Vaginal/Vulvar Hematoma

A postpartum vaginal or vulvar hematoma forms when childbirth injures vessels in the richly vascularized perineal or vaginal plexus. Blood then collects and dissects through surrounding tissue rather than leaving the body as visible vaginal bleeding. This is why the external blood loss can appear modest while the patient’s circulating volume is falling. The usual triggers are operative vaginal birth, episiotomy, and a prolonged second stage of labour. Risk also rises with nulliparity, a macrosomic infant weighing more than 4,000 g, vulvar varicosities, and maternal coagulation disorders. Reported frequency varies from approximately 1 in 300 to 1 in 1,500 deliveries. An experienced nurse notices a change in the quality of postpartum pain. Expected perineal soreness should gradually settle and remain proportionate to the birth trauma. Hematoma pain is often sudden, severe, progressive, unilateral, or described as deep pressure or fullness. A tense asymmetric swelling, new ecchymosis, rectal pressure, or difficulty passing urine adds weight to the concern. A hematoma can enlarge slowly and then destabilize the patient. As pressure rises within the tissue, pain increases and the urethra or vaginal...