A woman delivers a 4.2 kg baby after a prolonged second stage. One hour postpartum she has lost 900 mL blood. Uterine fundus is at the umbilicus and well-contracted. Placenta is confirmed complete. Laceration inspection reveals no cervical tear. BP is 90/60 mmHg. What is the most likely cause of hemorrhage and first-line specific intervention?
- A Genital tract trauma; surgical repair of occult vaginal tear ✓
- B Uterine atony; IV oxytocin infusion
- C Coagulopathy; fresh frozen plasma
- D Retained placental fragments; manual removal
Explanation
The 'Four Ts' of PPH are Tone, Trauma, Tissue, and Thrombin. A well-contracted uterus and complete placenta effectively exclude atony (most common cause) and retained tissue. Absent coagulopathy history makes thrombin less likely acutely. With macrosomia (4.2 kg) and prolonged second stage, genital tract trauma is the next most likely cause. A well-contracted uterus with ongoing bleeding specifically points to an occult vaginal or paravaginal tear not identified on initial inspection — sulcus tears in the vaginal fornices are commonly missed. Surgical repair is the specific definitive treatment.
Reference: Williams Obstetrics, 26th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.