Clinical predictors of postpartum vaginal and vulvar hematomas and the need for surgical treatment.

OBJECTIVE: To identify risk factors for postpartum vaginal or vulvar hematoma and to determine clinical predictors of surgical intervention. STUDY DESIGN: A retrospective matched case-control study was conducted at a tertiary, university-affiliated center (2012-2024). Women diagnosed with vaginal or vulvar hematoma (cases) during the postpartum hospitalization were matched in a 1:3 ratio by maternal and gestational age to controls. Independent risk factors were identified using conditional logistic regression with a Cox regression model. A risk score was derived from the multivariable model, and ROC analysis was used to assess performance. A subgroup analysis evaluated predictors of surgery. RESULTS: Among 147,045 deliveries, 57 women (0.04%) had postpartum hematoma; 170 matched controls were included. Mean diagnosis time was 1.0 ± 1.6 days post-partum. Hematoma was associated with vacuum-assisted delivery (21.1% vs. 4.7%, p < 0.001), episiotomy (24.6% vs. 2.4%, p < 0.001), second-degree laceration (38.6% vs. 15.3%, p < 0.001), nulliparity, and lower body mass index (BMI; p < 0.001). In multivariable analysis, episiotomy (odds ratio [OR] 35.9, 95% confidence interval [CI] 5.6-232.4), second-degree laceration (OR 10.3, 95% CI 3.2-32.9), and vacuum delivery (OR 5.0, 95% CI 1.0-24.5) independently increased risk, whereas higher BMI (OR 0.69/unit, 95% CI 0.55-0.85) and epidural analgesia (OR 0.33, 95% CI 0.12-0.93) were protective. The model's AUC was 0.83; a score ≥3 yielded 68% sensitivity and 79% specificity and a 97.8% negative predictive value, supporting its utility in ruling out hematoma and reducing surgical interventions. Among women with a hematoma, 26.3% required surgery. Mean time to surgery from diagnosis averaged 6.5 ± 3.8 h. Prolonged second stage (20% vs. 2.4%, p < 0.05) was significantly associated with surgery, with trends toward more vacuum deliveries, no epidural, and greater hemoglobin decline. Postpartum hemorrhage and blood transfusion rates did not differ between groups. CONCLUSION: Postpartum hematoma is rare but associated with vacuum delivery, episiotomy, second-degree laceration, and low BMI, while epidural analgesia is protective. Early recognition supports timely management.