MEDizzy - A 37-year-old G5P5 woman with diabetes is immediately

Feed Library Learning Discuss Leaderboard Journal

USMLE I Test Block II

A 37-year-old G5P5 woman with diabetes is immediately postpartum from delivery of a 4.5-kg (10-lb) baby boy at 37 weeks’ gestation. Time elapsed from the onset of labor to delivery of the placenta was 4.5 hours. Delivery was complicated by a second-degree perineal tear. Postpartum vital signs are within normal limits when the patient begins to hemorrhage vaginally. Estimated blood loss is 200 mL so far. Bimanual examination reveals a soft, enlarged, “boggy” uterus. Which of the following is the most appropriate first step in treatment?

ExplanationThe correct answer is A. In a normal postpartum uterus, continued contractions help compress the vessels and stop bleeding. This patient is experiencing postpartum hemorrhage secondary to uterine atony. Risk factors include uterine overdistention secondary to diabetes and macrosomia, and myometrial exhaustion secondary to a prolonged labor (especially third stage). The most appropriate first step in treating uterine atony is bimanual uterine massage. This technique is usually successful in controlling bleeding without the need for medication infusions.