Vaginal/Vulvar Hematoma

A vaginal or vulvar hematoma is a collection of blood in the soft tissues of the genital tract after childbirth. Delivery can tear vessels in the richly vascularized perineal plexus, even when the skin incision or laceration appears small. Blood then dissects into tissue planes rather than exiting onto a pad. That is why the visible lochia may look modest while the patient develops severe pain, pressure, swelling, tachycardia, or shock. The injury is most often associated with operative vaginal delivery, episiotomy, or a prolonged second stage of labor. Nulliparity, a newborn weighing more than 4000 g, vulvar varicosities, and maternal clotting disorders add risk. The condition is uncommon, reported in approximately 1 in 300 to 1 in 1500 deliveries, but its concealed blood loss makes it dangerous to dismiss. A small leak into a confined perineal space behaves differently from blood spilled onto a pad: the pressure builds where it cannot be seen easily. Increasing tissue pressure accounts for pain that may be severe or disproportionate to the external appearance. As the collection enlarges, it can compress the urethra...