Hematoma questions

[Free Thinker]

After the birth of my second baby I had a hematoma, which my Dr. described as trauma causing lots of internal buising and bleeding, that eventually swells up into a lump, and he cut it to allow it to bleed so that I wouldn't need surgery later on. It did heal up, but took MONTHS to stop hurting. It was very bruised, much more than my previous birth (and the fist one was bigger?). This time around I would like to know if there is anything I can do to prevent having another hematoma? Am I more likely to have one since I had one before? What exactly causes it? When I had her head out, and she started to turn the kept telling me to not push, and while it was hard, Imanaged to wait until she was turned a bit. It was also a quick labor and delivery IMO. I only pushed 3 times. Any tips or info would be appreciated. Most info I could find on hematoma was related to post surgery, not childbirth.

[Free Thinker]

bumping, any info on hematomas is greatly appreciated!

[Jane]

Well, a hematoma is a broken vessel inside the skin. If the skin was ruptured, too, it would be a tear, but if it's unbroken, it's a hematoma.
When a vessel gets broken and it's big enough that the body can't clot it, all the blood will continue to flow out until there is no room left in the tissues. The soft tissues of the vagina aren't that restrictive, so lots of blood can accumulate. This triggers the nerves that register "stretch" and it can be really, really, really painful. When a mama has an unusual amount of pain in the hours after birth, looking for a hematoma is on the differential because it's one of the things that can be sooo painful, and yet everything seems okay.

So, why a hematoma? Well, something pointy on the baby went over a weak vessel that was near the surface. Or, the baby somehow stretched the tissues beyond the vessel's ability to stretch. Or it would have stretched if given time to stretch.

I suspect that that vessel might not be there anymore. Or it might be in a different area. Or have more muscle and connective tissue around it.

I don't think it will happen again. For prevention - good nutrition to try to have healthy tissues. Perhaps a waterbirth for the counterpressure of the water?

[mothercat]

Graphic and possibly scarey explanation

Can I just add one word of caution?
It's about the usual picture of a hematoma. Apricot is right about the amount of pain, but in the very rare occurence of a purely vaginal hematoma there is a lot of space in the pelvis that has little nerve supply. A lot of blood can accumulate and mom doesn't have much pain.
This is not something I learned in school but had experience with earlier this year. Mom had a very rare vaginal hematoma. We didn't know that's what is was , but her uterus was rock hard and rapidly rising and shifting right. She just started saying she really wasn't feeling well. Decided to transport because hematoma, even w/o the pain, felt like the right diagnosis. The EMT's, the nurses, and initially the doc all assumed it was clots in the uterus. In only a short time the doc also figured out it was a vaginal hematoma (hadn't seen one in 10 years practice) and mom went stat to surgery. Really needed the 2 units of blood she got.

I did a little research and could only find one paper about this type of hematoma. The risk factors are:
1) 1st baby
2) baby larger than 9#
3) mom 29 y/o

My poor client had all three.

The other thing about what makes hematomas dangerous and painful. As the blood begins to accumulate it causes additional splits between the muscles and the mucous membranes. This enlarges the area where blood can accumulate and more blood vessels tear in the process, causing more bleeding. The pain, although horrible, is a sign of the tamponade taking place. The blood has nowhere else to accumulate so the bleeding slows and clotting takes place because of the pressure that is created by your skin and the mucous membranes and supporting structures. The usual plan is not to do surgery if the woman becomes stable and you can give enough drugs to manage the pain. A lot of those bleeders are very small and almost impossible to tie off. Tamponade from the pressure is much safer, if mom is stable.

[Jane]

mothercat, good point. Anytime the mother's vital signs aren't stable post-partum, bleeding should be suspected, from hidden uterine bleeding, an unsuspected rupture, a hematoma, cervical tears, etc. If bleeding can't be seen, it could be a hematoma forming in the pelvis or abdomen. I don't think it should be too scary for a pregnant mama to hear about as a possibility. If her condition is not stable, it's obvious after a while. Not the cause of the problem sometimes, but that more investigation needs to be done.

I cared for someone who'd had a vaginal hematoma...and it did not repeat.

[mothercat]

A vaginal hematoma by itself is pretty rare so I'm hoping that that is the only one I ever see.

The dad felt the need to stay in the mom's hospital room and care for the baby. He just needed to feel grounded and the doctor had asked me to go to surgery with the mom to keep her calm until they did the general anesthesia. The anesthesiologist decided she was stable enough for a spinal so I stayed for the whole thing. I like and respect the doctor, but I could hear the fear and concern in her voice when she realized what was happening. It scared me when the anesthesiologist kept asking if the mom was still responding as I talked with her. She had minimal drugs but had lost a lot of blood. The loss was about 1200 cc.

I used to work postpartum in the hospital as a nurse and am aware that given the time of night that baby was born and mom was really tired, and she became unstable 3.5 hours after the birth; the circumstances were such that she may have bled out into that hematoma and no one would have known for several hours. One of the doctors told her this is why babies should be born in the hospital and I thought to myself, "This is precisely why women she could carefully watched by someone who knows them well."
We wasted time trying to convince staff that she was unstable for a reason other than a boggy uterus. What if it was a nurse at 3 AM trying to convince the doctor there was a problem?

A good example of the midwives model of care working well.

[Free Thinker]

Interesting, and thank you all for responding. I have none of those risk factors. Last time I was 24 (will be 27 this time), and baby was a full 1lb4oz smaller than my first baby, and just a 1/2 oz shy of 7lbs, so not big at ALL compared to baby #1. Of course, w/ #1 I did get an episiotomy. I had my Dr. wait until I gave him permission to cut me (I was starting to tear upwards, OUCH!), and he just made a small incision, and she was out in no time. The second baby they again had instructions to not cut me unless I asked them to, and I didn't end up w/ any tears at all, but then he had to cut where the hematoma was forming, it was about 3 little cuts he made, none big enough to need stitches. He did this while she was still attached to the placenta, which was still inside me (sorry if TMI), so it wasn't very long of a wait, KWIM?

So for my next birth should I tell them to give me an epi if THEY think I need it, or should I stick w/ my "Do NOT cut me unless I give you permission" stance? (btw, my OB's office doens't to routine epis, they believe in doing the massage and helping the skin to streatch,ect). Is an epi better than a hematoma (it certainly healed up much quicker and without pain)?