Vaginal/Vulvar Hematoma

A postpartum vaginal or vulvar hematoma forms when childbirth injures vessels in the richly vascularized perineal or vaginal tissues. Blood collects and dissects through surrounding tissue rather than necessarily leaving the body as visible vaginal bleeding. External blood loss can therefore appear modest while circulating volume is falling. Associated factors include operative vaginal birth, episiotomy, primiparity, hypertensive disease, and coagulopathy; a hematoma can also occur with an intact perineum. Notice a change in the quality and trajectory of postpartum pain. Hematoma pain is often severe, progressive, unilateral, or described as deep pressure or fullness. A tense asymmetric swelling, new bruising, rectal or pelvic pressure, or difficulty passing urine adds to the concern. A hematoma can enlarge and destabilize the patient. Continued concealed blood loss may produce worsening tachycardia, hypotension, pallor, dizziness, reduced urine output, altered mental status, and shock. The absence of heavy lochia does not make the situation safe.