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Difficulty: MediumLabor, Delivery, and Puerperium

Match each of the following intrapartum or postpartum clinical presentations to the most likely underlying obstetric etiology.

  • Following a rapid, precipitous vaginal birth, a patient develops continuous bright red vaginal bleeding. Abdominal palpation demonstrates a firmly contracted, midline uterine fundus positioned at the umbilicus.Genital tract laceration
  • Shortly after the vaginal delivery of a macrosomic infant complicated by a prolonged second stage of labor, a patient exhibits heavy vaginal bleeding. The uterine fundus is poorly contracted, soft, and located well above the level of the umbilicus.Uterine atony
  • During an active trial of labor after a prior low transverse cesarean section, a patient reports sudden, tearing lower abdominal pain, which is immediately followed by a loss of fetal station on pelvic examination and a cessation of previously regular uterine contractions.Uterine rupture
  • Immediately following placental extraction involving excessive umbilical cord traction before complete separation, a patient presents with severe pain and hemorrhagic shock. Pelvic examination reveals a beefy red, rounded mass protruding through the cervical os into the vaginal canal.Uterine inversion

Answer

Precipitous delivery with a firm uterus matches genital tract laceration; macrosomia with a boggy uterus matches uterine atony; trial of labor with loss of fetal station matches uterine rupture; and excessive cord traction with a protruding vaginal mass matches uterine inversion.
Each obstetric emergency has a distinct pathophysiologic mechanism that dictates its clinical presentation. Uterine atony presents with a boggy uterus; genital tract lacerations present with bleeding despite a firm uterus; uterine rupture is characterized by loss of fetal station and sudden pain; and uterine inversion features a visible mass in the vagina following cord traction.

Step-by-Step Solution

1
Analyze the first clinical scenario involving continuous bleeding with a firm, midline uterus.
Identified as a genital tract laceration.
Because the uterus is well-contracted (firm and at the umbilicus), the bleeding must be originating from a lower genital tract injury, a common complication of rapid (precipitous) deliveries.
2
Evaluate the second scenario describing a boggy, elevated uterus after a macrosomic delivery.
Identified as uterine atony.
A soft, poorly contracted uterus unable to compress the myometrial spiral arteries results in atony, frequently exacerbated by uterine overdistention from macrosomia or muscle fatigue from prolonged labor.
3
Assess the third scenario featuring sudden pain, loss of fetal station, and cessation of contractions in a patient with a prior cesarean scar.
Identified as uterine rupture.
The integrity of the previous uterine scar failed, leading to extrusion of the fetus into the abdominal cavity (loss of station) and loss of coordinated myometrial function.
4
Review the final scenario involving excessive cord traction and a visible mass in the vagina.
Identified as uterine inversion.
Pulling on an undetached placenta can cause the uterine fundus to prolapse through the cervix, presenting as a beefy red mass and leading to profound vagal responses and hemorrhagic shock.

Key Concept

Diagnosis of obstetric emergencies and postpartum hemorrhage etiologies based on distinct physical examination findings and clinical history.
Estimated Time:1m 30s
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Topics

Labor, Delivery, and Puerperium

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