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Question

Difficulty: HardLabor, Delivery, and Puerperium

Match each clinical vignette describing an intrapartum or postpartum complication to the most appropriate immediate intervention.

  • A 28-year-old G2P1 with a history of poorly controlled asthma develops excessive vaginal bleeding after a spontaneous vaginal delivery. The uterus is soft and boggy. Bleeding persists despite bimanual uterine massage, an oxytocin infusion, and tranexamic acid.Intramuscular methylergonovine administration
  • A 32-year-old G1P0 at 39 weeks gestation receives epidural anesthesia during active labor. Ten minutes later, her blood pressure drops to 80/50 mm Hg, and the fetal heart tracing shows recurrent late decelerations.Intravenous phenylephrine or ephedrine administration
  • A 30-year-old G3P2 at 38 weeks gestation undergoes artificial rupture of membranes for labor augmentation while the fetal head is at -3 station. Immediately after, the fetal heart rate drops to 70/min and remains there. Vaginal examination reveals a pulsating, rope-like structure in the cervical canal.Manual elevation of the fetal presenting part
  • A 35-year-old G4P3 at 40 weeks gestation with a history of two prior low transverse cesarean deliveries is undergoing a trial of labor. She suddenly reports a sharp, tearing abdominal pain. Contractions cease, and the fetal heart tracing shows prolonged bradycardia. The fetal head is no longer palpable on vaginal examination.Immediate exploratory laparotomy and cesarean delivery

Answer

The correct matches pair the specific obstetric emergency with its targeted, most critical immediate intervention based on the clinical presentation and maternal history.
Each clinical scenario describes a classic obstetric emergency requiring a specific, evidence-based intervention. Postpartum hemorrhage in an asthmatic patient is treated with methylergonovine to avoid carboprost-induced bronchospasm. Epidural-induced hypotension causing late decelerations is treated with vasopressors to restore placental perfusion. Umbilical cord prolapse necessitates manual elevation of the presenting part to prevent compression. Uterine rupture during a trial of labor requires immediate laparotomy.

Step-by-Step Solution

1
Analyze the first vignette presenting postpartum hemorrhage in a patient with asthma.
Identify uterine atony that requires a second-line uterotonic. Recognize that carboprost is contraindicated in asthma, making methylergonovine the correct choice.
To safely select the next pharmacologic intervention based on the patient's comorbidities.
2
Evaluate the second vignette presenting sudden hypotension and late decelerations following epidural placement.
Identify epidural-induced sympathetic blockade as the cause of uteroplacental insufficiency, which is treated with IV fluids and vasopressors like phenylephrine or ephedrine.
To correct the underlying maternal hemodynamic instability causing fetal compromise.
3
Examine the third vignette describing fetal bradycardia and a palpable pulsating mass after amniotomy at a high station.
Diagnose umbilical cord prolapse and determine that the most urgent action is manual elevation of the fetal head to relieve cord compression.
To prevent severe fetal asphyxia while the operating room is prepared for emergent delivery.
4
Assess the fourth vignette featuring tearing pain, loss of fetal station, and bradycardia in a patient with prior cesarean deliveries.
Diagnose uterine rupture, which mandates an immediate exploratory laparotomy.
To rapidly rescue the fetus and manage life-threatening maternal internal hemorrhage.

Key Concept

Management of acute intrapartum and postpartum emergencies
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Topics

Labor, Delivery, and Puerperium

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