Lower Genital Tract Lacerations and Hematomas



Lower Genital Tract Lacerations and Hematomas


Steven L. Clark



GENERAL PRINCIPLES



Physical Examination



  • Vaginal lacerations are typically diagnosed during a thorough examination of the lower genital tract that should follow every vaginal birth. The cervix undergoes lacerations during the course of vaginal birth in over half of cases; fortunately, most such tears are shallow and do not result in significant bleeding. Because cervical lacerations up to 2 cm in length are so common, the standard teaching is that cervical tears that are not bleeding do not require repair. However, cervical lacerations may bleed profusely, and if not recognized and repaired, may lead to serious maternal morbidity. Following any vaginal birth, the full circumference of the cervix must be examined visually, using assistants with retractors and ring forceps as necessary.


  • Hematomas are generally visualized upon perineal/vaginal examination within an hour or two of birth.


Differential Diagnosis



  • Laceration


  • Hematoma


Nonoperative Management



  • If lacerations are not bleeding, they generally do not require surgical repair. Small hematomas causing minimal pain may also be observed and managed without operation if they are not expanding.


IMAGING AND OTHER DIAGNOSTICS



  • No imaging is typically required. With high vaginal or cervical lacerations that may extend abdominally, ultrasound or computed tomography (CT) scanning may be helpful.


PREOPERATIVE PLANNING



  • Most lacerations are repaired at the time of diagnosis. In general, sufficient exposure may be obtained in the delivery room without the need for additional anesthetic support. This is facilitated by the common use of epidural anesthesia for labor. However, the clinician should never hesitate to request an assistant to give additional exposure with retractors, or to take the patient to the operating room (OR) if exposure in the delivery room is difficult, or if an extensive repair is necessary.


  • Many hematomas that require evacuation will require transfer to the OR and the use of conduction or general anesthesia.


SURGICAL MANAGEMENT


Positioning



  • Obstetric stirrups

Sep 9, 2022 | Posted by in OBSTETRICS | Comments Off on Lower Genital Tract Lacerations and Hematomas
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