What is the management for a vulvar hematoma after vaginal delivery?

Management of Vulvar Hematoma After Vaginal Delivery

Vulvar hematomas after vaginal delivery require prompt recognition and management, with surgical drainage being the primary treatment for large or symptomatic hematomas to prevent complications and promote healing.

Assessment and Diagnosis

• Perform systematic evaluation including visual inspection and thorough perineal examination 1
• Differentiate between hematoma and abscess using characteristic features:
  • Hematoma: Fluctuant mass, may stabilize or improve over time, usually without systemic symptoms
  • Abscess: Progressive pain, significant erythema, marked warmth, systemic symptoms 2
• Ultrasound can help differentiate between hematoma and abscess when diagnosis is uncertain 2

Management Algorithm

Small Hematomas (<3-5 cm)

• Conservative management:
  • Close observation
  • Pain control with analgesics (NSAIDs and acetaminophen)
  • Ice packs for first 24-48 hours only (avoid prolonged use)
  • Avoid direct application of ice to prevent tissue damage 3

Large Hematomas (>5 cm) or Symptomatic Hematomas

1. Surgical drainage is the primary treatment:

   • Ensure adequate anesthesia
   • Make incision at the point of maximal fluctuance
   • Evacuate blood clots completely
   • Identify and ligate bleeding vessels
   • Explore for loculations 2

2. Post-drainage management:

   • Consider selective placement of drains for large cavities
   • Vaginal packing is optional and does not appear to decrease postoperative bleeding or hematoma formation 1
   • If used, remove packing within 24 hours to reduce infection risk 1

3. For refractory bleeding:

   • Consider arterial embolization as an effective alternative to laparotomy when suturing and packing fail 4
   • This minimally invasive approach can achieve hemostasis with minimal morbidity 4

Wound Care

• Clean the wound with warm water or saline solution during showering or sitz baths 2-3 times daily 2
• Apply non-adherent absorbent dressing to cover the wound 2
• For deeper wounds, consider alginate or hydrofiber dressings that can conform to the wound cavity 2
• Maintain good hygiene due to risk of fecal contamination 2

Antibiotic Considerations

• Antibiotics are generally not needed unless there are signs of systemic infection, immunosuppression, or extensive surrounding cellulitis 2
• If infection is suspected, consider culture of wound drainage and broad-spectrum antibiotics covering gram-negative and anaerobic bacteria 2

Follow-up and Monitoring

• First follow-up within 48-72 hours after drainage procedure 2
• Monitor for:
  • Signs of recurrent hematoma formation
  • Infection (increasing pain, redness, swelling, fever)
  • Delayed healing 2
• Subsequent follow-ups every 1-2 weeks until complete healing 2

Special Considerations

• For pregnant patients with vulvar hematomas, prompt recognition and treatment can allow for complete recovery and enable continuation of pregnancy with uncomplicated vaginal delivery 5
• In cases of large vulvar hematomas during labor, consider the risk of rupture during delivery and prepare for potential excessive blood loss 6
• Mode of delivery consideration: In the third trimester, cesarean delivery may be performed to prevent vulvar wound dehiscence. For smaller wounds that have already healed well, vaginal delivery remains an option 1

Complications to Monitor

• Infection and wound dehiscence (risk increases with larger hematomas)
• Excessive blood loss requiring transfusion
• Tissue necrosis from pressure effect of large hematomas
• Complications from overuse of cold therapy, which can impair local perfusion mechanisms 3