After vital signs are assessed, attention should be directed to the amount of bleeding. A small amount of bleeding is expected after any vaginal hysterectomy. Steady bleeding 2 to 3 hours after surgery suggests lack of hemostasis. The patient should be taken promptly to the examining room, where the operative site is viewed using a large speculum and good lighting. If bleeding is not excessive, the vaginal cuff can be inspected, and in many instances, bleeding from the cuff edge will be found. Hemostasis can easily be achieved with one or two sutures placed through the mucosa.
If bleeding is excessive or appears to be coming from above the cuff, or if the patient is too uncomfortable to tolerate adequate examination, she should be taken to the operating room.
General anesthesia should be administered and the vaginal operative site should be thoroughly explored. Any bleeding point may be sutured or ligated. Bleeding that is coming from above the cuff or is extremely heavy usually cannot be controlled through the vaginal route. An exploratory laparotomy is necessary to examine the pelvic ﬂoor, identify and isolate the bleeding vessel, and achieve hemostasis. The ovarian vessels and uterine arteries should be thoroughly inspected because they often are the source of excessive vaginal bleeding. If it is difficult to localize bleeding to a specific pelvic vessel, or if these maneuvers do not work, ligation of the hypogastric artery may be performed.
In the patient with little vaginal bleeding in whom vital signs have deteriorated, retroperitoneal hemorrhage should be suspected. Input and output should be monitored. Hematocrit assessment, along with cross-matching of packed red blood cells, should be performed immediately. Examination may reveal tenderness and dullness in the ﬂank. In cases of intraperitoneal bleeding, abdominal distention may occur. Diagnostic radiologic studies can be used to confirm the presence of retroperitoneal or intra-abdominal bleeding. Ultrasonography is one option for viewing low pelvic hematomas; CT provides better visualization of retroperitoneal spaces and can delineate a hematoma.
If the patient’s condition stabilizes rapidly with intravenous ﬂuids, one of two approaches may be used for continued care. The first is to give the patient a transfusion and follow serial hematocrit assessments and vital signs. In many instances, retroperitoneal bleeding will tamponade and stop, forming a hematoma that may eventually be resorbed. The risk with this approach is that the hematoma will become infected, necessitating surgical drainage. In some instances when the patient’s condition is stable, radiologic embolization may be considered.
Another option is to perform abdominal exploratory surgery while the patient’s condition is stable. This approach adds the morbidity of a second procedure but avoids the possibility of the patient’s condition deteriorating with continued delay or the formation of a pelvic abscess. Once adequate exposure is obtained, the peritoneum over the hematoma should be opened and the blood evacuated. All bleeding vessels should be identified and ligated. If bleeding is difficult to control, consideration should be given to unilateral or bilateral ligation of the anterior division of the internal iliac artery. Once hemostasis is achieved, the pelvis should be drained using a closed system.
Urinary Retention Urinary retention after hysterectomy is an uncommon occurrence. If the urethra is unobstructed and retention occurs, it is usually the result of either pain or bladder atony resulting from anesthesia. Both are temporary effects.
If a catheter was not placed after surgery, retention can be relieved initially with the insertion of a Foley catheter for 12 to 24 hours. Most patients are able to void after the catheter is removed 1 day later. If the patient still has trouble voiding and urethral spasm is suspected, success can be achieved with a skeletal muscle relaxant such as diazepam (2 mg twice a day). In most cases, waiting is the best course, and voiding usually occurs spontaneously.