A 32-year-old primigravida delivered vaginally 4 hours ago. She has persistent vaginal bleeding (approximately 800 mL so far) despite uterine massage and oxytocin infusion. Vital signs are stable. On abdominal examination, the uterus is well-contracted and non-tender. Which investigation is most appropriate to identify the source of ongoing hemorrhage?

Explanation

## Investigation of Choice in Persistent Postpartum Hemorrhage ### Clinical Scenario Analysis The patient has: - Persistent vaginal bleeding 4 hours postpartum (800 mL) - Well-contracted, non-tender uterus (rules out uterine atony as primary cause) - Stable vital signs - Ongoing hemorrhage despite standard first-line measures ### Why Speculum Examination is the Correct Investigation **Key Point:** When uterine atony is excluded by clinical findings (firm, contracted uterus), the source of postpartum hemorrhage is most likely **genital tract trauma** — cervical lacerations, vaginal tears, or episiotomy extension. **High-Yield:** Speculum examination under good lighting allows direct visualization of the cervix and lower vagina to identify and grade lacerations. This is the **most specific and immediately diagnostic** investigation in this scenario. ### Why This Is the Next Step 1. **Uterine atony ruled out** — firm, well-contracted uterus on palpation excludes the most common cause 2. **Genital tract trauma is the second most common cause** of postpartum hemorrhage 3. **Speculum exam is non-invasive, rapid, and therapeutic** — identifies the source and allows immediate repair 4. **No need for imaging or labs first** — clinical examination is diagnostic ### Differential Approach to Postpartum Hemorrhage | Cause | Clinical Clue | Investigation | |-------|---------------|----------------| | Uterine atony | Soft, boggy uterus | Clinical diagnosis; ultrasound if unclear | | Genital tract trauma | Firm uterus, bleeding continues | **Speculum exam** (direct visualization) | | Retained products | Firm uterus, history of incomplete delivery | Ultrasound | | Coagulopathy | Bleeding from multiple sites, oozing | Coagulation profile | **Clinical Pearl:** A well-contracted uterus with ongoing hemorrhage is a **red flag for cervical or vaginal laceration** — do not delay speculum examination. [cite:Williams Obstetrics 26e Ch 41]