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Incision and drainage of vaginal hematoma; obstetrical/postpartum

CPT4 code

Name of the Procedure:

Incision and drainage of vaginal hematoma; obstetrical/postpartum


In layman's terms, this procedure involves making a small cut to drain a collection of blood (hematoma) that has formed in the vaginal area after childbirth.


The procedure addresses the condition of a vaginal hematoma, which can cause severe pain and swelling. The goal is to relieve discomfort and prevent complications such as infection or tissue damage.


  • Severe pain and swelling in the vaginal area post-childbirth
  • Visible or palpable mass in the vaginal area indicating a hematoma
  • Signs of infection or pressure symptoms affecting urination or bowel movements


  • The patient may be instructed to fast for a few hours before the procedure.
  • Medication adjustments might be necessary, particularly blood thinners.
  • A physical examination and possibly an ultrasound may be conducted to evaluate the hematoma.

Procedure Description

  1. The patient is positioned and local anesthesia or sedation is administered.
  2. The healthcare provider makes a small incision in the vaginal area to access the hematoma.
  3. Fluid and blood are drained from the hematoma.
  4. The area is thoroughly cleaned and the incision may be closed with sutures or packed to allow further drainage.
  5. A sterile dressing is applied to the site to protect it from infection.


The procedure typically takes about 30 minutes to an hour.


This procedure is usually performed in a hospital or an outpatient surgical center.


  • Obstetrician/Gynecologist or surgical specialist
  • Nurses
  • Anesthesiologists (if sedation or general anesthesia is required)

Risks and Complications

  • Infection at the incision site
  • Bleeding
  • Pain or discomfort during and after the procedure
  • Rarely, injury to nearby structures or recurrent hematoma formation


  • Immediate relief from pain and pressure
  • Reduced risk of infection and other complications
  • Faster healing and recovery process


  • The patient may need to stay in the hospital for observation for a few hours post-procedure.
  • Instructions will include keeping the area clean and dry, monitoring for signs of infection, and possibly using pain medications.
  • Recovery time is generally a few days, with most patients resuming normal activities gradually.
  • A follow-up appointment is often scheduled to ensure proper healing.


  • Conservative management with pain relief and monitoring, although this might prolong discomfort and does not always lead to resolution.
  • In some cases, less invasive methods might be attempted, but they are not always effective.

Patient Experience

During the procedure, the patient will feel minimal discomfort due to the anesthesia. Post-procedure, there might be some pain or swelling at the incision site, which can be managed with medications and proper care. Most patients experience significant relief from the initial symptoms shortly after the procedure.

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