When to Suspect a Vulvar Hematoma Post Birth
A vulvar hematoma should be suspected postpartum when a patient presents with painful vulvar swelling, ecchymosis, and perineal pain disproportionate to the visible trauma, especially when accompanied by hemodynamic changes or urinary symptoms. 1
Clinical Presentation
Primary Signs and Symptoms
- Painful, unilateral or bilateral vulvar swelling
- Ecchymotic discoloration of the vulva
- Perineal pain disproportionate to visible trauma
- Sensation of pressure in the perineum
- Difficulty sitting or walking due to pain
Associated Symptoms
- Urinary retention or difficulty voiding
- Hemodynamic instability (in severe cases)
- Progressive enlargement of vulvar tissues
- Visible bulging of perineal tissues
Risk Factors
Certain factors increase the risk of developing vulvar hematomas:
- Primiparity (first-time delivery)
- Instrumental deliveries (forceps or vacuum)
- Episiotomy, especially midline
- Prolonged second stage of labor
- Preexisting vulvovaginal varicosities
- Coagulopathies or anticoagulant therapy
- Precipitous delivery
- Large infant (macrosomia)
Diagnostic Approach
Physical Examination
- Systematic evaluation of the perineum with adequate lighting 1
- Visual inspection for asymmetric swelling and ecchymosis
- Palpation to assess tenderness, fluctuance, and extent
- Digital rectal examination to evaluate for concurrent rectal injury
- Assessment of hemodynamic stability (vital signs)
Imaging (when indicated)
- Ultrasound with Doppler: To evaluate size and vascular involvement
- CT with IV contrast: For suspected large or expanding hematomas to identify active bleeding 1
- CT angiography: When pseudoaneurysm is suspected or for persistent hemorrhage 1
Classification of Vulvar Hematomas
Vulvar hematomas can be categorized based on location:
- Vulvar hematoma: Limited to external genitalia
- Vulvovaginal hematoma: Involving both vulva and vagina
- Vaginal hematoma: Limited to vaginal tissues
- Pelvic-abdominal hematoma: Extension into pelvic or abdominal spaces 2
Management Considerations
The management approach depends on:
- Size of the hematoma
- Rate of expansion
- Hemodynamic stability
- Presence of active bleeding
- Associated symptoms (urinary retention, severe pain)
Small, Stable Hematomas (<5 cm)
- Conservative management with:
- Ice packs (important: limit to 20-30 minutes at a time, only for first 24-48 hours) 3
- Analgesics (NSAIDs if no contraindications)
- Perineal rest
- Close monitoring for expansion
Large or Expanding Hematomas (>5 cm)
- Surgical evacuation
- Identification and ligation of bleeding vessels
- Placement of drainage
- Hemodynamic support as needed
Hemodynamically Unstable Patients
- Immediate surgical intervention
- Blood product replacement
- Consider selective arterial embolization if bleeding source identified 2, 4
Complications to Monitor
- Infection of the hematoma
- Abscess formation
- Tissue necrosis
- Urinary retention
- Severe pain
- Wound dehiscence (if surgical evacuation performed)
- Recurrent bleeding
Common Pitfalls
- Failure to recognize: Vulvar hematomas may be missed during routine postpartum examination if not specifically looked for
- Underestimating severity: Small external hematomas may have significant extension into deeper tissues
- Overuse of cold therapy: Excessive application of ice can lead to tissue damage and delayed healing 3
- Delayed intervention: Waiting too long to intervene surgically when conservative management fails
- Inadequate pain control: Vulvar hematomas can cause severe pain requiring multimodal analgesia
Follow-up Recommendations
- Regular assessment of hematoma size and symptoms
- Monitoring for signs of infection (fever, increasing pain, purulent discharge)
- Evaluation of urinary function
- Assessment of wound healing if surgical evacuation performed
- Pain management optimization
Early recognition and appropriate management of vulvar hematomas are essential to prevent complications and improve maternal outcomes in the postpartum period.