Vulval Perineal Haematomas in the Immediate Postpartum Period and their Management

EDITORIAL COMMENT: We accepted this paper for publication because there are surprisingly few papers in the literature about how best to deal with vaginal lacerations and pelvic haematomas. It is generally agreed that postpartum haemorrhage from the uterus cannot be dealt with effectively by packing the uterus because the uterus distends, bleeding continues and the pack becomes dislodged. However bleeding from vaginal lacerations, with or without an associated episiotomy, is a different matter because the vagina lies within the bony basin of the pelvis and this can be effectively packed to give rapid haemostasis, if the blood is clotting normally, although the ribbon gauze pack must be long and wide (200 ± 10cm) and in the editor's experience 2 such packs need to be tied together to do the job properly. The pack should be moistened with obstetric cream so it can be introduced without causing trauma to the vagina. Since such packing occludes the urethra, an indwelling (Foley) catheter is required until the pack is removed, usually 12 hours later; healing of any unsutured vaginal lacerations is usually quite satisfactory (A). The editor has the indelible memory of a patient who in 1964, following a difficult mid‐forceps delivery, was seen to have large bilateral vaginal tears which bled profusely. There was no possibility of dealing with the problem with sutures and 2 packs as mentioned above were quickly inserted, together with an indwelling catheter, and the patient was given a 2‐pint blood transfusion. The pack was removed the next day without any further problems. At the 6 weeks postnatal visit the vagina was well healed but somewhat distorted. However at the patient's first antenatal visit in her next pregnancy, the vagina appeared normal and she proceeded to term and had an uneventful, safe delivery. Following this experience and throughout his obstetric lifetime, the editor always used a gauze pack in any patient who had a large episiotomy as a prophylaxis against a paravaginal or vulval haematoma. Cases of vulval haematoma reoccurring after an episiotomy has been repaired, sufficient to take the patient to theatre, as described in the 5 cases reported here, is a major surgical exercise which can probably be avoided, in many cases, by routinely packing the vagina when a large episiotomy repair has been necessary, as outlined above. During the subsequent 30 years of obstetric practice the editor was certainly not taking 1 in every 290 patients he delivered, the incidence herein reported, to theatre to deal with a vulval haematoma. This pack, catheter plus antibiotic regimen avoids serious morbidity and probably also mothers’lives.