gestation?
- Referral to an early pregnancy assessment service
- They will arrange an ultrasound scan which will confirm the location and viability of the pregnancy.
What is the management for an incomplete miscarriage?
- If less than <35mm then can offer expectant, medical or surgical
- If greater than 35mm then offer surgical management
What is medical management for a miscarriage?
Misoprostol which is a prostaglandin analogue which softens the cervix and stimulates uterine contractions
Can be a vaginal suppository or an oral dose
What are the side effects of misoprostol?
- Heavier bleeding
- Pain
- Vomiting
- Diarrhoea
What are the surgical options for to treat a miscarriage?
Manual vacuum aspiration under local anaesthetic as an outpatient
Electric vacuum aspiration under general anaesthetic
Anti-rhesus D prophylaxis is given to rhesus negative women having surgical management of miscarriage.
What is the management for an incomplete miscarriage?
Medical management (misoprostol)
Surgical management (evacuation of retained products of conception)
Evacuation of retained products of conception (ERPC) is a surgical procedure involving a general anaesthetic. The cervix is gradually widened using dilators, and the retained products are manually removed through the cervix using vacuum aspiration and curettage (scraping).
What is a complication of ERPC?
Endometritis (infection of the endometrium)
What is needed to diagnose a delayed miscarriage?
- Diagnosed on transvaginal scan
- Requires visualisation of gestation sac, yolk sac and foetal pole, with a CRL of greater than 7mm and no foetal heart activity
- Need 2 sonographers to diagnose
What is the management of a delayed miscarriage?
- If CRL is less than 22mm then anything can be offered
- If CRL is less than 54mm then medical or surgical
- If CRL is greater than 54mm then medical treatment should be offered
What criteria can justify the decision to proceed with an abortion?
if continuing the pregnancy involves greater risk to the physical or mental health of:
The woman
Existing children of the family
It is a matter of clinical judgement and must be agreed by 2 separate doctors
What is a molar pregnancy?
- Type of gestational trophoblastic disease
- Complete mole caused by a single or two sperm fertilising an egg which has lost its DNA
- 2-4% risk of developing into a choriocarcinoma
- partial is when 2 sperm supply chromosomes but mother are also present
- Looks likes bunch of grapes
- Only treated with surgical management
When can an abortion be performed at anytime?
Continuing the pregnancy is likely to risk the life of the woman
Terminating the pregnancy will prevent “grave permanent injury” to the physical or mental health of the woman
There is “substantial risk” that the child would suffer physical or mental abnormalities making it seriously handicapped
What is the medical way to cause an abortion?
- Give Mifepristone (anti-progestogen)
- Give Misoprostol (prostaglandin analogue) 1 – 2 day later
Mifepristone is an anti-progestogen medication that blocks the action of progesterone, halting the pregnancy and relaxing the cervix.
What are some complications of having an abortion?
Bleeding
Pain
Infection
Failure of the abortion (pregnancy continues)
Damage to the cervix, uterus or other structures
What are monozygotic twins?
Identical twins
What are dizygotic twins?
Non-identical twins
What are monoamniotic twins?
Single amniotic sac
What are diamniotic twins?
Two separate amniotic sacs
What are monochorionic and dichorionic twins?
Monochorionic: share a single placenta
Dichorionic: two separate placentas
What type of twins have the best outcomes?
The best outcomes are with diamniotic, dichorionic twin pregnancies, as each foetus has their own nutrient supply.
How can you determine which type of twins are present on an ultrasound scan?
- Dichorionic diamniotic twins have a membrane between the twins, with a lambda sign or twin peak sign
- Monochorionic diamniotic twins have a membrane between the twins with a T sign
- Monochorionic monoamniotic twins have no membrane between them
What is the lambda/twin peak sign?
The triangular appearance where the membrane between the twins meets the chorion
What is the t-sign?
Where the membrane between the twins abruptly meets the chorion giving a t-sign
What are some complications to the mother with a twin pregnancy?
Anaemia
Polyhydramnios
Hypertension
Malpresentation
Spontaneous preterm birth
Instrumental delivery or caesarean
Postpartum haemorrhage
What are the risk to the foetuses and neonates in twin pregnancies?
Miscarriage
Stillbirth
Fetal growth restriction
Prematurity
Twin-twin transfusion syndrome
Twin anaemia polycythaemia sequence
Congenital abnormalities
What is twin transfusion syndrome?
- It occurs when foetuses share a placenta it is when there is a connection between the blood supplies of the two foetuses
- One foetus may receive the majority of the blood from the placenta while the other one is starved of blood
- The recipient will become fluid overloaded with heart failure and polyhydramnios
- The donor has growth restriction, anaemia and oligohydramnios
What is the treatment for foetal transfusion syndrome?
Laser treatment may be used to destroy the connection between the two blood supplies
What is twin anaemia polycythaemia sequence?
One twin becomes anaemic and the other develops polycythaemia
What extra care is a women given with multiple pregnancies?
A specialist multiple pregnancy obstetric team manages women with a multiple pregnancy.
Women with multiple pregnancies require additional monitoring for anaemia, with a full blood count at:
Booking clinic
20 weeks gestation
28 weeks gestation
They also have scans:
every 2 weeks for monochorionic twins
every 4 weeks for dichorionic twins
When is planned birth offered with twins?
- 32 and 33 weeks for uncomplicated monochorionic twins, monoamniotic twins (require a C-section)
- 36 weeks for uncomplicated monochorionic diamniotic twins
- 37 and 37 + 6 weeks for uncomplicated dichorionic diamniotic twins
- Before 35 + 6 weeks for triplets
Corticosteroids are given to help mature the lungs
How would you deliver diamniotic twins?
Diamniotic twins (aim to deliver between 37 and 37 + 6 weeks):
Vaginal delivery is possible when the first baby has a cephalic presentation (head first)
Caesarean section may be required for the second baby after successful birth of the first baby
Elective caesarean is advised when the presenting twin is not cephalic presentation
What is gestational diabetes?
Diabetes caused by pregnancy due to decreased insulin sensitivity and resolves after birth
What are the implications of gestational diabetes?
- Can cause larger for dates foetus and macrosomia. This causes implications for birth causing a risk of shoulder dystocia.
- Women are also at higher risk of developing type 2 diabetes after pregnancy.
- Anyone with risk factors should be screened with an oral glucose tolerance test at 24-28 weeks
What are the risk factors for developing gestational diabetes?
- Previous gestational diabetes
- Previous macrosomic baby
- BMI above 30
- Ethnic origin
- Family history of diabetes
When would you screen for gestational diabetes?
- Risk factors
- Larger for date foetus
- Polyhydramnios
- Glucose on urine dipstick
What are the figures for gestational diabetes?
- Fasting above 5.6
- At 2 hours above 7.8
What is the management for gestational diabetes?
- They need four weekly ultrasound scans to monitor foetal growth and amniotic fluid from 28-36 weeks
- Fasting glucose less than 7 mmol/l: trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin
- Fasting glucose above 7 mmol/l: start insulin ± metformin
- Fasting glucose above 6 mmol/l plus macrosomia (or other complications): start insulin ± metformin
Glibenclamide is another option
How do you manage pre-existing diabetes in a pregnant women?
- They should take 5mg folic acid preconception
- Retinopathy screening should be performed shortly after booking and at 28 weeks gestation
- Advise a planned delivery between 37 and 38+ 6 weeks for women with pre-existing
How is type 1 diabetes managed during labour?
A **sliding-scale insulin regime*
- A dextrose and insulin infusion is titrated ti blood sugar levels. Also considered
How do you treat gestational diabetes after birth?
- Women can stop their diabetes medications immediately after birth and will need follow up after 6 weeks
- Women should be wary of hypoglycaemia in postnatal period, insulin sensitivity will increase with birth and breastfeeding
What are the babies at risk of if their mother has had gestational diabetes?
- Neonatal hypoglycaemia- babies will need regular blood glucose checking
- Polycythaemia
- Jaundice
- Congenital heart disease
- Cardiomyopathy
What are the two major impacts of gestational diabetes on neonates?
two complications of gestational diabetes, remember macrosomia and neonatal hypoglycaemia
Babies become accustomed to a large supply of glucose during the pregnancy, and after birth they struggle to maintain the supply they are used to with oral feeding alone.
Name 3 major things that women are at risk of during puerperium.
- Sepsis.
- Sever haemorrhage.
- Pre-eclampsia.
- VTE.
- Prolapse.
- Incontinence.
- Depression.
Give 3 risk factors for sepsis in pregnancy.
- Obesity.
- Anaemia.
- Diabetes.
- Amniocentesis/invasive procedures
.Impaired immunity/ immunosuppressant medication
What can cause sepsis in pregnancy?
- Endometritis.
- Skin infections.
- Pyelonephritis.
- Chorioamnionitis.
- Pneumonia.
Define sepsis. Define septic shock
Sepsis is a condition where the body launches a large immune response to an infection, causing systemic inflammation and affecting the functioning of the organs of the body
Septic shock is defined when arterial blood pressure drops and results in organ hypo-perfusion.
What are the two key causes of sepsis in pregnancy?
Chorioamnionitis
Urinary tract infections
What is chorioamnionitis?
Chorioamnionitis is an infection of the chorioamniotic membranes and amniotic fluid.
E coli is most common
What are some key features of sepsis?
(3Ts white with sugar)
Temperature <36 or >38 degrees
Tachycardia -Heart rate > 90bpm (PN)
Tachypnoea - Respiratory rate > 20bpm
WCC >12 or <4 x 109/l
Hyperglycaemia >7.7mmol
Low blood pressure
Altered consciousness
Reduced urine output
What is the some of the management steps for dealing with maternal sepsis?
Bloods cultures
Urine output
Fluid Resuscitation
Antibiotics
Lactate
Oxygen
piperacillin and tazobactam (tazocin) plus gentamicin, or amoxicillin, clindamycin and gentamicin.
Continuous maternal and fetal monitoring is required. Depending on the condition of the mother and fetus, early delivery may be needed. Emergency caesarean section may be indicated when there is fetal distress, guided by a senior obstetrician. General anaesthesia is usually required for women with sepsis, as spinal anaesthesia is avoided.
Name some obstetric conditions that obesity is a huge risk factor for
Pre-eclampsia
Sepsis
Shoulder Dystocia
Gestational diabetes
Name 3 reproductive disorders that are associated with obesity.
PCOS.
Miscarriage.
Infertility.
What are some causes of primary hypertension?
It has multifactorial aetiology
Genetic factors – can run in families 40%-60% have a genetic component
Foetal factors – low birth weight is associated with hypertension
Obesity
High alcohol Alcohol intake
Insulin intolerance
Lack of physical activity
Metabolic Syndrome X cluster of conditions, such as high insulin levels, glucose intolerance, low levels of HDLs, central obesity
What are some main causes of secondary hypertension?
○ Renal e.g. CKD
○ Endocrine e.g. Conn’s syndrome, acromegaly, Cushing’s syndrome
○ Coarctation of the aorta
○ Pre-eclampsia occurring during third trimester of pregnancy
Define chronic hypertension.
A patient with high BP which is diagnosed prior to pregnancy or before week 20 of pregnancy. Their high BP is not resolved postpartum.
Define gestational hypertension.
New high BP after 20w gestation and resolves after giving birth. There is no proteinuria or end organ damage
Key definitions hypertension in pregnancy
- Chronic hypertension: High blood pressure that exists before 20 weeks gestation
- Pregnancy induced hypertension: is hypertension that occurs after 20 weeks gestation without proteinuria
- Pre-eclampsia is pregnancy induced hypertension associated with organ damage notably proteinuria
- Eclampsia is when seizures occur as a result of pre-eclampsia
What is the classic triad of pre-eclampsia?
- Hypertension
- Proteinuria
- Oedema
How does normal blood flow between the placenta and endometrium?
- When a placenta grows into the endometrium it forms finger-like projections called chorionic villi these contain foetal blood vessels
- When invasion occurs the endometrium sends signals to spiral arteries in the area to reduce their vascular resistance, this causes them to breakdown and causes pools of blood called lacunae
- Maternal blood flows in and out of these lacunae through uterine veins and arteries (this occurs at 20 weeks)
What causes pre-eclampsia?
- When the process of forming lacunae is inadequate, women can develop pre-eclampsia
- It is caused by high vascular resistance in the spiral arteries and poor perfusion of the placenta.
- This causes oxidative stress in the placenta and the release of inflammatory chemical leading to systemic inflammation and impaired endothelial function in the blood vessels
What are the high risk factors for pre-eclampsia?
- Pre-existing hypertension
- Previous hypertension in pregnancy
- Existing autoimmune conditions (SLE)
- Diabetes
- Chronic kidney disease
What are the moderate risk factors for pre-eclampsia?
- Older than 40
- BMI above 35
- More than 10 years since previous pregnancy
- Multiple pregnancy
- First pregnancy
- Family history of pre-eclampsia
What is the prophylaxis for pre-eclampsia and when is it given?
Aspirin women are offered from 12 weeks until birth if they have 1 high risk factor or more than 1 moderate risk factor
What are the symptoms of the complications of pre-eclampsia?
- Headache
- Visual disturbance or blurriness
- Nausea and vomiting
- Upper abdominal or epigastric pain (due to liver swelling)
- Oedema
- Reduced urine output
- Brisk reflexes (clonus)
How can you diagnose pre-eclampsia?
Systolic blood pressure above 140 mmHg
Diastolic blood pressure above 90 mmHg
PLUS any of:
Proteinuria (1+ or more on urine dipstick)
Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia)
Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies)
What is tested if a women is suspected to have pre-eclampsia?
Measure placental growth factor levels will be Low in pre-eclampsia
Measure between 20-35 weeks to rule out
What is the management for gestational hypertension?
Treating to aim for a blood pressure below 135/85 mmHg
Admission for women with a blood pressure above 160/110 mmHg
Urine dipstick testing at least weekly
Monitoring of blood tests weekly (full blood count, liver enzymes and renal profile)
Monitoring foetal growth by serial growth scans
PlGF testing on one occasion
When is the management for pre-eclampsia?
Scoring systems are used to determine whether to admit the woman (fullPIERS or PREP‑S)
Blood pressure is monitored closely (at least every 48 hours)
Urine dipstick testing is not routinely necessary (the diagnosis is already made)
Ultrasound monitoring of the fetus, amniotic fluid and dopplers is performed two weekly
What is the medical management of pre-eclampsia?
- Labetalol is first-line as an antihypertensive
- Nifedipine (modified-release) is commonly used second-line
- Methyldopa is used third-line (needs to be stopped within two days of birth)
- Intravenous hydralazine may be used as an antihypertensive in critical care in severe pre-eclampsia or eclampsia
What is given during labour in women with pre-eclampsia?
- Iv magnesium sulphate to prevent seizures
- Fluid restriction to avoid fluid overload
What is the medical treatment of pre-eclampsia after birth?
- Enalapril (first-line)
- Nifedipine or amlodipine (first-line in black African or Caribbean patients)
- Labetalol or atenolol (third-line)
What is anaemia?
A low concentration of haemoglobin in the blood
When are women screened for anaemia in pregnancy?
- Booking clinic
- 28 weeks gestation
Why do women often develop anaemia in pregnancy?
- Plasma volume increases during pregnancy, this results in a reduction in the haemoglobin concentration
What are the normal Hb concentrations in pregnancy?
Booking bloods:
> 110 g/l
28 weeks gestation:
> 105 g/l
Post partum:
> 100 g/l
What are the risk factors for VTE in pregnancy?
Smoking
Parity ≥ 3
Age > 35 years
BMI > 30
Reduced mobility
Multiple pregnancy
Pre-eclampsia
Gross varicose veins
Immobility
Family history of VTE
Thrombophilia
IVF pregnancy
When would VTE prophylaxis be recommended?
- 28 weeks if there are 3 risk factors
- First trimester if there are 4 or more risk factors
What is the prophylaxis of VTE in pregnant women?
- LMWH such as enoxaparin, dalteparin, tinzaparin
What are the symptoms of DVT?
Almost always unilateral
- Calf or leg swelling
- Dilated superficial veins
- Tenderness to the calf
- Oedema
- Colour changes to the leg
What is the common presentionation of endometritis? When does it most commonly occur?
Endometritis is a clinical diagnosis with fever, uterine tenderness, a foul purulent vaginal discharge, and/or increased vaginal bleeding.
It occurs most commonly 5–10 days after delivery.
What is Mastitis, and what is the most common cause of it?
This is a condition that refers to inflammation of the breast
– It is associated with breastfeeding: milk stasis can cause an inflammatory response -> may then get secondary infection, most commonly with staphylococcus aureus
What are some signs and symptoms of mastitis, and what is the management of it?
Erythematous, tender, swollen area of breast
– Systemic upset with fevers, chills and fatigue
– 1st line is to advise continue breastfeeding, ensuring the breast is fully emptied
– If symptoms do not improve after 24 hours of milk removal –> Flucloxacillin 10-14 days
What is breast engorgement? When and why can it happen?
Caused by vascular
and lymphatic stasis
May occur on days 2–4 postpartum in women who are not nursing
or at any time if breastfeeding is interrupted.
Management conservatively with ice packs and painkillers
What are the different types of malpresentation you may see
Cephalic vertex presentation is the most common and is considered the safest
Other presentations include breech, shoulder, face and brow
What are the different types of abnormal lie you may see?
Longitudinal, transverse or oblique
Describe a first degree vaginal tear.
First degree - tear within vaginal mucosa only.
Describe a second degree vaginal tear.
Second degree - tear into sub-cutaneous tissue.
Describe a third degree vaginal tear.
Third degree - laceration extends into external anal sphincter.
Describe a fourth degree vaginal tear.
Fourth degree - laceration extends through external anal sphincter into rectal mucosa.
