Case 3: Diagnosis and Treatment

Diagnosis

• Heavy bright-red bleeding immediately after delivery points to an active arterial/venous source
• The uterus is firm and well contracted - this rules out uterine atony (the most common cause of PPH, >50% of cases). With a contracted uterus, the bleeding source must be elsewhere
• Large perineal/vaginal laceration is directly noted - forceps-assisted deliveries carry a significantly elevated risk of genital tract injury
• Hemodynamic instability confirms significant hemorrhage: BP 95/60 mmHg (hypotension) + HR 118 bpm (tachycardia) = early hemorrhagic shock

"Significant lacerations to the cervix or vagina may also occur during childbirth, particularly with instrumented deliveries ... These lacerations may present as persistent bleeding, not readily recognized due to their location, and often in association with a firmly contracted uterus." - Schwartz's Principles of Surgery, 11th ed., p.1833

Differential Diagnosis to Exclude

Treatment

Step 1 - Immediate Resuscitation (Hemorrhagic Shock)

• 2 large-bore IV lines - begin aggressive fluid resuscitation
• Type and cross-match for blood transfusion; activate massive transfusion protocol if needed
• Oxygen supplementation
• Continuous monitoring of BP, HR, urine output
• Call for obstetrics, anesthesia support

Step 2 - Inspect and Repair the Laceration

• Full inspection of the vagina, cervix, and perineum under adequate lighting and analgesia/anesthesia
• Classify the laceration degree:
  • 1st degree - perineal skin only; may or may not need repair
  • 2nd degree - involves perineal body; repair with continuous 2-0 or 3-0 synthetic delayed absorbable suture
  • 3rd degree - extends through the perineal body and involves the external anal sphincter
  • 4th degree - involves the internal anal sphincter and rectal mucosa

1. Place a vaginal sponge to control the operative field
2. Place the first suture 1 cm above the apex of the laceration to secure hemostasis
3. Use continuous locked absorbable suture to close the vaginal epithelium from apex to hymenal ring
4. Use interrupted absorbable sutures to close deep perineal fascia and levator ani
5. Close superficial fascia and complete with a subcuticular stitch back to the hymenal ring
6. For 3rd/4th degree: repair anal mucosa first, then internal sphincter, then reconstruct the external anal sphincter (end-to-end or overlapping technique) - Schwartz's, p.1833

"Vaginal lacerations may be repaired primarily but should only be closed after deeper tissues are inspected to ensure no active bleeding." - Schwartz's Principles of Surgery, 11th ed.

Step 3 - Rule Out Concurrent Causes

• Manual exploration of the uterus - ensure placenta is complete and no retained products remain
• If bleeding persists despite laceration repair - consider uterotonic agents (oxytocin, misoprostol), intrauterine balloon tamponade, or escalation to surgical/IR embolization

Step 4 - Monitor and Prevent Complications

• Serial CBCs, coagulation panel, electrolytes
• Broad-spectrum antibiotics (forceps delivery + laceration repair = infection risk)
• Tetanus prophylaxis if indicated
• Assess for puerperal hematoma (can conceal significant blood loss; manage conservatively if small, drain if expanding or patient is unstable)
• Thromboprophylaxis once hemostasis is achieved

Summary