NSVD with a vulvar hematoma

  1. My patient had a beautiful vaginal delivery, delivered a 7 lb baby after pushing for a half hour. I recovered her for a half an hour and then reported off to the day shift. Ends up, she developed a vulvar hematoma and had to go back to the OR where they drained 75mls from it.

    Her recovery seemed to be going so "normal" to me. She had had an epidural and had just started feeling discomfort with the fundal checks when I left. Had this happened to anyone? The day shift said that she started reporting severe vaginal pain. Would it have appeared swollen to me? Did I miss something? From what I have read, this usually occur after vacuum delivery, but hers was such a straightforward vaginal delivery. thoughts??
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  2. 7 Comments

  3. by   RNLaborNurse4U
    I believe that a hematoma can happen at any vaginal delivery, but traumatic deliveries (operative deliveries, etc) increase the risk. Sounds like she was one of the unlucky few who developed a hematoma with obvious risk factors.
  4. by   bagladyrn
    No, it's not always obvious. If the hematoma is external, the one side of the labia may appear swollen and firm to the touch. If inside the vagina, the most common complaint from the pt. may be a feeling of needing to move her bowels. (The swelling puts pressure on the associated nerves, leading to that feeling).
  5. by   NPinWCH
    In 12 years I've only cared for 1 woman who developed a hematoma, except this one was vaginal. G2 P1 6 hrs of labor, no epidural pushed about 40-50 min and delivered a nice 8 1/2 # baby with a 1st degree laceration.

    She didn't complain much in labor, but about 30 min after doc finished repair and left for home she started complaining about vaginal pain. I assessed her perineum, but couldn't see anything mild edema, redness but approximated, so I medicated her with 2 percocet and 800mg Motrin but she couldn't sit still she just kept bouncing around the bed from side to side. I called doc, gave her some demerol she didn't have any relief and pain was getting worse...called him back he said, "leave me alone!".

    I went in with a light, seperated her labia and lo and behold a large purple thing was starting to bulge from her vagina. At first I thought it might be her cervix, but I had another nurse check and then we called the doc and told him we were pretty sure she had a hematoma and I insisted he come in. After being yelled at, "My patients NEVER get hematomas!!" He took her to OR, and drained 750 mls!! OUCH! I then got to give her 2 units prbc, since by then she was symptomatic and her hgb was down to 6.

    All of the above happened in a little under 2 hours...these things can develop fast and get HUGE!
  6. by   NurseNora
    Above poster is right--they can come on quickly and be severe. If you have a patient who exhibits unusual amounts of perineal or vulvar pain that is unrelieved by the usual pain medications, suspect a hematoma. The ones in the vaginal wall don't usually show until they get as big as the one mentioned above. Sometimes, turning the patient on her side and pressing on either side of the perineum will allow you to feel one side as being harder than the other, indicating a hematoma. But not always.

    The most important sign for me is the first one I mentioned--extreme pain, unrelieved by the usual measures. Others, as mentioned, are rectal pressure, visable swelling, occult swelling you can feel, change in patient's vital signs. But by the time her vital signs change, it'll be huge.
  7. by   OzMW
    They can be huge. Did your woman have sutures? They can occur if the apex of a tear isn't picked up in the start of the suturing.
  8. by   ElvishDNP
    We had a lady a few years ago get close to DIC from her hematoma...got like 8u PRBCs & I can't remember how many of plts. Freakin' scary. I always get a little nervous when my mamas' bottoms don't feel better after the ice/topicals/motrin and/or perc combo.
  9. by   33-weeker
    Quote from rninwch
    In 12 years I've only cared for 1 woman who developed a hematoma, except this one was vaginal. G2 P1 6 hrs of labor, no epidural pushed about 40-50 min and delivered a nice 8 1/2 # baby with a 1st degree laceration.

    She didn't complain much in labor, but about 30 min after doc finished repair and left for home she started complaining about vaginal pain. I assessed her perineum, but couldn't see anything mild edema, redness but approximated, so I medicated her with 2 percocet and 800mg Motrin but she couldn't sit still she just kept bouncing around the bed from side to side... All of the above happened in a little under 2 hours...these things can develop fast and get HUGE!
    I'm a nursery nurse, but worked PP for about a 1 1/2 years as a student. Had 1 lady develop one of these PP vag. As it got worse, she just kept squirming and shifting - couldn't sit still in the bed. I remeber thinking check her for urinary retention, but then as the pain got worse and bladder was ok, we found the hematoma. I think we caught it farily early. It's been too long ago (late 80's) but I remember doc put a drain in. (penrose?) Anyhow, the bouncing, shifting or whatever in the bed is the giveaway. If it's not her bladder that's the problem - better get to checking her for a hematoma.

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