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What Causes A Blue Bruise At The Site Of C-section Incision?

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Posted on Fri, 14 Oct 2016
Question: Hi Doctor,
My wife is 25 years old, she gave birth with c-section at 38 weeks of pregnancy on 17th September 2016. Her last period was on December 31st. our first visit to Obstetrician was when she was 7 weeks and based on her last period date and ultrasound her expected due date was 4th of October 2016 but had to do c-section due to thin scar from previous c-section.
We have one son who was born in 31st of September 2014, she gave birth with c-section as well, so the c-section she did this time is a repeat c-section.
Some brief history of her complaints during her pregnancy. She visited OBG couple of times because she had painful Irritable Uterus, at 33 weeks we went for a visit which showed 3rd-degree calcification of the Placenta, the Doctor said to visit her every once a week to make sure if the calcification is not getting worse.
At 35+ weeks we went to see an OBG Specialist, which checked on the baby movements which seem normal, she then sent us to a Specialist ultrasound Doctor to check scar thickness and fetal growth. everything was normal however the previous C-section scar tissue thickness that was only 1.7mm
The doctor said that the Scar is quite thin and she wouldn't suggest to try VBAC because the risk of uterine rupture is high, she rather suggested us to do C-section at 38 weeks. she gave my wife dexamethasone injection to help mature the baby lungs.
Coming back to her sitatuon now, we did the c-section as per the planned date 17/09/2016.
The c-section was overall successful and the baby is in good health and currently nursing from the mother. The doctor told us that when she was performing the c-section she saw a lot of adhesions from the previous c-section and that she decided to not use the same area from the previous uterus incision, instead she did incision in a nearby place to avoid complication, she also told us that she didn't suture the fatty tissue after the uterus to avoid complication and further adhesions. she said she also put a gel between uterus and the subcutaneous area where she didn’t suture to avoid further adhesions
So far the recovery from the c-section looks good she had very painful scar episodes she was given PCA, diclofenac and paracetamol at different times. she was also given Antibiotics and anticoagulants as a preventive measure.

Her recovery was sitting down on the first night after the c-section (17/09), standing up and walking around with help of nurse at second day evening (18/09) , standing and walking around by her self with no significant pain today (19/09). Planned to be discharged tomorrow.

So everything is normal now, our only concern and the reason I'm asking this question is that she developed a bruise near the incision area, which started to appear at the night of the c-section day, it was bluish bruise below the scar area.
The doctor said it's normal after c-section, however on second day the bruise looked abit distended down
Now at third night of c-section the bruise is more distended and it's around the scar also some at top of the scar (there wasn't any above the scar before) and it distended to the right side of the scar and down to the pubic area. the distended bruise looks more red( doctor said red colour mean that it developed with the last 12 hours).
Today the doctor checked her and the Doctor said she doesn't know what's the cause of this bruise, she never seen it before , she said the bruise is not a big concern according to her view, it looks superfecial on the cutaneous area and that it's not serious internal bleeding to be concerned about, she also said since my wife is walking around perfectly then nothing to worry. however she said tomorrow she will call another consultant to see my wife to get a second opinion. she also decided to remove the plastic patch that was on the scar, also decided to stop anticoagulation injection she was talking everyday (she thinks that could cause it too). She did CBC which showed normal pt/ptt , normal haemoglobin and normal platelets.
i uploaded pictures of the bruise above. these pictures are second and third day when the bruise started to get abit worse than first day
My questions.
1.whats your opinion about this bruise? what should we do about it?
2. does stopping the anticoagulation medicine now put my wife at risk of thromboembolism? when i asked the doctor this question she told me the guideline is to give anticoagulant injection to women for 10 days after c-section but she had to stop because this bruise seem to be worse and the anticoagulant medicine might be making it worse, however I shouldn't be worried about it as long as she is XXXXXXX and walking around well. do you agree?
3.what does it mean that she had a lot of adhesions from previous c-section? does that put her at risk of more complications or future pregnancies?
4.do you agree with the doctor did during the c-section ,such as using another incision area, and not suturing the fatty tissue?

Thanks

doctor
Answered by Dr. Jacqueline Brown (50 minutes later)
Brief Answer:
Your wife has a hematoma under the skin that will resolve

Detailed Answer:
Hello, and I hope I can help you today.

Thank you very much for providing such a detailed history and the photographs. I hope I can explain your wife's situation and help you to understand some of the terms your doctor used in describing what happened during the c-section.

Adhesions are internal (under the skin) scars that cause the internal organs to be literally stuck to one another, which can distort their anatomy and make surgery difficult. Having to separate organs from one another (which is necessary in the standard steps to do a c section) can increase blood loss and put organs at risk of damage. So adhesions make surgery more technically difficult to perform. Your surgeon did a good job if your baby was born healthy and it sounds like from what the surgeon used a few techniques to avoid injury to your wife's bladder. Techniques to prevent adhesions for the future include avoiding unnecessary stitches (the fat is an optional later) and applying that gel helps to prevent the subcutaneous tissues to the front of the uterus.

The amount of adhesions that form in an individual woman is completely unpredictable, so no surgeon in advance can know how bad an individual patient's scarring will be. So in summary, I think your doctor handled the surgery well.

Your wife had only one complication- a blood vessel under her skin near the incision started to bleed and a pocket of blood formed there. It is likely due to the postoperative Heparin that she bled as much as she did. The fact that the blood is tracking into her leg and mons pubis is because of the distribution of the fascia layers in the abdominal wall. If the bleeding is near her public bone, it can travel into her leg and perineum in this way.

If she had a hematoma (the blood pocket) the way it goes away is the blood spreads under the skin and is gradually reabsorbed. After the hemoglobin breaks down, the bruise will turn green and then finally fade, but that may take months. The fact that your wife is not in pain there shows that the hematoma is not getting bigger.

At home,
just be prepared that she may bleed from her incision on the side with the worst bruising, in that case the area would be opened to drain out the blood and then bandaged until it heals.

So I hope this helped you understand your doctor's reasoning and I do think your wife was managed well. It is standard to treat c/section patients with heparin to prevent blood clots, as blood clots that travel to the lungs can cause death. But occasionally some women do bruise, but it is a condition that will go away in its own.

I hope I adequately answrered iYour question today. If you are satisfied with my response, please close the question and post a review. I am also available if you need any further clarification.

Best wishes,

Dr. Brown


Above answer was peer-reviewed by : Dr. Arnab Banerjee
doctor
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Follow up: Dr. Jacqueline Brown (19 hours later)
Dear Doctor,

Thank you very much for the well-detailed information,it was brief and very easy to understand, I and my wife are at peaceful mind now. It's as you said above when i just checked now the bruise appeared lighter and more yellow.

few more questions I would appreciate if you can help us understand.

1.My wifes legs are swollen when I try to push down there is no sign of pitting edema or anything like that, but both of her legs are swollen specially above the feet. should we be concerned?
2.The area above the scar incision is swollen it wasn't that much swollen before today, is that considered normal ? we thought it might have to do with the hematoma

3. The Doctor stopped giving her the Anticoagulation medicine because she said she believes this medicine could be the reason making the bruise even worse. Does stopping the anticoagulation medicine now put my wife at risk of thromboembolism? when I asked the doctor this question she told me the guideline is to give anti-coagulant injection to women for 10 days after c-section however I shouldn't be worried about it as long as she is XXXXXXX and walking around well. do you agree?

4.Can we say that my wife is not at risk of thromboembolism now since the c-section was almost 4 days ago, or if I put the question in another way after how many days can we say there is no reason to worry about risk thromboembolism

5.after how many days can we say there is no more risk of scar infection?

6. She still feels pain on scar area, sometimes hard to work , she takes paracetamol and ponstan forte to help with pain, her previous c-section was healed quicker and she didn't have to take painkillers after she was discharged, is that XXXXXXX thing to be concerned about ?

Thank you again, truly appreciate it
doctor
Answered by Dr. Jacqueline Brown (25 minutes later)
Brief Answer:
I will be happy to address your additional queries.

Detailed Answer:
Hello again sir- I will be happy to address your concerns:

First of all, leg and foot swelling is normal after delivery and tends to get worse before it gets better. The swelling around the incision is likely from the hematoma and will take time to go away, but it will resolve.

Regarding the anticoagulation, unless your wife has a predisposition to blood clots, the heparin can be discontinued as long as your wife is ambulating well. I generally only give it to my patients for the first 24 hours after delivery for a c/section. Any woman who has had pelvic surgery is at risk for blood clots (especially in the legs) but if your wife does not stay in bed for extended periods and changes her position regularly, you do not need to really be concerned.

As far as infection or bleeding from the scar- it takes about 2 weeks for the skin to heal completely, so if she has not had any bleeding or pus leakage from the wound by then she is unlikely to have any wound complcations later. Usually the surgeon will schedule a post-operative follow up visit for 1 to 2 weeks after delivery to re-evaluate the incision.

It is normal for your wife to have incisional pain tha,t requires additional pain medication than what is available over-the-counter, especially in only 4 days after the surgery because it was a repeat c/section and she had adhesions and bruising around the incision. You should ask her doctor for a stronger prescription medication for pain. It is not unusual for women to require narcotic pain relief for even up to 2 weeks after a repeat c/section. Her first c/section did not have all the scarring and bruising because it was her first surgery. Putting a heating pad on her abdomen in the evening may also help with the pain.

I hope this additional information was helpful, and I wish your wife a speedy recovery.

Regards,

Dr. Brown

I hope this clarified your additional queries.
Above answer was peer-reviewed by : Dr. Arnab Banerjee
doctor
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Follow up: Dr. Jacqueline Brown (48 hours later)
Thanks Doctor, i have well understood the points you mentioned above.

last question...

My wife is recovering well, she now uses paracetamol once a day because the pain is not as strong as before.

I have only one concern at the moment.

My wife complains of a pain on her hand, near her wrist. when i touch it she tells me it's painful , and when i feel it feels like a tiny bean like feeling area.
She told me it was near where they inserted the Cannula for her.

my question is, as i read thromboembolism starts from the leg and reaches to heart or lungs where it gets life threatening... Can thromboembolism start from the hand? or near the wrist? could the pain she has be start of thromboembolism or just a pain from the cannula?

Thank you for your help . this will be last question
doctor
Answered by Dr. Jacqueline Brown (32 minutes later)
Brief Answer:
She likely just has some bruising from the cannula.

Detailed Answer:
Hello again sir,

The kind of thromboembolism we are concerned about in pelvic surgeries takes place in the deep veins of the legs, called a DVT. Clots that form in the deep veins in the leg connect to the heart via the vena cava and then can be pumped to more dangerous areas of the body, like the lungs.

Superficial thromboembolism is when clots form in blood vessels close to the skin. Your wife may have has some bleeding under her skin from the cannula, which has now clotted, forming a bump. It is also possible that some of the IV fluid was trapped under the skin when her catheter was removed. Clots from this area cannot spread to the vital organs, so the best thing to do is to have your wife apply warm compresses to that area on her hand, which should help the bump to dissolve and relieve the pain. It will likely go away on it's own in a week or two.

If at any time the area where the cannula was placed gets red and hot to the touch, or discharges pus, it may be infected and she should be evaluated by a physician. But otherwise, pain control and warm compresses should likely resolve her symptoms.

I wish your wife the best of luck in her further recovery, and thank you for using healthcaremagic.com

Take care,

Dr. Brown
Above answer was peer-reviewed by : Dr. Raju A.T
doctor
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Follow up: Dr. Jacqueline Brown (4 minutes later)
I uploaded pictures of wifes hand.

The second picture where my wife is pointing her index finger is the place where she feels pain, she can point to the area of pain, when she wore long sleeve shirt she could feel some pain on that area. when I felt it, it didn't feel warm, cold or anything, i only felt a bean like hard thing that's immobile, I avoided touching it more. you can also see the area to which cannula was inserted, she was given all IV medications through there and she was also taking PCA morphine from that area. There is also slight yellowish on where she feels pain but you can't see it on picture because of the flash.
The first picture only shows the bruised area but she doesn't have pain there.


Should i take her to emergency or is it nothing to worry about?
doctor
Answered by Dr. Jacqueline Brown (11 minutes later)
Brief Answer:
No it looks typical for an infiltrated IV with some bruising

Detailed Answer:
The yellow color is from old bruising under the skin which is in the last stages of fading. The lump you feel under the skin is likely where the IV most likely infiltrated (some of the IV fluid tracked under the skin instead of going into the vein). This can happen to anyone with an IV and will resolve spontaneously. So I do not think you need to take her to the doctor- I would just have her apply warm compresses (like a washcloth soaked in warm to hot water) a few times a day and the area should get softer gradually and grow less painful. There are no visible signs of infection in the photos you provided.

So, in summary, the photos are consistent with what I suggested in my last answer. Thank you for providing them, as it makes it much easier for me to give you an accurate diagnosis.

I hope this was helpful, and good luck,

Dr. Brown


Above answer was peer-reviewed by : Dr. Raju A.T
doctor
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Follow up: Dr. Jacqueline Brown (2 hours later)
Oh I see, it's all clear doctor thank you sooo much...

I will be closing this discussion and rate after this question if you don't mind.

my wife mentions some pain near the groin area between her thigh and up to the groin area left side, and some pain on the right side of her abdomen just under her ribs. when I touch them there is no feeling of warmth or something of that sort, just she mentions pain when I touch there. Is that something to be concerned about?


Thank you again and again and hope you all the best, your answers has made us understand everything in detail and helped us a lot. hope to see you again when we will have other questions some day.

Bye
doctor
Answered by Dr. Jacqueline Brown (17 hours later)
Brief Answer:
Your wife will have pain referred to other areas from the aurgery

Detailed Answer:
Hello again sir- and I apologize for the delayed reply

Groin pain is common after any kind of pelvic surgery, because the nerves that supply that area can get pulled or stretched during the delivery of the baby. Also getting pain in the upper abdomen can just be referred from other areas of the belly. It is also possible that internal adhesions were stretched during the surgery and it is normal to be sore until full healing has taken place. I really think the pain is likely referred from other areas because there is no evidence of injury in the specific places your wife feels pain.

I really think your wife will feel significantly better in a week or so. All her symptoms are common with women who had difficult repeat c/sections.

Things to be concerned about include fever, (taken with a thermometer greater than 38 Celsius) vomiting, bleeding or fluid from the incision, and heavy vaginal bleeding. Encourage your wife to be patient, and every day she will get a little bit better.

Thank you again for using my services and healthcaremagic.com,

Dr. Brown
Above answer was peer-reviewed by : Dr. Yogesh D
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What Causes A Blue Bruise At The Site Of C-section Incision?

Brief Answer: Your wife has a hematoma under the skin that will resolve Detailed Answer: Hello, and I hope I can help you today. Thank you very much for providing such a detailed history and the photographs. I hope I can explain your wife's situation and help you to understand some of the terms your doctor used in describing what happened during the c-section. Adhesions are internal (under the skin) scars that cause the internal organs to be literally stuck to one another, which can distort their anatomy and make surgery difficult. Having to separate organs from one another (which is necessary in the standard steps to do a c section) can increase blood loss and put organs at risk of damage. So adhesions make surgery more technically difficult to perform. Your surgeon did a good job if your baby was born healthy and it sounds like from what the surgeon used a few techniques to avoid injury to your wife's bladder. Techniques to prevent adhesions for the future include avoiding unnecessary stitches (the fat is an optional later) and applying that gel helps to prevent the subcutaneous tissues to the front of the uterus. The amount of adhesions that form in an individual woman is completely unpredictable, so no surgeon in advance can know how bad an individual patient's scarring will be. So in summary, I think your doctor handled the surgery well. Your wife had only one complication- a blood vessel under her skin near the incision started to bleed and a pocket of blood formed there. It is likely due to the postoperative Heparin that she bled as much as she did. The fact that the blood is tracking into her leg and mons pubis is because of the distribution of the fascia layers in the abdominal wall. If the bleeding is near her public bone, it can travel into her leg and perineum in this way. If she had a hematoma (the blood pocket) the way it goes away is the blood spreads under the skin and is gradually reabsorbed. After the hemoglobin breaks down, the bruise will turn green and then finally fade, but that may take months. The fact that your wife is not in pain there shows that the hematoma is not getting bigger. At home, just be prepared that she may bleed from her incision on the side with the worst bruising, in that case the area would be opened to drain out the blood and then bandaged until it heals. So I hope this helped you understand your doctor's reasoning and I do think your wife was managed well. It is standard to treat c/section patients with heparin to prevent blood clots, as blood clots that travel to the lungs can cause death. But occasionally some women do bruise, but it is a condition that will go away in its own. I hope I adequately answrered iYour question today. If you are satisfied with my response, please close the question and post a review. I am also available if you need any further clarification. Best wishes, Dr. Brown