Case 3 – A 28-year-old pregnant woman with postpartum bleeding

A 28-year-old G1P1 woman at 39 weeks’ gestation presents to the emergency department complaining of severe, regular uterine contractions. On cervical examination she is 5 cm dilated and is promptly admitted to the labor and delivery unit. The patient reports no complications with her pregnancy and has no medical problems. After almost 22 hours of active laboring, the patient delivers a 3.6-kg (8-lb) healthy baby girl. The placenta is delivered without difficulty, but the patient continues to bleed postpartum. Vaginal examination reveals the patient has extensive perineal lacerations.

How is this condition classified?

First-degree perineal laceration due to birth trauma are a common obstetric complication caused by stretching of the birth canal by the infant. First-degree lacerations are limited to the vaginal mucosa, skin, and superficial subcutaneous and submucosal tissues. Perineal lacerations due to birth trauma are categorized into four groups. First-degree lacerations are explained above. Second-degree lacerations penetrate into the superficial fascia and transverse perineal musculature, while third-degree lacerations extend further, tearing the anal sphincter. Fourth-degree lacerations extend beyond the anal sphincter and into the rectal lumen.

What are the risk factors for this condition?

Risk factors associated with lower genital tract trauma in the obstetric setting include nulliparity, a large infant, precipitous birth, operative delivery, and/or episiotomy.

What is the most appropriate management for this patient?

First-degree lacerations of the perineum or vagina not involving underlying tissues rarely require repair, as they tend to heal quickly and neatly. Sutures are needed only for such injuries in the event of active bleeding. Second-, third-, and fourth-degree lacerations, however, always require surgical repair. In these lacerations the tissues may be frayed and in some cases macerated, making identification of the tissue ends and suture lines more difficult. In the event of a fourth-degree laceration, the torn rectal mucosa must be repaired separately from the rest of the tissue and with specific attention and care to avoid fistula formation.

By Hindi Stohl Posy, MD, Resident in Obstetrics and Gynecology, Johns Hopkins University; in association with Le TT, Schabelman E, Shivaram A, and Klein J, eds: First Aid Cases for the USMLE Step 2 CK. New York: McGraw-Hill, 2007.