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6-13. HEMATOMAS http://www.brooksidepress.org/Products/Obstetric_and_Newborn_Care_II/lesson_6_Section_3.

ht m Vulvar hematoma is a localized collection of blood in the connective tissue beneath the skin covering the external genitalia or vaginal mucosa. It generally forms as a result of injury to the perineal blood vessels during the delivery process.

Vulvar Hematoma a. Causes of Hematomas. (1) Rapid, spontaneous delivery. (2) Perineal varicosities. (3) Episiotomy repairs. (4) Laceration of perineal tissues. b. Signs and Symptoms. (1) Severe, sharp perineal pain. (2) Appearance of a tense, sensitive mass of varying size covered by discolored skin.

and trauma may result in formation of a hematoma. Most puerperal hematomas arise from bleeding lacerations related to operative deliveries or episiotomy. (5) Inability to void due to pressure/edema on or around the urethra.(3) Swelling in the perineal wall. pseudoaneurysm. bleeding is directed toward the skin where the loose subcutaneous tissues afford little resistance to hematoma formation. (4) Often seen on the opposite side of the episiotomy. rarely.7-9]. vagina. and vulva have rich vascular supplies that are at risk of trauma during the birth process. or clotting disorders [3. a hematoma may also result from injury to a blood vessel in the absence of laceration/incision of the surrounding tissue (eg.3-6]. while the anal fascia limits extension of bleeding in the posterior triangle. are a potentially life-threatening complication of childbirth [1. This is consists of analgesics given for discomfort. Medical Treatment. Superficial hematomas can extend from the posterior margin of the anterior triangle (at the level of the transverse perineal muscle) anteriorly over the mons to . and the deep and dorsal arteries of the clitoris) that occur during episiotomy or from perineal lacerations (figure 1) [1. Vulva — Most vulvar hematomas result from injuries to branches of the pudendal artery (inferior rectal. Women at increased risk of developing puerperal hematomas include those who are nulliparous or who have an infant over 4000 grams. vaginal/paravaginal area.3]. opening the hematoma so blood clots can be evacuated and the bleeders can be ligated. prolonged second stage of labor.uptodate. and retroperitoneum. http://www. (6) Complaint of fullness or pressure in the vagina. and urethral arteries. (2) Observe for evidence of enlarged hematoma. posterior labial. Nursing Interventions. (1) Apply ice to area of hematoma. d. (3) Flag the patient's chart if packing was inserted. The superficial compartment of the anterior triangle communicates with the subfascial space of the lower abdomen below the inguinal ligament. preeclampsia. Puerperal hematomas occur in 1:300 to 1:1500 deliveries and. the artery of the vestibule.2]. COMMON LOCATIONS The most common locations for puerperal hematomas are the vulva.com/contents/management-of-hematomas-incurred-as-a-result-of-obstetricaldelivery INTRODUCTION The pregnant uterus. These vessels are typically located in the superficial fascia of the anterior (urogenital) or posterior pelvic triangle (figure 2). vulvar varicosities. however. Extension of bleeding in the anterior triangle is limited by Colles' fascia and the urogenital diaphragm. c. traumatic arteriovenous fistula) [1. multifetal pregnancy. perineal. As a result. and packing for pressure.

More often than not. [2] Some others are often due to rupture of varicose vein of the vulva that consequently collects in the dead space of the surrounding tissues of the labial folds and the perineal body on one side. after a normal spontaneous vaginal delivery. A recent report by UN and World Bank revealed that 144 women die in Nigeria everyday from pregnancy and childbirth complications. The cases present usually with a huge vulvar swelling that is associated with pain. [5] This could actually contribute to maternal mortality under the hemorrhagic causes even though it is rare. [1] The index case had exploration and evacuation of the hematoma under general anesthesia. they present in pains with swelling. Necrosis caused by pressure and rupture of the tissue surrounding the hematoma may lead to external hemorrhage [9].[2] It is important to cover the patient with broad-spectrum antibiotics to reduce the chances of infection. .org/article. which is occasionally encountered during the course of labor. The repair is usually done to ensure that there is no dead space to avert recurrence and complication of abscess collections. they usually present . Considering the etiological factors of maternal mortality.issue=1. [1].spage=37. Vulva hematoma is usually a unilateral injury of the vulva with edematous swelling. Our maternal mortality stands at 59. It could also be due to tear of the mucosal vessels of the lateral wall of the vagina following normal or instrumental delivery. Though the period of pregnancy is longer than that of labor and delivery. This results in a vulvar hematoma. Conservative management is done when it is self limiting (when the haematoma arrest further bleeding and there is no appreciable increase in the swelling. The objective of this study is to discuss the presentation and management of vulva hematoma. Vulvar abscess is a notable complication. When a woman falls while straddling a fixed structure. the latter records more mortality.year=2012. a rare but life-threatening cause of maternal mortality and morbidity. [5]Ignorance. In our environment. it is a common occurrence that the peri-clitoral vessels on one side or the other will be crushed against the pubic bone. Whatever can be done to reduce maternal mortality in a developing nation like Nigeria is significant and should not be underestimated. such as chair. Management options are either conservative or definitive depending on the size and the rate of progression of the hematoma. sawhorse or fire hydrant. In some cases. it is usually noticed after delivery [1] though it had been reported in literature to occur following coital trauma [3] or sometimes spontaneous.000 maternal deaths annually in recent United Nations data.epage=38. The country's 59. as such hospital deliveries should be encouraged. [6] The data show that Nigeria has the second highest maternal mortality rate in the world. in shock.asp?issn=22789596. and inadequate facilities are reported to be the prime reasons for the increasing maternal mortality rate in the country. [4] At times. [6] It is very important to encourage our patients not only to book for antenatal care but also to ensure that they deliver in the hospitals so as to reduce our maternal mortality and morbidity. where we are reporting from. Locally available statistics also show that the Northwest zone of the country. the patient may require blood transfusion.volume=2. has the second highest mortality rate in Nigeria after the Northeast zone. adding this remote factor makes it significant. The pain is usually severe that they sometimes present with neurogenic shock. [1] Majority of cases develop insidiously with a sudden collapse and severe groin pain. this case report brings to mind the rare causes of hemorrhage as a factor of maternal mortality. illiteracy. railing. Few cases have been associated with imperfect repair of episiotomy.000.the fusion of fascia at the inguinal ligament.archintsurg. especially where the attending physician is not conversant with its management. The exploration rarely revealed the bleeding point as it was in this patient.000 maternal deaths annually rank second to India's 117.aulast=Akpa Vulvar Hematoma A vulvar hematoma is usually the consequence of a "straddle" injury. http://www. it is so large that it extends up the vagina and occludes it as it was in this patient. [1] [2]Otherwise. Introduction Vulva hematoma is a very rare maternal injury that usually presents in the third stage of labor.

oral narcotics and then NSAIDs will give satisfactory results.Most of the vulvar enlargement is soft tissue swelling. This will help control the pain and limit swelling and further bleeding into the hematoma. ice. Dramatic resolution will occur. Clinical management consists of:        An icepack is placed over the perineum and left in place for 24-48 hours. If you explore them. this may need injectable narcotics. Most of these hematomas will not require surgical exploration and drainage. http://www. A Foley catheter is inserted and left in place. The local swelling may be sufficient to impair voluntary voiding and the Foley is much easier to insert earlier in the process. Bedrest for several days to a week. in about half the cases. Initially.org/Products/Military_OBGYN/Textbook/Vulva/VulvarHematoma. Foley and bedrest are usually better choices for treatment. In following these. Particularly in operational settings. Diagnosis is made on the basis of history of a fall and the typical physical findings of unilateral swelling and pain. Later.brooksidepress. Appropriate analgesia. no bleeding point will ever be found. Opening them introduces bacteria into an otherwise sterile hematoma. When completely healed in a few weeks. the vulva will look normal and function normally. but some is due to an encapsulated hematoma. As they are feeling less pain.htm . patients will often feel that the hematoma is enlarging. it may prove useful to measure the hematoma with a tape measure to compare the size over time. Having objective measures of its' size will be very reassuring to the patient.