Case study!!!

Vulvar hematomas occur rarely outside the obstetric population but may present after other trauma to the pelvis or perineum. Spontaneous rupture of the internal iliac artery is described mostly in the presence of an aneurysm, with atherosclerosis, connective tissue disease, infection, and trauma as causative factors. It most often presents with abdominal pain and neurologic or urologic symptoms. We present an unusual case of a spontaneous rupture of the internal iliac artery that presented as a vulvar hematoma in a nulliparous woman that was successfully treated with selective arterial embolization and surgical evacuation. The literature is reviewed and management options discussed. Explosion of a vulvar: Abstract BACKGROUND: Vulvar hematoma formation during a spontaneous vaginal birth is rare. Although conservative management or observation is an option, complications, including delivery obstruction and excessive vaginal bleeding, may occur. CASE: A woman presented in active labor with an enlarging vulvar hematoma reaching the size of a softball. Spontaneous vaginal delivery occurred with an "explosion" of the hematoma and excessive blood loss. To obtain homeostasis, the hematoma cavity was explored and the bleeding points sutured. CONCLUSION: With a large intrapartum vulvar hematoma, the risk of rupture exists. If it occurs, delivery should be accomplished expediently, homeostasis achieved rapidly and blood loss monitored closely. NTRODUCTION Any female child, adolescent, or adult with a complaint of vaginal pain or genital bleeding or swelling should undergo a careful examination to look for vulvar or vaginal trauma or laceration. It should also be kept in mind that patients with vulvar or vaginal trauma sometimes present with abdominal or low back pain as their chief complaint. External lesions can be identified easily, but need to be carefully evaluated for deeper extension. Internal lesions are more difficult to assess. Patients may not be forthcoming with details of the events that caused the trauma, therefore identifying those at risk is a crucial step in management. The history should always be consistent with the physical findings; further questioning is important if there is a discrepancy. The possibility of sexual abuse or assault must always be considered. ETIOLOGY Obstetrical Lacerations of the cervix, vagina, and/or vulva commonly occur during childbirth. Risk factors associated with lower genital tract trauma in the obstetrical setting include nulliparity, large baby, precipitous birth, operative delivery, and/or episiotomy.

Gynecological: Vulvar trauma The rich vascular supply to the perineum places it at risk for bleeding from trauma. Vulvar hematomas are the most common sequelae.In adult women, the labia majora are comprised of large fat pads, which act to protect the vulva against injury. In contrast, children lack well-developed fat pads in this area and often engage in play activities predisposing them to vulvar trauma; thus, they are more likely to sustain vulvar injuries than adults. A Caesarean section, (also C-section, Caesarian section, Cesarean section, Caesar, etc.) is a surgical procedure in which one or more incisions are made through a mother's abdomen (laparotomy) and uterus (hysterotomy) to deliver one or more babies, or, rarely, to remove a dead fetus. A late-term abortion using Caesarean section procedures is termed a hysterotomy abortion and is very rarely performed. The first modern Caesarean section was performed by German gynecologist Ferdinand Adolf Kehrer in 1881. A Caesarean section is usually performed when a vaginal delivery would put the baby's or mother's life or health at risk, although in recent times it has been also performed upon request for childbirths that could otherwise have been natural.

Anaesthesia Both general and regional anaesthesia (spinal, epidural or combined spinal and epidural anaesthesia) are acceptable for use during Caesarean section. Regional anaesthesia is preferred as it allows the mother to be awake and interact immediately with her baby.[53] Other advantages of regional anesthesia include the absence of typical risks of general anesthesia: pulmonary aspiration (which has a relatively high incidence in patients undergoing anesthesia in late pregnancy) of gastric contents and Oesophageal intubation.[54] Regional anaesthesia is used in 95% of deliveries, with spinal and combined spinal and epidural anaesthesia being the most commonly used regional techniques in scheduled Caesarean section.[55] Regional anaesthesia during Caesarean section is different to the analgesia (pain relief) used in labor and vaginal delivery. The pain that is experienced because of surgery is greater than that of labor and therefore requires a more intense nerve block. The dermatomal level of anesthesia required for Caesarean delivery is also higher than that required for labor analgesia.[54]

Recovery period: Typically the recovery time depends on the patient and their pain/ inflammation levels. Doctors do recommend no strenuous work i.e. lifting objects over 10 lbs., running, walking up stairs, or athletics for up to six weeks.

Complications of labor and factors impeding vaginal delivery such as

prolonged labour or a failure to progress (dystocia) foetal distress cord prolapse uterine rupture increased blood pressure (hypertension) in the mother or baby after amniotic rupture increased heart rate (tachycardia) in the mother or baby after amniotic rupture placental problems (placenta praevia, placental abruption or placenta accreta) abnormal presentation (breech or transverse positions) failed labour induction failed instrumental delivery (by forceps or ventouse. Sometimes a 'trial of forceps/ventouse' is tried out This means a forceps/ventouse delivery is attempted, and if the forceps/ventouse delivery is unsuccessful, it will be switched to a Caesarean section. overly large baby (macrosomia) umbilical cord abnormalities (vasa previa, multi-lobate including bilobate and succenturiate-lobed placentas, velamentous insertion) contracted pelvis

Other complications of pregnancy, preexisting conditions and concomitant disease such as

pre-eclampsia hypertension [20] multiple births precious (High Risk) Fetus HIV infection of the mother Sexually transmitted infections such as genital herpes (which can be passed on to the baby if the baby is born vaginally, but can usually be treated in with medication and do not require a Caesarean section) previous Caesarean section (though this is controversial see discussion below) prior problems with the healing of the perineum (from previous childbirth or Crohn's Disease) Bicornuate uterus

Other

Lack of Obstetric Skill (Obstetricians not being skilled in performing breech births, multiple births, etc. [In most situations women can birth under these circumstances naturally. However, obstetricians are not always trained in proper procedures])[21] Improper Use of Technology (Electric Fetal Monitoring

There are two main types of cesarean operations, each named according to the location and direction of the uterineincision: 1.Cervicala transverse(horizontal) or vertical incision in the lower uterus, and2.Classicala vertical incision in the main body of the uterus

Choosing CS 1. Convenience. A scheduled c-section would allow a woman to choose the time and date of delivery to avoid conflicting with work or familyobligations.2.Fear of childbirth. A woman might fear the pain of labor and delivery and feel that a scheduled c-section would allow her to circumvent it 3. Avoiding risks of vaginal delivery. Certain risks inherent to vaginal delivery (urinary or rectal The cesarean can also be a lifesaving procedure when the following conditions are present: Placenta previawhen the placenta blocks the infant from being born. Abruptio placentewhen the placenta prematurely separates from the uterine wall and hemorrhage occurs. Obstructed laborwhich can occur with a fetus in the shoulder breech, or any other abnormal position. Ruptured uterus. Presence of weak uterine scars from previous surgery or cesarean. Fetus too large for the mothers birth canal. Rapid toxemiaa condition in which high blood pressure can lead to convulsions in late pregnancy. Vaginal herpes infectionwhich could infect an infant being born vaginally, and lead to its eventual death. Pelvic tumorswhich obstruct the birth canal and weaken the uterine wall. Absence of effective uterine contractions after labor has begun. Prolapsed of the umbilical cordwhen the cord is pushed out ahead of the infant, compressing the cord and cutting off blood flow. Risks and Complications for the Mom: Take into account that most of the following risks are associated with any type of abdominal surgery. Infection Hemorrhage or increased blood loss: Injury to organs Adhesions Extended hospital stay:

Extended recovery time: Reactions to medications: Risk of additional surgeries Maternal mortality Emotional reactions