CHHS17/287

Canberra Hospital and Health ServicesClinical ProcedureHaematoma Management following Vaginal Birth Contents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Alerts.........................................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Risk Factors.............................................................................................................2

Section 2 – Management..........................................................................................................3

Implementation........................................................................................................................ 4

Related Policies, Procedures, Guidelines and Legislation.........................................................4

References................................................................................................................................ 4

Search Terms............................................................................................................................ 4

Doc Number Version Issued Review Date Area Responsible PageCHHS17/287 1 27/11/2017 01/12/2021 WY&C - Maternity 1 of 5

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS17/287

Purpose

Midwives and medical officers will initiate and provide appropriate care and interventions for women who develop a haematoma following a vaginal birth.

To quickly identify and manage vulval and vaginal haematomas appropriately.

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Alerts

Vulval/vaginal Haematomas can develop rapidly and lead to significant pain and maternal haemodynamic compromise. Prompt recognition and management is required to prevent adverse outcomes.

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Scope

This document applies to the following Canberra Hospital and Health Services (CHHS) staff working within their scope of practice: Medical Officers Registered Midwives and Nurses Student Midwives and Nurses under direct supervision.

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Section 1 – Risk Factors

Risk factors: episiotomy instrumental birth primiparity prolonged second stage of labour macrosomia multiple pregnancy vulval varicosities preeclampsia perineal repair where haemostasis has not been adequately achieved.

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Section 2 – Management

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The three primary approaches for managing puerperal haematomas are 1. Conservative management with observation and supportive care 2. surgical intervention 3. selective arterial embolisation.

After birth observe the woman for the following signs and symptoms of vulval or vaginal hematoma feeling of pain/fullness in vagina or rectum pain that is disproportionate to that expected with an episiotomy or tear hardness and swelling of vulval area excessive bruising signs of maternal compromise disproportionate to observed/ measured blood loss unusually small or no visible signs of blood loss.

Procedure advise the Obstetric Registrar/Consultant promptly if a haematoma is suspected or

discovered monitor the woman’s haemodynamic state rigorously perform gentle vaginal examination if required with consent if vaginal wall haematoma is

suspected. Ensure the woman is positioned as comfortably as possible and ensure adequate pain relief and good visualisation

if the hematoma is at the site of a laceration that has been repaired, the repair may need to be taken down by the Obstetric Registrar/Consultant staff to evacuate the hematoma. The hematoma cavity is inspected to determine the extent of the injury and identify bleeding vessels, which are individually ligated

ensure adequate pain relief; psychological support, Ice packs, Nitrous oxide and oxygen, +/- IMI analgesia may be necessary

frequent observations of vital signs as haemodynamic compromise can be significant. Refer to MEWs pathway

catheterise if the woman is unable to pass adequate volumes of urine. Ensure adequate analgesia for the procedure

bleeding may track posteriorly, vaginally, or into the retroperitoneum and may not be immediately recognised. Monitor pain level, swelling and haemodynamic status frequently

document in the clinical records a description of the size and position of haematoma and treatment

puerperal hematomas should be suspected in all postpartum women who demonstrate signs of acute blood loss or hypovolemia, such as unexplained tachycardia, loss of consciousness/ syncope or decreased urine output

there is no evidence regarding the benefit of antibiotic therapy for women experiencing a haematoma

should evacuation under general anaesthetic be required, keep woman fasted and facilitate transfer to theatre.

Outcomes

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The woman remains haemodynamically stable The haematoma is identified and managed effectively to minimise blood loss, other

morbidity and pain discomfort is relieved effectively with appropriate analgesia and positioning the woman is aware of what has occurred and the necessary interventions.

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Implementation

This guideline will be discussed at Multidisciplinary Education and Unit meetings. It will be available to access via Policy and Clinical Guidance on the ACT Health Intranet.

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Related Policies, Procedures, Guidelines and Legislation

Policies Consent and treatment

Procedures Clinical Procedure, Perineal Care- Maternity

Guidelines Clinical Guideline, Obstetric Emergencies

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References

1. South Australian Perinatal Practice Guidelines Puerperal genital haematomas (2012) http://www.sahealth.sa.gov.au/wps/wcm/connect/149020804eedac35b186b36a7ac0d6e4/Puerperal-genital-haematomas-WCHN-PPG-22052013.pdf?MOD=AJPERES&CACHEID=149020804eedac35b186b36a7ac0d6e4

2. Qld Government Clinical Guideline (2012) Perineal Care https://www.health.qld.gov.au/__data/assets/pdf_file/0022/142384/g_pericare.pdf

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Search Terms

Vulval, Haematoma, Perineum, Vaginal

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Doc Number Version Issued Review Date Area Responsible PageCHHS17/287 1 27/11/2017 01/12/2021 WY&C - Maternity 4 of 5

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS17/287

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval 15/11/2017 Complete Revision Penny Maher, A/g DON

WY&CCHHS Policy Committee

This document supersedes the following: Document Number Document Name3.2.14 Maternity - Haematoma Management Following a Vaginal Birth

Doc Number Version Issued Review Date Area Responsible PageCHHS17/287 1 27/11/2017 01/12/2021 WY&C - Maternity 5 of 5

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register