Hematoma after a Vacuum Delivery
Dec 2012 – by T. Barrett, MD
Case: Two hours after a vacuum delivery a gravida 2 female complains of vaginal pain and a “ball down there.” On inspection a 9 x 5 cm mass, with a reddish hue is protruding from the right side of her vulva. The mass extends from the perineal body to the mons. The overlying skin is taut. You make the diagnosis of vulvar hematoma.
Puerperal hematomas can occur after spontaneous or operative vaginal delivery. Frequently cited risk factors include the use of instruments (vacuum or forceps), nulliparity, preeclampsia, coagulation disorders, multiple gestation and improper surgical repair of an episiotomy. The patient usually complains of pain or an inability to void depending on the size and location of the hematoma.
The mechanism of puerperal hematoma formation in the anterior and posterior triangles involves rupture of branches of the internal pudendal and inferior rectal arteries, respectively. Rupture of descending branches of the uterine artery can cause paravaginal hematoma formation. Rupture of any vessel of the perineal venous plexus may also result in a hematoma. Trauma to the above mentioned vessels may also occur as a result of a compound presentation, rapid descent, lacerations from an operative vaginal delivery including unrecognized subcutaneous tissue caught in the vacuum cup. Vessel rupture can occur without laceration of the superficial tissue. Since the subcutaneous tissue in the vagina is quite pliable, hematomas can achieve massive dimensions before expansion ceases.
The diagnosis is generally obvious but should prompt a thorough vaginal examination to determine the extent of the lesion. The hematoma may be located at the vulva, may track into the vagina or may expand into the retroperitoneal space or abdominal cavity. In the latter case, blood loss can be concealed leading to hemodynamic instability if not recognized and addressed promptly. Clot formation can cause pressure necrosis and skin rupture resulting in life threatening hemorrhage. Imaging studies can help define the dimensions of the hematoma in situations where physical examination is insufficient. Vital signs and symptoms of hypovolumia should be monitored more frequently in situations where concealed bleeding is suspected. Failure to recognize on-going retroperitoneal bleeding can be fatal.
Management depends on prompt recognition and the clinical acumen of the patient care team. In some situations, the clot may provide sufficient pressure to tamponade bleeding vessels. If the hematoma is not acutely expanding, conservative measures such as ice packs, observation, pain management and bladder drainage may be all that is necessary. In situations where there is an acutely expanding hematoma or a concealed hemorrhage is suspected, more aggressive management is required. The patient’s Inpur and Output (I and O) should be closely monitored, intravenous access should be maintained in case fluid resuscitation and/or blood transfusion is a possibility, and the other members of the healthcare team, e.g. the Operating Room and Anesthesia personnel) should be notified. Surgical management includes prophylactic antibiotic administration, evacuation of the hematoma, identification and ligation of the bleeding vessel(s) and repair of the cavitary defect left from the evacuated hematoma. Artery embolization has been used successfully to manage on-going hemorrhage in situations where bleeding is not controlled with conventional surgical techniques.
Benrubi G, Neuman C, Nuss RC, Thompson RJ. Vulvar and vaginal hematomas: a retrospective study of conservative versus operative management. Southern Medical Journal. 80(8):991-994, 1987.
Hankins, G, et al. eds. (1995) Operative Obstetrics, New York: Appleton & Lange, p. 257-268.
Cunningham FG, et al. eds. (2010) Williams Obstetrics, New York: McGraw-Hill, Chapter 35.