What is the cause of profuse vaginal bleeding in a 27-year-old woman, gravida 2 para 1, at 40 weeks gestation, with a history of preeclampsia with severe features, who underwent a forceps-assisted vaginal delivery and has a firm, nontender uterus with a right vaginal sidewall defect?

From the Guidelines

The patient is experiencing a vaginal sidewall laceration causing postpartum hemorrhage, and immediate management should focus on surgical repair of the right vaginal sidewall defect. The patient should be placed in lithotomy position with adequate lighting and assistance. The laceration should be repaired using absorbable sutures such as 2-0 or 3-0 Vicryl in a continuous or interrupted fashion, ensuring hemostasis is achieved. Before repair, the full extent of the laceration should be identified, including any extension to the cervix or deeper tissues. Adequate anesthesia should be provided, which may include local infiltration with lidocaine 1% if regional anesthesia is no longer effective. Blood loss should be quantified, and if significant, intravenous fluid resuscitation with crystalloids or blood products may be necessary, as suggested by the American College of Radiology 1. The patient's vital signs should be closely monitored, particularly given her preeclampsia with severe features and ongoing magnesium sulfate infusion. The firm uterus at the umbilicus level indicates that uterine atony is not the cause of bleeding, and the intact perineum with minimal bleeding from the cervical os directs attention to the vaginal laceration as the source. Forceps-assisted delivery increases the risk of vaginal lacerations, especially in patients with previous cesarean deliveries, as scar tissue may alter tissue elasticity during the second stage of labor.

Some key considerations in the management of postpartum hemorrhage include:

• Maintaining the patient's temperature above 36 °C to ensure proper clotting factor function, as noted in the American Journal of Obstetrics and Gynecology 1
• Avoiding acidosis and hypofibrinogenemia, which can exacerbate bleeding
• Using viscoelastic coagulation testing, such as thromboelastography or rotational thromboelastometry, to rapidly assess coagulopathy and guide transfusion management
• Transfusing packed red blood cells, fresh frozen plasma, and platelets in a fixed ratio to replace lost blood volume and clotting factors, as recommended by the American College of Radiology 1
• Considering additional interventions, such as uterine artery embolization or surgical ligation of uterine/internal iliac arteries, if bleeding is uncontrolled and life-threatening, as discussed in the Journal of the American College of Radiology 1

The most recent and highest quality study, published in the Journal of the American College of Radiology in 2020 1, emphasizes the importance of prompt and effective management of postpartum hemorrhage to prevent morbidity and mortality. Surgical repair of the vaginal sidewall defect is the most appropriate initial management strategy for this patient, given the presence of a firm, non-tender uterus and minimal bleeding from the cervical os.

From the FDA Drug Label

OVERDOSAGE Overdosage with oxytocin injection (synthetic) depends essentially on uterine hyperactivity whether or not due to hypersensitivity to this agent Hyperstimulation with strong (hypertonic) or prolonged (tetanic) contractions, or a resting tone of 15 to 20 mm H2O or more between contractions can lead to tumultuous labor, uterine rupture, cervical and vaginal lacerations, postpartum hemorrhage, uteroplacental hypoperfusion and variable deceleration of fetal heart, fetal hypoxia, hypercapnia or death The patient's profuse vaginal bleeding and right vaginal sidewall defect are consistent with a laceration, which is a possible complication of oxytocin overdose due to hyperstimulation. However, the patient is currently receiving magnesium sulfate, and the uterus is firm and nontender, suggesting that uterine hyperactivity is not currently present. The FDA label does not provide information on the management of vaginal lacerations or sidewall defects. 2

From the Research

Postpartum Hemorrhage Management

• Postpartum hemorrhage (PPH) is defined as a blood loss of 500 mL or more after birth, and it is the leading cause of maternal mortality worldwide 3, 4, 5, 6, 7.
• The patient in question is experiencing profuse vaginal bleeding after a forceps-assisted vaginal delivery, which is a risk factor for PPH.
• The use of uterotonic agents, such as oxytocin, is recommended for the prevention and treatment of PPH 3, 4, 5, 6, 7.

Uterotonic Agents

• Oxytocin is the first-line uterotonic agent for the prevention and treatment of PPH, and it is effective in reducing the risk of bleeding 3, 4, 5, 6, 7.
• Other uterotonic agents, such as ergot derivatives and prostaglandins, may be used as second-line agents, but they have potential side effects 3, 4, 5, 6, 7.
• Misoprostol may be used as an alternative to oxytocin in resource-limited settings, but it has been shown to have a higher risk of side effects and may not be as effective 5, 6, 7.

Management of the Patient

• The patient's firm, nontender uterus and the presence of a right vaginal sidewall defect suggest that the bleeding is not due to uterine atony, but rather to a laceration or other trauma 3, 4, 5, 6, 7.
• The use of uterotonic agents, such as oxytocin, may still be beneficial in reducing the risk of further bleeding, but the primary management should focus on repairing the laceration or trauma 3, 4, 5, 6, 7.
• The patient's blood pressure and pulse should be closely monitored, and additional interventions, such as fluid resuscitation and blood transfusion, may be necessary to manage the bleeding and prevent shock 3, 4, 5, 6, 7.