Vaginal Laceration

Vaginal laceration is a tear in the vaginal wall, either an extension of a perineal tear or a separate sulcal tear in the upper vagina. It is more common after forceps and vacuum delivery. It results from rapid expulsion, a large baby, rotational delivery and weak vaginal tissue. It matters because it causes bleeding with a firm uterus, haematoma, infection and later dyspareunia.

• Risk factors: instrumental delivery, precipitate labour, macrosomia, first labour, shoulder dystocia, previous tears.
• High sulcal tears are easily missed.
• Careful examination after every birth finds them.

Women have bleeding from the vagina with a firm uterus, perineal or vaginal pain, and in large tears a feeling of pressure or inability to pass urine. Examination shows a laceration, often along the sulcus.

• Bright red steady bleeding with a contracted uterus.
• Pain and swelling in the vagina.
• Differential diagnosis: uterine atony, cervical laceration, retained placenta, vaginal haematoma, uterine rupture, perineal tear.
• Complications: postpartum haemorrhage, vaginal haematoma, infection, wound breakdown, vaginal stenosis, dyspareunia, rectovaginal or vesicovaginal fistula in deep tears.

The diagnosis is made by inspection of the whole vagina after the third stage with light and a speculum.

• Inspect the vagina to the cervix; digital rectal examination to check for rectal and sphincter involvement.
• Uterine tone, fundal height and blood loss.
• Pulse, blood pressure, haemoglobin if bleeding was heavy.
• Assess for haematoma and urethral involvement.

The principle is to repair the tear in layers from the apex, with analgesia and good exposure.

• Supportive: lithotomy in theatre with good light and an assistant; vaginal retractors; bladder catheter; ice packs for 24 hours; sitz baths twice daily from day 2; resume intercourse after healing and review.
• Pharmacological: lignocaine 1 percent 10 to 20 mL (maximum 3 mg/kg, not above 200 mg) or spinal or epidural for high tears; oxytocin 10 IU IM after birth and 20 IU in 1 litre Ringer's lactate at 125 mL per hour for 4 hours; tranexamic acid 1 g IV over 10 minutes for bleeding above 500 mL; cefazolin 2 g IV as a single dose for deep tears; amoxicillin-clavulanate 625 mg oral 8-hourly for 5 days for extensive tears; paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours); diclofenac 50 mg oral 8-hourly for 3 days if no contraindication.
• Procedures: repair with continuous 2/0 polyglactin, starting 1 cm above the apex, closing dead space without tension; packing the vagina for 12 to 24 hours with a tampon or gauze (with catheter in place) for oozing; laparotomy for a tear extending above the vagina into the broad ligament.
• Red flags: persistent bleeding, expanding vaginal or vulval swelling, rectal pressure, inability to pass urine, fever above 38 degrees Celsius, foul discharge.
• Follow-up: remove the pack and catheter after 12 to 24 hours; wound review at 1 week; review at 6 weeks with a speculum examination if there were deep tears.