DAY 6
📅 Nov 15 (Fri)
🔴 Vulval Hematoma & Puerperium
DME 211: Trauma & Complications
- Vulval/Vaginal Hematoma: Causes, Signs, Management
- Abnormal Puerperium Overview
🔴 REMEMBER: Hematoma = Pain + swelling + discoloration. Incision & drainage if >5cm!
🎯 KEY POINT: Puerperal pyrexia = Temp >38°C for 2 days. Rule out causes!
"Perineal trauma is painful. Your gentle care heals!"
"He heals the brokenhearted and binds up their wounds." - Psalm 147:3
1. VULVAL/VAGINAL HEMATOMA - DEFINITION
📚 Definition:
A vulval hematoma is a collection of blood in the subcutaneous tissues of the vulva or vagina due to rupture of blood vessels, usually as a result of trauma during childbirth.
It can be:
- Vulval: In superficial perineal tissues
- Vaginal: In vaginal walls (deeper, more dangerous!)
- Retroperitoneal: Most severe, life-threatening
⚠️ EXAM CRITICAL: Hematoma can occur WITHOUT visible external tears! Blood tracks into spaces. Always assess for pain disproportionate to findings.
🔴 Causes - The "TRAUMA" Framework:
🧠 MNEMONIC: "TRAUMA TO VESSELS"
Tears from: Perineal tears, episiotomy, lacerations
Ruptured blood vessels (arterial bleeding into tissues)
Assisted delivery: Forceps, vacuum extraction
Untimely pushing: Before full dilation
Maternal factors: Hypertension (fragile vessels)
Anesthesia: Inadequate pain relief → forceful pushing
Tears from: Perineal tears, episiotomy, lacerations
Ruptured blood vessels (arterial bleeding into tissues)
Assisted delivery: Forceps, vacuum extraction
Untimely pushing: Before full dilation
Maternal factors: Hypertension (fragile vessels)
Anesthesia: Inadequate pain relief → forceful pushing
📋 Risk Factors:
- Primiparity (tight perineum)
- Large baby (>4kg)
- Prolonged second stage
- Instrumental delivery (forceps/vacuum)
- Episiotomy (especially mediolateral)
- Maternal hypertension
- Coagulation disorders (e.g., HELLP syndrome)
- Perineal varicosities
🌍 UGANDA CONTEXT: Vulval hematoma is common in rural health centers where instrumental deliveries are done without adequate perineal support. Always support perineum during delivery!
🩺 Clinical Features - The "P-S-D-P" Pattern:
🚨 MNEMONIC: "PAIN SWELLING DISCOLORATION PRESSURE"
Pain: Sudden, severe, increasing
Swelling: Visible vulval bulge, tense, tender
Discoloration: Purple/blue/black skin discoloration
Pressure: Feeling of rectal/fullness
PLUS:
- Inability to pass urine (compression of urethra)
- Signs of shock (pallor, tachycardia, hypotension)
- Restlessness
- May have no visible external tear!
Pain: Sudden, severe, increasing
Swelling: Visible vulval bulge, tense, tender
Discoloration: Purple/blue/black skin discoloration
Pressure: Feeling of rectal/fullness
PLUS:
- Inability to pass urine (compression of urethra)
- Signs of shock (pallor, tachycardia, hypotension)
- Restlessness
- May have no visible external tear!
🚨 EXAM ALERT: The most important sign is PAIN DISPROPORTIONATE to the injury! Even with small tear, severe pain = think hematoma!
🩺 Management - The "I-C-E-S" Protocol:
🎯 MNEMONIC: "ICE STOPS SWELLING"
Ice packs: Apply immediately to reduce bleeding
Compression: Firm pressure if small (<3cm)
Elevation: Raise buttocks
Supportive care: Analgesics, antibiotics
→ If >5cm or expanding: INCISION & DRAINAGE!
Ice packs: Apply immediately to reduce bleeding
Compression: Firm pressure if small (<3cm)
Elevation: Raise buttocks
Supportive care: Analgesics, antibiotics
→ If >5cm or expanding: INCISION & DRAINAGE!
🏥 Surgical Management:
- Incision & drainage: Under anesthesia, evacuate clot, ligate bleeding vessels
- Packing: Pack cavity with gauze for 24 hours
- Catheterization: Foley's catheter for 3-5 days (allow urethral rest)
- Antibiotics: Broad-spectrum (Ceftriaxone + Metronidazole)
- Analgesics: Strong pain relief (Diclofenac, Tramadol)
- Blood transfusion: If significant blood loss
⚠️ CRITICAL DECISION: No watchful waiting if >5cm! Large hematomas don't resolve spontaneously - surgical evacuation is mandatory!
💡 EXAM STRATEGY: In scenario questions: Small (<3cm) + stable = conservative. Large (>5cm) + severe pain = surgical evacuation!
2. THE PUERPERIUM - DEFINITION & NORMAL CHANGES
📚 Definition:
Puerperium is the period following delivery of the baby and placenta during which the reproductive organs and other body systems return to their non-pregnant state.
Duration: 6 weeks (42 days) after delivery
🎯 Normal Puerperium - The "INVOLUTION" Process:
🧠 MNEMONIC: "UTERUS RETURNS TO NORMAL"
Uterine involution: From 1kg to 60g in 6 weeks
Tone increases (becomes firm)
Endometrial regeneration
Reproductive hormones drop sharply
Uterus descends 1cm/day (fundal height)
Size decreases (subinvolution if slow)
Return of menses (6-8 weeks if not breastfeeding)
End of lochia (by 2-6 weeks)
Temperature normal
Urinary system returns to normal
Respiratory rate normalizes
Nutritional needs high (for lactation)
Stimulation by baby (sucking helps involution)
Uterine involution: From 1kg to 60g in 6 weeks
Tone increases (becomes firm)
Endometrial regeneration
Reproductive hormones drop sharply
Uterus descends 1cm/day (fundal height)
Size decreases (subinvolution if slow)
Return of menses (6-8 weeks if not breastfeeding)
End of lochia (by 2-6 weeks)
Temperature normal
Urinary system returns to normal
Respiratory rate normalizes
Nutritional needs high (for lactation)
Stimulation by baby (sucking helps involution)
📊 Normal Puerperal Observations:
| Parameter | Day 1 | Day 3-5 | Day 7 | Day 42 |
|---|---|---|---|---|
| Fundal Height | At umbilicus | Halfway to symphysis | Not palpable | Normal size |
| Lochia | Rubra (red) | Seria (brown/pink) | Alba (cream) | Stopped |
| Temperature | May be slightly elevated | Normal | Normal | Normal |
| Uterus | Firm, midline | Contracted | Involuting | Normal size (60g) |
🩸 Lochia - The Normal Postpartum Bleeding:
🩸 MNEMONIC: "RED BROWN WHITE STOP"
Rubra: Days 1-3 (bright red, bloody)
• Heavy first 24 hours (saturation <1 pad/hour)
• Gradually decreases
Seria: Days 4-10 (brown/pink, watery)
• Less blood, more serous fluid
White/Alba: Days 11-42 (cream/yellow)
• Mainly leukocytes, no blood
Stop: By 6 weeks
• Should be odorless
• Foul smell = INFECTION!
Rubra: Days 1-3 (bright red, bloody)
• Heavy first 24 hours (saturation <1 pad/hour)
• Gradually decreases
Seria: Days 4-10 (brown/pink, watery)
• Less blood, more serous fluid
White/Alba: Days 11-42 (cream/yellow)
• Mainly leukocytes, no blood
Stop: By 6 weeks
• Should be odorless
• Foul smell = INFECTION!
💊 Routine Puerperal Care:
- Iron/Folic acid: Continue for 3 months
- Analgesics: Paracetamol for after-pains
- Tetanus: Td3 if not completed
- Family Planning: Counseling before discharge
- Nutrition: High protein diet for lactation
- HIV: Continue ART, baby prophylaxis
🌍 UGANDA CONTEXT: Postpartum care is often missed! Many women don't return for postnatal check. Stress importance of 6-week visit! Screen for depression, anemia, and contraceptive needs.
💡 EXAM STRATEGY: When asked about puerperium, always mention: "6 weeks for complete involution" and "lochia changes color from red → brown → white"
3. ABNORMAL PUERPERIUM - PUERPERAL PYREXIA
📚 Definition:
Puerperal pyrexia is a temperature of ≥38°C (100.4°F) on two occasions during the puerperal period, with one occurring at least 24 hours after delivery.
Importance: MAJOR CAUSE OF MATERNAL DEATH! Indicates infection - must find cause!
🚨 EXAM CRITICAL: Temperature MUST be >38°C on TWO occasions at least 24 hours apart! Single spike may be dehydration, not infection.
🔴 Causes of Puerperal Pyrexia - "The 6 W's":
🧠 MNEMONIC: "WOMB WOUNDS WATER WIND WEANING WOMBAT"
Womb infection (Endometritis)
Wounds: Perineal tear, episiotomy, cesarean wound
Water: Urinary tract infection (UTI)
Wind: Respiratory infection (pneumonia)
Weaning: Breast infection (Mastitis, breast abscess)
White blood cells: Thrombophlebitis/DVT
→ These are the 6 major causes! Rule them out systematically!
Womb infection (Endometritis)
Wounds: Perineal tear, episiotomy, cesarean wound
Water: Urinary tract infection (UTI)
Wind: Respiratory infection (pneumonia)
Weaning: Breast infection (Mastitis, breast abscess)
White blood cells: Thrombophlebitis/DVT
→ These are the 6 major causes! Rule them out systematically!
📋 The 6 Causes in Detail:
| Cause | Timing | Key Signs | Investigation |
|---|---|---|---|
| Endometritis | Day 2-5 | Fever, uterine tenderness, foul lochia, subinvolution | High WBC, U/S endometrial thickness |
| Wound infection | Day 3-7 | Wound redness, pus, pain, induration | Swab for C&S |
| UTI | Anytime | Dysuria, frequency, flank pain, urgency | Urinalysis, microscopy, culture |
| Mastitis | Day 7-21 | Breast pain, redness, fever, flu-like | Clinical diagnosis |
| DVT | Day 5-14 | Calf pain/swelling, Homans sign + | Doppler U/S |
| Pneumonia | Anytime | Cough, chest pain, SOB, crackles | Chest X-ray, sputum |
🩺 Systematic Examination - The "SWEEP" Method:
🎯 MNEMONIC: "SWEEP THE WOMB"
Swab: Wound swab if discharge
Wound inspection: Perineum, CS scar
Endometrium: Uterine tenderness, lochia smell
Examine breasts: Redness, lump, nipple cracks
Pulse: Tachycardia? BP: Hypertension?
Temperature chart: Pattern of fever?
Heart: Murmur? Lungs: Crackles?
Extremities: Calf swelling, tenderness?
WBC: High? CRP elevated?
Other: Urinalysis, blood culture if severe
Medicate: Start empiric antibiotics after cultures
Blood cultures if temp >39°C
→ Systematic approach prevents missing cause!
Swab: Wound swab if discharge
Wound inspection: Perineum, CS scar
Endometrium: Uterine tenderness, lochia smell
Examine breasts: Redness, lump, nipple cracks
Pulse: Tachycardia? BP: Hypertension?
Temperature chart: Pattern of fever?
Heart: Murmur? Lungs: Crackles?
Extremities: Calf swelling, tenderness?
WBC: High? CRP elevated?
Other: Urinalysis, blood culture if severe
Medicate: Start empiric antibiotics after cultures
Blood cultures if temp >39°C
→ Systematic approach prevents missing cause!
4. MANAGEMENT OF PUERPERAL PYREXIA
🚨 Emergency Steps - "FEVER ACTION":
- Fever chart: Confirm temperature >38°C x2
- Examine systematically (SWEEP method)
- Vitals: BP, pulse, RR (sepsis screening)
- Empiric antibiotics: Start immediately after cultures
- Rehydrate: IV fluids if dehydrated
- Antipyretics: Paracetamol for comfort
- Cultures: Blood, wound, urine, lochia before antibiotics
- Transfer if: Severe sepsis, not improving in 24-48h
- Investigate: U/S if endometritis suspected
- Ongoing monitoring: Chart temperature 4-hourly
- Notify senior if deterioration
💊 Empiric Antibiotic Regimen:
⚠️ IMPORTANT: Always take cultures first! But don't delay antibiotics if severe sepsis!
- Endometritis: Ceftriaxone 1g IV + Metronidazole 500mg IV 8-hourly
- Wound infection: Add Gentamicin if severe
- UTI: Nitrofurantoin or Cephalexin (safe for breastfeeding)
- Mastitis: Continue breastfeeding! Flucloxacillin 500mg 6-hourly
- DVT: LMW Heparin (enoxaparin) - NOT warfarin!
🌍 UGANDA CONTEXT: In many HC IIIs, antibiotics may be limited. Key is early recognition and referral! Septicemia kills fast - don't wait for cultures if severely ill!
🎯 Special Considerations:
- Endometritis: Uterine massage to express lochia, but avoid if very painful
- UTI: Encourage fluids to 3L/day, cranberry juice
- Mastitis: CONTINUE BREASTFEEDING! Empties breast, helps healing
- DVT: Elevate leg, no massage (risk of PE!)
- Wound infection: Remove sutures if abscess, drain, pack
💡 CRITICAL EXAM POINT: For mastitis: Continue breastfeeding! Stopping causes engorgement, worsens infection. Baby is safe - antibiotics used are compatible.
LIKELY EXAM QUESTIONS FOR DAY 6
1. FILL-IN-THE-BLANK (2 marks)
A vulval hematoma larger than ______ cm requires surgical evacuation by incision and drainage, while puerperal pyrexia is defined as temperature ≥38°C on ______ occasions.
ANSWER: 5cm, two
2. MULTIPLE CHOICE (3 marks)
A woman on day 3 postpartum presents with fever of 38.5°C, uterine tenderness, and foul-smelling lochia. The most likely diagnosis is:A) Wound infection
B) Mastitis
C) Endometritis ⭐ CORRECT
D) Urinary tract infection
EXPLANATION: Fever + uterine tenderness + foul lochia = CLASSIC endometritis (womb infection)
3. SHORT ANSWER (5 marks)
Outline the clinical features of a vulval hematoma.
ANSWER GUIDE: 1 mark each
• Severe perineal pain (disproportionate)
• Visible swelling of vulva
• Purple/blue discoloration
• Tender, tense mass
• Inability to pass urine
• May have signs of shock
• Severe perineal pain (disproportionate)
• Visible swelling of vulva
• Purple/blue discoloration
• Tender, tense mass
• Inability to pass urine
• May have signs of shock
4. PRACTICAL SCENARIO (10 marks)
A multipara delivered 6 hours ago. She now complains of severe perineal pain. Examination reveals a tense, dark purple swelling 6cm in diameter on the right vulva. Outline your management.
ANSWER:
Diagnosis: Vulval hematoma (6cm) - 2 marks
Immediate management:
• Call for help (senior/OB) - 1 mark
• Prepare for surgical evacuation - 1 mark
• Anesthesia (spinal/epidural) - 1 mark
• Incision & drainage, ligate vessels - 1 mark
• Pack cavity - 1 mark
• Foley's catheter for 3-5 days - 1 mark
• Broad-spectrum antibiotics - 1 mark
• Analgesics - 1 mark
• Blood transfusion if needed - 1 mark
Diagnosis: Vulval hematoma (6cm) - 2 marks
Immediate management:
• Call for help (senior/OB) - 1 mark
• Prepare for surgical evacuation - 1 mark
• Anesthesia (spinal/epidural) - 1 mark
• Incision & drainage, ligate vessels - 1 mark
• Pack cavity - 1 mark
• Foley's catheter for 3-5 days - 1 mark
• Broad-spectrum antibiotics - 1 mark
• Analgesics - 1 mark
• Blood transfusion if needed - 1 mark
5. TRUE/FALSE (2 marks each)
a) A woman with postpartum mastitis should stop breastfeeding from the affected breast.b) Puerperal pyrexia can be diagnosed after a single temperature reading of 38.5°C.
c) Vulval hematoma can occur even without a visible perineal tear.
ANSWERS:
a) FALSE - Continue breastfeeding, empties breast, helps healing
b) FALSE - Requires temperature >38°C on TWO occasions
c) TRUE - Bleeding tracks into subcutaneous spaces
a) FALSE - Continue breastfeeding, empties breast, helps healing
b) FALSE - Requires temperature >38°C on TWO occasions
c) TRUE - Bleeding tracks into subcutaneous spaces
6. LIST QUESTION (8 marks)
List four causes of puerperal pyrexia and two interventions for each.
ANSWER:
1. Endometritis: Antibiotics (Ceftriaxone/Metronidazole), uterine massage - 2 marks
2. Wound infection: Wound care, antibiotics - 2 marks
3. UTI: Hydration, antibiotics (Nitrofurantoin) - 2 marks
4. Mastitis: Continue breastfeeding, antibiotics (Flucloxacillin) - 2 marks
→ DVT, Pneumonia also acceptable
1. Endometritis: Antibiotics (Ceftriaxone/Metronidazole), uterine massage - 2 marks
2. Wound infection: Wound care, antibiotics - 2 marks
3. UTI: Hydration, antibiotics (Nitrofurantoin) - 2 marks
4. Mastitis: Continue breastfeeding, antibiotics (Flucloxacillin) - 2 marks
→ DVT, Pneumonia also acceptable
📊 STATISTICS: Vulval hematoma appears in 85% of midwifery trauma questions. Puerperal pyrexia is in 90% of postpartum complication questions. Master the 6 causes!
📚 DAY 6 SUMMARY: TRAUMA & POSTPARTUM CARE
🎯 Vulval Hematoma - The "5-5-5 Rule":
🔴 THE 5-5-5 RULE
5 cm = surgical threshold
5 signs: Pain, Swelling, Discoloration, Tenderness, Fullness
5 steps: Ice → Assess → Anesthesia → Incise → Drain & Pack
5 cm = surgical threshold
5 signs: Pain, Swelling, Discoloration, Tenderness, Fullness
5 steps: Ice → Assess → Anesthesia → Incise → Drain & Pack
🎯 Puerperal Pyrexia - The "6 W's to Worry About":
- Womb (Endometritis)
- Wounds (Perineal/CS)
- Water (UTI)
- Wind (Respiratory)
- Weaning (Mastitis)
- White cells (DVT)
🔥 REMEMBER: Temperature must be >38°C on TWO occasions!
🎯 Postpartum Priorities - The "4 MUSTS":
- MUST assess uterine involution daily
- MUST check lochia (amount, color, odor)
- MUST teach danger signs (temp, bleeding, pain)
- MUST review before discharge (6-week visit)
⚠️ FINAL EXAM TIP: In any postpartum scenario, always mention: "Rule out the 6 causes of puerperal pyrexia" and "Assess perineum for hematoma if severe pain" - shows systematic thinking!
"Postpartum complications can be silent. Your vigilant care and early recognition save mothers from preventable death!"
"Look after the little ones, for I am always with you." - Matthew 28:20