Evidence Based Nursing

Name: Sarah Jean M. Vipinosa Date: November 16, 2013 Section/Group No. BSN406 Group 23B Article from: __EBSCO __OVID

I.Clinical Question How to diagnose early and managing a patient who is in a vulvar hematoma? II.Citation Spontaneous intrapartum vulvar haematoma III.Study Characteristics 1. Patients included (population and sample) A 28-year-old, G6P5 woman at 40+3 weeksgestation 2. Interventions compared No intervention compared 3. Outcomes monitored It was suggested that prompt surgical treatment helps to stop the pain, prevent further bleeding and tissue distraction and minimise risk of infection. Surgical treatment on a vulvar haematoma should be performed in an operating theatre with adequate analgesia. The haematoma should be widely opened through an accessible area, all clots should be evacuated and bleeding vessels ligated or diathermised. The majority of authors favour the layered closure of the wound. The cavity should be drained, however, it does not usually improve outcome. 4. Does the study focus on a significant problem in clinical practice. Yes, because spontaneous non-traumatic vulvar haematomas are unusual but should be recognised and managed promptly by clinical practices. And this vulvar haematomas are uncommon complications of pregnancy and usually result from traumatic injury in nonpregnant women or as a complication of delivery of the baby.

IV.Methodology/Design 1. Methodology Used Not mentioned 2. Design Not mentioned 3. Setting Hospital setting- Wexham Park Hospital (Department of Obstetrics and Gynaecology/Sugery) 4. Data Sources non-pregnant women or as a complication of delivery of the baby 5. Subject Selection a. Inclusion Criteria Postpartum or puerperal vulvar haematomas b. Exclusion Criteria None 6. Has the original study been replicated? No 7. What were the risks and benefits of the nursing action/intervention tested in the study? Associated risk factors, such as pre-eclampsia, clotting disorders, multiple gestation, operative vaginal delivery, nulliparity and genital tract varicosities. V.Results of the study 1. Discuss briefly the results of the study. Haemodynamic status and cardiovascular stability must be determined prior to surgical intervention. Conservative management can be considered when the single digit dimension of the haematoma is less than 5cm and it does not expand. It was suggested that prompt surgical treatment helps to stop the pain, prevent further bleeding and tissue distraction and minimise risk of infection.

2. If the original study has been replicated, are the findings similar in a variety of situations? none VI.Authors Conclusions/Recommendations 1.What contribution to client health status does the nursing action intervention make? Early diagnosis and prompt and appropriate management of the patient allowed good recovery without any further complications. 2.What overall contribution to nursing knowledge does the study make? The overall contribution to nursing knowledge about spontaneous non-traumatic vulvar haematomas are unusual but should be recognised and managed promptly. Management can be surgical, if the haematoma is over 5cm in size and rapidly expanding, or conservative, if less than 5cm in diameter. Prompt surgical management reduces pain, prevents tissue distraction and decreases the risk of infection. Conservative management includes broadspectrum antibiotics, good analgesia and close observation. Prompt resolution of haematoma will reduce scarring, postpartum pain and dyspareunia. VII.Applicability 1. Does the study provide a direct enough answer to your clinical question in terms of type of patients, intervention and outcome? Yes, since some of the management in treating hematoma are all in this article. For additional: An icepack is placed over the perineum and left in place for 24-48 hours. This will help control the pain and limit swelling and further bleeding into the hematoma. A Foley catheter is inserted and left in place. The local swelling may be sufficient to impair voluntary voiding and the Foley is much easier to insert earlier in the process. Bedrest for several days to a week. Appropriate analgesia. Initially, this may need injectable narcotics. Later, oral narcotics and then NSAIDs will give satisfactory results. Dramatic resolution will occur. When completely healed in a few weeks, the vulva will look normal and function normally. Most of these hematomas will not require surgical exploration and drainage. If you explore them, in about half the cases, no bleeding point will ever be found. Opening them introduces bacteria into an otherwise sterile hematoma.

Particularly in operational settings, ice, Foley and bedrest are usually better choices for treatment. In following these, it may prove useful to measure the hematoma with a tape measure to compare the size over time. As they are feeling less pain, patients will often feel that the hematoma is enlarging. Having objective measures of its' size will be very reassuring to the patient.

2. Is it feasible to carry out the nursing action in the real world? Yes, since all the management being performed are all practiced in the medical field. VIII.Reviewers Conclusion / Commentary Traumatic disruption of the female perineum is not uncommon. Women are at risk during parturition additionally, their increasing participation in sports activities increases the incidence of injury to this area. Tragically, women continue to be the victims of sexual abuse; however, many of these injuries involve only superficial structures and heal spontaneously with local care. When tissue disruption extends to deeper tissue planes or involves the vascular anatomy or structural integrity of the perineal support system, operative intervention is required.