Perineal Injury and Pelvic

Hematoma
Dr. Bibek Kr. Lal
Intern
PAHS

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 Introduction
• Reference to laceration repair dates back to Hippocrates
• Morbidity associated with perineal injury related to childbirth is a
major health problem that affects thousands of women
• Major aetiological factor in the development of perineal pain, sexual
dysfunction, prolapse and disturbance in bowel and bladder function
• Perineal lacerations may occur with normal or instrumental vaginal
delivery and are classified by their depth

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 Introduction
• Long-term, they are linked with higher rates of anal incontinence and
dyspareunia
• The incidence of higher-order lacerations varies from 0.25 to 6
percent
• The repair of perineal lacerations is virtually the same as that of
episiotomy incisions, albeit sometimes less satisfactory because of
tear irregularities

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Associated Risk Factors
• Asian ethnicity
• Nulliparity
• Increasing birth weight
• OT or OP positions
• Shoulder dystocia
• Prolonged second stage of labor
• Precipitous delivery
• Persistent occiput

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 Associated Risk Factors
• Episiotomy
• Midline > mediolateral
• Operative delivery
• Forceps > vacuum

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• Pelvis contains
urinary bladder,
uterus and rectum
supported by pelvic
diaphragm
• Other supports of
pelvic viscera
• Perineal body
• Urogenital diaphragm

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Perinea pouches
• Superficial perineal pouch
• Present below colles fascia
• Contents
• Bulbospongiosus
• Ischiocavernosus
• Superficial transverse perineal
muscles
• Deep perineal pouch
• Contains urogenital diaphragm
• Contributed by
• Deep transverse perineal muscle
• External urethral sphincter

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Classification of perineal injury - Sultan
(1999)
1. First-degree tear
• Involving perineal or vaginal skin only
2. Second-degree tear
• Perineal skin and muscles torn, but intact anal sphincter
3. Third-degree tear
• Perineal skin, muscles and anal sphincter are torn
• 3a - less than 50% of the external anal sphincter thickness is torn
• 3b - more than 50% of the external anal sphincter thickness is
torn, but internal anal sphincter intact
• 3c - both external and internal anal sphincters are torn, but anal
mucosa intact
4. Fourth-degree tear
• Perineal skin, muscles, anal sphincter and anal mucosa torn

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Classification of perineal injury
• Buttonhole tear - anal sphincter intact but anal mucosa torn
• Third- and fourth-degree tears that involve the anal sphincter
complex are also termed “Obstetric anal sphincter injuries” (OASIS)

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 Prevention
• Avoid operative delivery
• Vacuum if needed
• Avoid episiotomy
• Antenatal perineal massage
• Lateral birth position
• Perineal warm packs during second stage

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 Prior to Repair
• Evaluate laceration
• Prepare equipment
• Instruments
• Sutures
• Call for assistance
• Provide
• Analgesia
• Lighting
• Visualization

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 Equipment
• Sponges
• Vaginal pack
• Irrigation
• 2 Allis clamps
• Needle holder
• Sharp tooth tissue forceps
• Sutures
• Polyglycolic acid derivative
• 2‐0 and 3‐0
• Local anesthesia
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Rectal Mucosa
• Identify apex
• Begin closure above apex
• Close with running or interrupted 3‐0
polyglycolic suture
• Transmucosal sutures are not
recommended

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Internal Anal Sphincter Closure
• Identify the internal anal sphincter
• Longitudinal fibromuscular layer
• Between the rectal mucosa and the external anal
sphincter
• Close with running locked 3‐0 polyglycolic
suture

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Rectovaginal Septum
• Goal
• Decreased dead space
• Strengthened septum
• Reapproximate rectovaginal fascia
• Run 2‐0 polyglycolic suture
• Repair may occur before or after external
anal sphincter
• Avoid entry into rectal lumen

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External Anal Sphincter
• End‐to‐end traditional
• Overlap is a newer technique
• Some heterogeneity in the evidence, but the end‐to‐end technique
seems to have better continence outcomes

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External Anal Sphincter: End‐to‐End
• Identify ends of sphincter
• Grasp with Allis clamps
• Reapproximate with at least four 2‐
0 polyglycolic sutures
• Don’t strangulate

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External Anal Sphincter: Overlap
• Similar to end‐to‐end
• Grasp with Allis clamps
• Reapproximate with at least four 2‐0
polyglycolic sutures
• Overlap muscle as shown

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 Vagina
• Begin above apex
• Use polyglycolic suture
• Close to hymeneal ring
• Suture placed deep enough to
repair rectovaginal septum but
not into rectal lumen

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Perineal Body
• New suture, or continue with vaginal
suture
• Assess defect
• Close in one or two layers
• Place “crown stitch” and complete
closure

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Perineal Muscles

Repair of Perineal Body

Muscles: Bulbocavernosis (bulbospongiosis)

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Perineal Skin
• Continue stitch as a subcuticular closure
• Transepithelial stitches are not recommended
because of increased pain
• Leaving skin unsutured is an option if a minimal
gap exists after muscles repaired
• Complete closure by bringing suture into vagina
for tying

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Evaluation of Surgical Repair
• Assure correct sponge and instrument count
• Vaginal examination to assess repair, look for other lacerations
• Rectal examination for
• Palpable defects
• Intact rectal sphincter
• “Squeeze my finger”
• Consider need to revise repair if problems are noted, but may not be
beneficial in case of suture placed in rectal lumen
• Prepare operative note

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Complications
• Infection
• Dehiscence
• Hematoma
• Rectovaginal fistula
• Rectocutaneous fistula
• Perineal abscess
• Anal incontinence
• Dyspareunia

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Etiology of Complications
• Infection • Blunt or penetrating trauma
• Hematoma • Forceful coitus
• Poor tissue approximation • Cigarette smoking
• Obesity • Inflammatory bowel disease
• Poor perineal hygiene • Connective tissue disease
• Malnutrition • Prior pelvic radiation
• Anemia • Hematologic disease
• Constipation • Endometriosis

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Summary
• Avoid episiotomy and operative vaginal delivery
• Identification of the depth of laceration and anatomy is essential
• Ensure adequate lighting
• Provide hemostasis and good approximation of tissue planes
• Examine repair and rectum
• Stay vigilant for post‐op infection and treat judiciously

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 Pelvic hematomas
• Most often associated with a laceration, episiotomy, or an operative
delivery
• May develop following rupture of a blood vessel without associated
lacerations
• Occasionally associated with an underlying coagulopathy
• Consumptive coagulopathy - Placental abruption or fatty liver failure
• Congenital bleeding disorder - von Willebrand disease

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Classification
• Vulvar
• Vestibular bulb or branches of the
pudendal artery (Inferior rectal,
perineal, and clitoral arteries)
• Vulvovaginal
• Paravaginal
• Descending branch of uterine artery
• Retroperitoneal hematomas

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 Vulvovaginal Hematomas
• May develop rapidly and frequently cause
excruciating pain
• If bleeding ceases, then small- to moderate-sized
hematomas may be absorbed
• Tissues overlying the hematoma may rupture from
pressure necrosis
• Profuse hemorrhage may follow, or hematoma drains in
the form of large clots and old blood
• In those that involve the paravaginal space and
extend above the levator sling, retroperitoneal
bleeding may be massive and occasionally fatal

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Diagnosis
• Vulvar hematoma
• Severe perineal pain
• Tense, fluctuant, and tender swelling of varying size
• Eventually covered by discolored skin

• Paravaginal hematoma
• May escape detection temporarily
• Symptoms of pelvic pressure, pain, or inability to void should prompt
evaluation with discovery of a round, fluctuant mass encroaching on the
vaginal lumen

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• Supralevator extension
• Hematoma extends upward in the paravaginal space and between the leaves
of the broad ligament
• May escape detection until it can be felt on abdominal palpation or until
hypovolemia develops
• Imaging with sonography or computed tomographic (CT) scanning can be
useful to assess hematoma location and extent
• Can lead to hypovolemic shock and death

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Management
• Vulvovaginal hematomas are managed according to their size,
duration since delivery, and expansion
• Smaller vulvar hematomas identified after the woman leaves the
delivery room may be treated expectantly
• Conservative management, including analgesia and application of cold packs
• If pain is severe or the hematoma continues to enlarge, then surgical
exploration is preferable
• Imaging modalities, such as ultrasound, are performed serially, as
needed, to help determine if there is expansion of the hematoma

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Management
• An incision is made at the point of maximal distention, blood and
clots are evacuated, and bleeding points ligated
• The cavity may then be obliterated with absorbable mattress sutures
• Often, no sites of bleeding are identified
• Nonetheless, the evacuated hematoma cavity is surgically closed, and
the vagina is packed for 12 to 24 hours
• Foley catheter is necessary to drain the bladder in the presence of a
vaginal pack or significant edema

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Management
• Supralevator hematomas are more difficult to treat
• Although some can be evacuated by vulvar or vaginal incisions,
laparotomy is advisable if there is continued hemorrhage
• Retroperitoneal hematomas

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• Blood loss with large puerperal hematomas is nearly always considerably
more than the clinical estimate
• Hypovolemia is common, and transfusions are frequently required when
surgical repair is necessary.
• Angiographic embolization has become popular for management of some
puerperal hematomas
• Embolization can be used primarily, or more likely secondarily, if surgical
attempts at hemostasis have failed or if the hematoma is difficult to access
surgically
• The use of a Bakri balloon for a paracervical hematoma has also been
described
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Postoperative Care
• Perineal hygiene with Sitz baths and gentle cleansing with saline rinse
are encouraged after vulvar surgery
• Adequate analgesia should be prescribed
• Pelvic rest (no vaginal coitus or placement of tampons or vaginal
medications) for four to six weeks, depending upon the extent of the
injury, to avoid disruption of healing tissues
• Pressure necrosis of the swollen external genitalia may be prevented by
having patients rest primarily on their side or back
• At discharge, patients should be counseled to call their provider
promptly if they develop fever, new or worsening pain, or bleeding
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References
• 1. Advanced Life Support in Obstetrics
• 2. Williams Obstetrics 24th Ed
• 3. Dewhurst's Textbook of Obstetrics and Gynaecology 8th Ed
• 4. Textbook of Anatomy Abdomen and Lower Limb - Singh, Vishram
Thank You
Vaginal hematomas
• Conservative management is same as vulvar hematoma
• If surgical intervention is required, good surgical exposure is
important, as these hematomas are less accessible than vulvar
hematomas.
• Evacuation usually needs to be done under general or regional
anesthesia in an operating room (rather than a labor or procedure
room), where good lighting, appropriate surgical instruments, and a
surgical assistant should be available.
Retroperitoneal hematomas
• Because the retroperitoneal space is large, many patients with a
retroperitoneal hematoma require either surgical (Laparotomy) or
angiographic intervention
• Hemostasis can be achieved after opening the retroperitoneal space by
identifying and ligating the lacerated blood vessel or by ligating the
hypogastric artery. As with the other types of puerperal hematomas,
identification of a bleeding vessel may be difficult. Ligation of the ipsilateral
hypogastric artery usually stops the bleeding and avoids the delay
associated with searching for the discrete source of bleeding. If bleeding
does not respond to ipsilateral hypogastric artery ligation, then bilateral
hypogastric artery ligation should be performed. Although hypogastric
artery ligation reduces pelvic blood flow by approximately one-half, it has a
greater impact on pulse pressure distal to the ligation (85 percent
reduction), reducing pulse pressures to that of the venous circuit which
promotes hemostasis
• Retroperitoneal packing is a technique used by trauma surgeons to
tamponade retroperitoneal hemorrhage related to pelvic fracture; it
can also be useful to control retroperitoneal bleeding in obstetric
patients. Through a midline incision just above the symphysis pubis, the
fascia is divided and the space of Retzius accessed, with care to avoid
cystotomy. Two to three laparotomy sponges are placed sequentially in
the retroperitoneal space, beginning at the sacroiliac joint and staying
deep to the pelvic brim [18]. The same procedure is then performed on
the opposite side. The resulting tamponade generally leads to prompt
cessation of blood loss. The packs are removed or exchanged 24 to 48
hours later, with care to avoid disruption of clot.
Second stage of labor

The bladder is palpated, and if it is distended, catheterization may be

necessary
Continued attention is also given to fetal heart rate monitoring - nuchal
cord often tightens with descent and may lead to deepening variable
decelerations
Antibiotic prophylaxis against infective endocarditis is not recommended
for vaginal delivery in most women with
cardiac conditions
Exceptions are in women with cyanotic heart disease or prosthetic
valves or both - 30 to 60 minutes before the anticipated procedure
• During second-stage labor, pushing positions may vary. But
• for delivery, dorsal lithotomy position is the most widely used
• and often the most satisfactory.
• . Corton and associates (2012) found no
• increased rates of perineal lacerations with stirrup use compared
• to without their use

• encirclement of the largest head diameter by the vulvar ring is termed crowning. Unless
an episiotomy has been made as described later, the perineum
thins and especially in nulliparous women, may undergo spontaneous laceration. The anus becomes greatly stretched, and the
anterior wall of the rectum may be easily seen through it.

• episiotomy increases the risk of a tear into the external anal sphincter, the rectum, or
both.
• Conversely, anterior tears involving the urethra and labia are more common in women
in whom an episiotomy is avoided.
• To limit spontaneous vaginal laceration, some perform
• intrapartum perineal massage to widen the introitus for head
• passage. With this, the perineum is grasped in the midline byn both hands
using the thumb and opposing fingers. Outward
and lateral stretch against the perineum is then repeatedly
applied.
Slow delivery of the head may decrease
• The umbilical cord is cut between two clamps placed 6 to 8 cm from the fetal abdomen,
and later an umbilical cord clamp is applied 2 to 3 cm from its insertion into the fetal
abdomen.
• A plastic clamp that is safe, efficient, and fairly inexpensive, suchc as the Double Grip
Umbilical Clamp (Hollister)
• A delay in umbilical cord clamping for up to 60 seconds may increase total body iron
stores, expand blood volume, and decrease anemia incidence in the neonate
•
For the preterm neonate, delayed cord clamping has several
• benefits. These include higher red cell volume, decreased need
• for blood transfusion, better circulatory stability, and lower
• rates of intraventricular hemorrhage and of necrotizing enterocolitis