Genital Tract Haematomas and Lacerations
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Direct answer
Genital tract haematomas and lacerations are soft-tissue injuries sustained during vaginal delivery, most often bleeding into the vulva or paravaginal space, or tearing of the perineum and cervix. Vulval and paravaginal haematomas present with pain and swelling, and large or expanding collections need surgical evacuation. Perineal tears are graded from first to fourth degree and repaired in layers.
What you must remember
- Vulval haematoma: Bleeding in the labia below the pelvic floor, presenting as a tense, painful swelling; small ones can be managed with ice and analgesia.
- Paravaginal haematoma: Bleeding above the pelvic floor, often silent until blood loss and shock develop, and diagnosed by vaginal examination and imaging.
- Cervical tear: Usually lateral, at the 3 and 9 o'clock positions, causing bleeding from the high vagina after delivery.
- First-degree tear: Involves perineal skin and vaginal mucosa only, without muscle; suturing is needed only if the edges are not well apposed or bleeding persists.
- Third-degree tear: Involves the anal sphincter complex, subdivided as 3a, 3b and 3c by how much of the sphincter is torn.
- Fourth-degree tear: Extends through the anal sphincter into the rectal mucosa, and needs careful repair by an experienced clinician.
- Repair order: Rectal mucosa first, then the anal sphincter, then the perineal layers, followed by a rectal examination to confirm the repair.
A classification you can apply at the bedside
Each injury needs a different response, so the first task is to name the site and the depth. The table summarises the usual management.
| Injury | Typical site | Usual management |
|---|---|---|
| Vulval haematoma | Labia and vulval tissue below the pelvic floor | Ice and analgesia if small, evacuation if large |
| Paravaginal haematoma | Space above the pelvic floor | Imaging, then surgical evacuation if expanding |
| Cervical tear | Lateral cervix | Suture repair after checking for bleeding |
| First and second degree tear | Skin, mucosa and perineal muscles | Layered repair |
| Third and fourth degree tear | Anal sphincter and rectal mucosa | Specialist repair in layers |
Clinicians should examine the anal sphincter and rectum after any perineal repair. A missed third or fourth degree tear is a recognised cause of later faecal incontinence.
Vulval haematomas are usually obvious on examination, whereas paravaginal haematomas can be missed. A high index of suspicion is needed in any woman with unexplained shock after delivery.
Where the exam tries to catch you
Questions on this topic test grading, the site of a haematoma and the repair order.
- Trap: Treating every vulval haematoma by incision and drainage. Correct: Small haematomas are often managed conservatively, and surgery is reserved for large, expanding or ongoing bleeding.
- Trap: Labelling a bleeding paravaginal haematoma as a perineal tear. Correct: Paravaginal haematomas lie above the pelvic floor and may be silent, so vaginal examination and imaging are needed.
- Trap: Assuming a third-degree tear needs no further check after repair. Correct: The rectum and sphincter are re-examined after repair, because a missed sphincter injury causes later incontinence.
- Trap: Repairing a fourth-degree tear by skin closure alone. Correct: The rectal mucosa, the sphincter and the perineal layers each need separate repair.
Frequently asked questions
Which genital tract haematoma presents with high vaginal swelling?
A paravaginal haematoma can present with high vaginal swelling and bleeding because it lies above the pelvic floor. It may be silent until shock develops. Diagnosis rests on vaginal examination and imaging, and surgical evacuation is needed if it expands.
What is the difference between a third-degree and a fourth-degree perineal tear?
A third-degree perineal tear involves the anal sphincter complex, while a fourth-degree tear extends through the sphincter into the rectal mucosa. Both are repaired in layers by an experienced clinician. Fourth-degree tears carry a higher risk of faecal incontinence if the repair is incomplete.
Which vulval haematoma needs surgical treatment?
A vulval haematoma that is large, expanding or still bleeding needs surgical evacuation and ligation of the bleeding vessel. Small haematomas can be managed with ice, analgesia and observation. The decision depends on the size and the trend of the swelling.
How are cervical tears repaired after delivery?
Cervical tears are usually repaired with absorbable sutures placed to control bleeding, after the uterus has been checked for retained tissue. Lateral tears at the 3 and 9 o'clock positions are the common ones. Bleeding from a high cervical tear should be assessed by speculum and vaginal examination.