Lower Genital Tract Lacerations and Hematomas
Steven L. Clark
GENERAL PRINCIPLES
Definition
Lacerations (generally following vaginal delivery) that may involve the cervix, vaginal sidewalls, or perineum.
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
Procedures and Techniques
Cervical Lacerations
Bleeding lacerations of the cervix should be repaired with running, locked 2-0 or 3-0 absorbable suture (Tech Figure 5.2.1).
Keys to successful repair include adequate visualization and anchoring the initial stitch beyond the cephalad most extension of the tear.
Vaginal Wall Lacerations
Vaginal wall lacerations are most commonly seen laterally. Although repair is straightforward, it is not always simple, and as with cervical lacerations, may require assistance and potentially repair in the OR with additional anesthesia.
Repairs that are bleeding but do not extend into the ischiorectal fossa are generally closed with a technique similar to that used for the vaginal portion of an episiotomy with a running, locked 2-0 or 3-0 absorbable suture that is initially placed beyond the cephalad most extension of the incision.
Deeper lacerations are often recognized when yellow adipose tissue is identified within the tear. In such cases, care must be taken to either rule out or identify and repair significant individual deep bleeding vessels before performing the running through-and-through repair of superficial tissues.
Failure to take this step may result in an expanding hematoma that requires reexploration and repair.
Tech Figure 5.2.1. Repair of a cervical laceration. The apex of the tear is first identified, a suture placed above the apex (A), and the laceration closed (B). (Reprinted from Beckmann CRB, Frank W, Smith RP, Barzansky BM, Herbert WNP, Laube DW. Obstetrics and Gynecology. 5th ed. Lippincott Williams & Wilkins; 2006.)
With deeper posterior vaginal wall lacerations, great care must be taken to avoid incorporating rectal mucosa into the suture line to avoid the development of a rectovaginal fistula; a finger inserted rectally will assist in proper suture placement.
With deeper anterior wall lacerations, closure may result in the inclusion of urethral or bladder mucosa in the suture line, with the subsequent development of urethral or vesicovaginal fistulae. A Foley catheter may assist the surgeon in the identification of the urethra and avoidance of such misplaced sutures.
Deep, higher anterior vaginal lacerations are uncommon but may require laparotomy for open closure. Unless a laceration in directly contiguous with an extension into the retroperitoneal space and vessels, such a vaginal laceration will not cause retroperitoneal bleeding.
Perineal Lacerations
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