Vulval haematomas usually result from injuries to the branches of the pudendal artery during spontaneous vaginal or operative delivery or in conjunction with episiotomy. These vessels are typically located in the superficial fascia of the anterior (urogenital) or posterior pelvic triangle.

The superficial compartment of the anterior triangle communicates with the subfascial space of the lower abdomen below the inguinal ligament. Colles’ fascia (superficial peritoneal fascia) and the urogenital diaphragm limit extension of bleeding into the anterior triangle, while the anal fascia limits extension of bleeding into the posterior triangle. As a result, bleeding is directed towards the skin where the loose subcutaneous tissues have little resistance to haematoma formation.

Superficial haematomas can extend from the posterior margin of the anterior triangle (at the level of the transverse perineal muscle) anteriorly over the mons to the fusion of fascia at the inguinal ligament. Necrosis caused by pressure and rupture of the tissue surrounding the haematoma may lead to external haemorrhage.

Large haematomas usually require exploration in the operating theatre. Initial resuscitation with IV fluids may be required, and blood should be sent for full blood count, coagulation screen and cross match.

An adequate linear skin incision should be made, the haematoma evacuated and bleeding points identified and ligated. The dead space is obliterated with interrupted sutures and the skin incision closed appropriately. Prophylactic antibiotics, urinary catheter, rectal examination and adequate postoperative analgesia are advisable [46].

Pain after delivery is common. Bone and soft tissue trauma might explain why some women have difficulty recovering postpartum owing to refractory pain or activity intolerance and the diverse clinical presentations of symphysis pubis dysfunction [47]. For most women, the associated pain and discomfort is temporary but in a minority it persists as chronic pain and discomfort [48].

Approximately one in ten women who sustained a perineal tear at vaginal delivery that required suturing, develop perineal wound infection. Instrumental deliveries and prolonged rupture of membranes predispose women to this complication [61–63]. By 2 weeks postpartum, patients who received prophylactic antibiotics at the time of third- or fourth-degree tear repair had a lower rate of perineal wound infectious complications than patients who did not [63].

The development of infection poses a greater risk for wound breakdown, fistula formation and anal incontinence. Given the severity of these complications, most authorities consider it prudent to prescribe antibiotic cover for both aerobic and anaerobic bacteria following primary repair [35, 51] (Figs. 13.3 and 13.4).

Perineal wound breakdown is one of the most devastating complications, with an incidence of 0.1–4.6% [64–66]. Although uncommon, perineal wound breakdown can lead to significant morbidity.

Up to 80 % of wound dehiscence cases are secondary to wound infection. The possible contributing factors of genital infection, which may lead to dehiscence, can be divided into antepartum, intrapartum and postpartum.

Antepartum risk factors include extremes of maternal age, smoking, poor maternal hygiene, poor nutrition and preexisting medical conditions such as diabetes, immunocompromise, severe anaemia and bacterial vaginosis, chlamydia, gonorrhoea or trichomoniasis.

Intrapartum factors include prolonged rupture of membranes, thick meconium staining, prolonged labour, intrapartum pyrexia, multiple internal examinations, operative vaginal delivery, poor aseptic technique, manual removal of placenta and retained products of conception.

Postpartum factors include delayed or omitted prophylactic antibiotics, suboptimal haemostasis, haematoma, contamination of wound or surgical site and residual dead space following wound closure [67].

Obesity remains an independent risk factor for wound infection and this may also apply to the perineum. A large retrospective study compared maternal outcomes in nearly 800 women based on pre-pregnancy weight. Women who were moderately obese (pre-pregnant weight, 90–120 kg) were 1.6 times (95% CI: 1.31–1.95) more likely to have caesarean wound and episiotomy infections when compared with non-obese women, and women who were severely obese (pre-pregnant weight, >120 kg) were 4.45 times (95 % CI: 3.00–6.61) more likely to have a wound infection when compared with non obese women [68].

Interestingly, a retrospective case – control study on 47 women whose episiotomies dehisced in the immediate postpartum period, found that human papilloma virus (HPV) infection was associated with poor healing of episiotomy repairs, as HPV was detected in up to 30 % of patients with episiotomy breakdown [69].

The management of wound breakdown varies depending on individual clinician’s preferences, as there is limited evidence and lack of guidelines on best practice. Most practitioners manage these cases conservatively, whereas, others offer secondary suturing.

The traditional approach is to allow healing by secondary intention, whereby the dehisced area fills with granulation tissue that gradually contracts to bring the wound edges together; however, this is a slow process and can take several weeks for the wound to heal completely. This approach may result in a protracted period of significant morbidity for women whereas re-suturing of perineal wound dehiscence within the first 2 weeks following childbirth may result in a reduction of perineal pain during the healing process for up to 6 months post-delivery, an improvement of dyspareunia symptoms, continuation of exclusive breastfeeding for up to 6 months and increased satisfaction with the aesthetic result of the perineal wound [70]. There is currently insufficient evidence available to support or refute secondary suturing for the management of broken down perineal wounds following childbirth.

Childbirth trauma causes considerable maternal morbidity such as perineal pain, vulval and vaginal stenosis, scar formation and gaping wound that leads frequently to decreased libido, dyspareunia and decreased sexual satisfaction in the months following vaginal delivery. General practitioners should consider referral to hospital for consideration of secondary repair if indicated [71].

Dyspareunia is defined as any pain that occurs during sexual intercourse, and affects a significant number of women following childbirth, approximately 20 % at 3 months postpartum [51, 72]. Twenty percent of women take longer than 6 months before sexual intercourse becomes comfortable. Inadequate repair of an episiotomy or vaginal tear can also lead to longstanding perineal discomfort and dyspareunia, so attention to anatomy and good surgical technique is important [73]. Women with obstetric anal sphincter injuries are at increased risk for dyspareunia after their delivery [74].

Traditional treatment includes perineal massage, topical oestrogens, perineal injections and, more recently, the use of intravaginal electrical stimulation.

De Oliveira Bernardes and Bahamondes [75] showed that electrical stimulation applied vaginally, was effective treatment for chronic pain with significantly fewer complaints of dyspareunia following treatment – an effect that lasted 7 months after treatment [51].

Surgical treatment is used for introital enlargement following failed manual dilatation. The appropriate surgical procedure depends on the site and extent of the vaginal constriction, the state of the surrounding tissue, and the overall length and caliber of the vagina. Fenton’s procedure, Z-plasty, vaginal incision of constriction ring, vaginal advancement, or placement of free skin graft are the most commonly used techniques [76] (Fig. 13.5).

Spontaneous approximation of lacerations of the labia may lead to distorted anatomical healing, with resultant dyspareunia, among other distressing symptoms. Prevention of labial or clitoral adhesions may be possible through personal hygiene techniques of instructing women to manually gently separate the labia several times a day while urinating. Oestrogen cream has been used for the management of adhesions of epithelium of the external genitalia, Surgical correction may be necessary when medical treatment fails [77].

Obstetric fistula, an opening that forms between the vagina and the bladder and/or the rectum, is most frequently caused by unattended prolonged labour, when the pressure of the baby’s head against the mother’s pelvic tissues cuts off blood supply to delicate tissues until it causes necrosis. Obstetric fistula is one of the most severe childbirth injuries that occur when labour is allowed to progress for a long period without timely intervention. Estimates indicate that more than two million women worldwide live with vesicovaginal fistula (VVF) or rectovaginal fistula (RVF) and the majority of these women reside in Africa and Asia [78–80]. Obstetric fistula is discussed in more detail elsewhere in this book.

Perineal wound complications can be associated with significant morbidity. Understanding the various factors associated with wound healing and complications is critical in antepartum counseling of patients, as well as intrapartum and postpartum practices. Modification of these factors may be critical in preventing long-term consequences such as wound infection, wound breakdown, fistula formation and introital narrowing. Furthermore, identification of these factors will determine the need for follow up of these patients in the postpartum period.