Vulvar Laceration

Vulvar laceration is a tear of the labia, clitoral area, periurethral tissue or fourchette, usually from spontaneous birth, shoulder dystocia or operative delivery. It results from rapid crowning, a large baby, a tight introitus and previous scarring. It matters because bleeding can be heavy from the vascular tissue, periurethral tears cause urinary retention, and untreated tears heal badly and cause pain.

• Risk factors: first labour, macrosomia, instrumental delivery, precipitate labour, previous scars, female genital cutting.
• Periurethral and clitoral tears bleed heavily.
• Most superficial labial tears heal without suturing.

Women have bleeding and pain at the vulva after birth, with a visible tear in the labia, clitoral hood or around the urethra. Periurethral tears may cause difficulty passing urine.

• Bleeding at the vulva with a firm uterus.
• Burning pain on passing urine.
• Differential diagnosis: perineal tear, vaginal laceration, vulval haematoma, cervical laceration, uterine atony, urethral injury.
• Complications: haemorrhage, vulvar haematoma, infection, wound breakdown, urinary retention, dyspareunia, scarring and distortion, chronic vulvar pain.

The diagnosis is made by inspection of the vulva, with good light, after birth.

• Inspect labia, clitoris, urethral meatus, fourchette and hymenal remnants; identify bleeding points.
• Catheterise to assess the urethra for injury and drain the bladder.
• Check vaginal and cervical tears if bleeding is not explained.
• Blood loss measurement, pulse and blood pressure.

The principle is to repair bleeding or gaping tears with fine sutures and to protect the urethra.

• Supportive: lithotomy with good light; clean the area with sodium chloride 0.9 percent; ice packs for 24 hours; sitz baths twice daily; bladder catheter for 12 to 24 hours for periurethral tears; keep the area clean and dry; fluids to dilute the urine.
• Pharmacological: lignocaine 1 percent 5 to 10 mL (maximum 3 mg/kg, not above 200 mg) infiltration; paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours); diclofenac 50 mg oral 8-hourly for 3 days if no contraindication; lignocaine 2 percent gel for passing urine; cefazolin 2 g IV as a single dose for deep or contaminated tears; oxytocin 10 IU IM after birth.
• Procedures: no suturing for shallow, non bleeding labial tears; suture bleeding or gaping tears with 3/0 or 4/0 polyglactin, interrupted, with a catheter in place for periurethral tears; haemostatic suture for clitoral bleeding; drainage and repair of an expanding haematoma.
• Special groups: women who have undergone female genital cutting need careful repair of the scarred tissue with a catheter in place and lower thresholds for incision of the scar.
• Red flags: heavy bleeding, expanding swelling, inability to pass urine, fever above 38 degrees Celsius, foul discharge, wound breakdown.
• Follow-up: wound check at 1 week; review at 6 weeks; advise on resuming intercourse after healing.