A 27-year old primigravid woman at 37 weeks' gestation comes to the emergency department because of frequent contractions for 4 hours. Her pregnancy has been complicated by hyperemesis gravidarum which subsided in the second trimester. The contractions occur every 10–15 minutes and have been increasing in intensity and duration since onset. Her temperature is 37.1°C (98.8°F), pulse is 110/min, and blood pressure is 140/85 mm Hg. Uterine contractions are felt on palpation. Pelvic examination shows clear fluid in the vagina. The cervix is 50% effaced and 3 cm dilated. After 4 hours the cervix is 80% effaced and 6 cm dilated. Pelvic examination is inconclusive for the position of the fetal head. The fetal heart rate is reassuring. Which of the following is the most appropriate next step?

Perform external cephalic version

Perform Mauriceau-Smellie-Veit maneuver

Immediately following prolonged delivery of the placenta at 40 weeks gestation, a 32-year-old multiparous woman develops vaginal bleeding. Other than mild asthma, the patient’s pregnancy has been uncomplicated. She has attended many prenatal appointments and followed the physician's advice about screening for diseases, laboratory testing, diet, and exercise. Previous pregnancies were uncomplicated. She has no history of a serious illness. She is currently on intravenous infusion of oxytocin. Her temperature is 37.2°C (99.0°F), blood pressure is 108/60 mm Hg, pulse is 88/min, and respirations are 17/min. Uterine palpation reveals a soft enlarged fundus that extends above the umbilicus. Based on the assessment of the birth canal and placenta, which of the following options is the most appropriate initial step in patient management?

Manual exploration of the uterus

A 30-year-old woman, gravida 2, para 1, at 42 weeks' gestation is admitted to the hospital in active labor. Pregnancy has been complicated by gestational diabetes, for which she has been receiving insulin injections. Her first child was delivered by lower segment transverse cesarean section because of a nonreassuring fetal heart rate. Her pulse is 90/min, respirations are 18/min, and blood pressure is 135/80 mm Hg. The fetal heart rate tracing shows a baseline heart rate of 145/min and moderate variation with frequent accelerations and occasional early decelerations. She undergoes an elective repeat lower segment transverse cesarean section with complete removal of the placenta. Shortly after the operation, she starts having heavy uterine bleeding with passage of clots. Examination shows a soft uterus on palpation. Her bleeding continues despite fundal massage and the use of packing, oxytocin, misoprostol, and carboprost. Her pulse rate is now 120/min, respirations are 20/min, and blood pressure is 90/70 mm Hg. Her hemoglobin is 8 g/dL, hematocrit is 24%, platelet count is 120,000 mm3, prothrombin time is 11 seconds, and partial thromboplastin time is 30 seconds. Mass transfusion protocol is activated and a B-Lynch uterine compression suture is placed to control her bleeding. Which of the following is the mostly likely cause of her postpartum complication?

Lack of uterine muscle contraction

Adherent placenta to myometrium

Infection of the endometrial lining of the uterus

A 34-year-old G5P5 woman gave birth to a healthy infant 30 minutes ago by vacuum-assisted vaginal delivery and is now experiencing vaginal bleeding. The placenta was delivered spontaneously and was intact upon examination. The infant weighed 5.2 kg and had Apgar scores of 8 and 9. No perineal tear or intentional episiotomy occurred. The patient has type 1 diabetes. She had good glycemic control throughout her pregnancy. She took a prenatal vitamin daily. Blood pressure is 135/72 mmHg, pulse is 102/min, and respirations are 18/min. Upon physical examination, the uterine fundus is soft and palpated 4 cm above the umbilicus. There are 3-cm blood clots on the patient’s bed pad. Which of the following is the next best step in management for the patient’s bleeding?

Perform uterine massage and administer oxytocin

Manually remove retained placental fragments

Perform uterine artery embolization

A 33-year-old woman, gravida 2, para 1, at 26 weeks' gestation comes to the emergency department because of frequent contractions. The contractions are 40 seconds each, occurring every 2 minutes, and increasing in intensity. Her first child was delivered by lower segment transverse cesarean section because of a nonreassuring fetal heart rate. Her current medications include folic acid and a multivitamin. Her temperature is 36.9°C (98.4°F), heart rate is 88/min, and blood pressure is 126/76 mm Hg. Contractions are felt on the abdomen. There is clear fluid in the vulva and the introitus. The cervix is dilated to 5 cm, 70% effaced, and station of the head is -2. A fetal ultrasound shows polyhydramnios, a median cleft lip, and fused thalami. The corpus callosum, 3rd ventricle, and lateral ventricles are absent. The spine shows no abnormalities and there is a four chamber heart. Which of the following is the most appropriate next step in management?

Perform dilation and evacuation

A 30-year-old woman, gravida 2, para 1, at 38 weeks' gestation comes to the hospital for regular, painful contractions that have been increasing in frequency. Her pregnancy has been complicated by gestational diabetes treated with insulin. Pelvic examination shows the cervix is 50% effaced and 4 cm dilated; the vertex is at -1 station. Ultrasonography shows no abnormalities. A tocometer and Doppler fetal heart monitor are placed on the patient's abdomen. The fetal heart rate monitoring strip shows a baseline heart rate of 145/min with a variability of ≥ 15/min. Within a 20-minute recording, there are 7 uterine contractions, 4 accelerations, and 3 decelerations that have a nadir occurring within half a minute. The decelerations occur at differing intervals relative to the contractions. Which of the following is the most appropriate next step in the management of this patient?

Placement of fetal scalp electrode

A 24-year-old primigravid woman at 38 weeks' gestation comes to the physician for a prenatal visit. At the last two prenatal visits, transabdominal ultrasound showed the fetus in breech presentation. She has no medical conditions and only takes prenatal vitamins. Her pulse is 95/min, respirations are 16/min, and blood pressure is 130/76 mm Hg. The abdomen is soft and nontender; no contractions are felt. Pelvic examination shows a closed cervical os and a uterus consistent with 38 weeks' gestation. The fetal rate tracing shows a baseline heart rate of 152/min and 2 accelerations over 10 minutes. Repeat ultrasound today shows a persistent breech presentation. The patient states that she would like to attempt a vaginal delivery. Which of the following is the most appropriate next step in management?

Offer external cephalic version

Observe until spontaneous labor

A 23-year-old primigravid woman comes to the physician at 36 weeks' gestation for her first prenatal visit. She confirmed the pregnancy with a home urine pregnancy kit a few months ago but has not yet followed up with a physician. She takes no medications. Vital signs are within normal limits. Pelvic examination shows a uterus consistent in size with a 36-week gestation. Laboratory studies show: Hemoglobin 10.6 g/dL Serum Glucose 88 mg/dL Hepatitis B surface antigen negative Hepatitis C antibody negative HIV antibody positive HIV load 11,000 copies/mL (N < 1000 copies/mL) Ultrasonography shows an intrauterine fetus consistent in size with a 36-week gestation. Which of the following is the most appropriate next step in management of this patient?

Start cART and schedule cesarean delivery at 38 weeks' gestation

Intrapartum zidovudine and vaginal delivery when labor occurs

Intrapartum zidovudine and cesarean delivery at 38 weeks' gestation

Start cART and prepare for vaginal delivery at 38 weeks' gestation

Conduct cesarean delivery immediately

A 36-year-old woman, gravida 1, para 1, has back pain and numbness in her lower extremities after an emergency cesarean delivery of a healthy 3856-g (8-lb, 8-oz) newborn male. She had a placental abruption and lost approximately 2000 ml of blood. During the procedure, she received two units of packed red blood cells and intravenous fluids. She has no history of serious illness and takes no medications. She is sexually active with one male partner, and they use condoms inconsistently. She is alert and oriented to person, place, and time. Her temperature is 37.2°C (98.9°F), pulse is 90/min, respirations are 15/min, and blood pressure is 94/58 mm Hg. Examination shows decreased sensation to temperature and pinprick below her waist and 0/5 muscle strength in her lower extremities. She feels the vibrations of a tuning fork placed on both of her great toes. Deep tendon reflexes are absent in the lower extremities and 2+ in the upper extremities. Which of the following is the most likely diagnosis?

Anterior spinal artery syndrome

Posterior spinal artery syndrome

Prior cesarean delivery management — USMLE Lesson

VBAC Counseling - Weighing the Options

Shared decision-making is key. Compare Trial of Labor After Cesarean (TOLAC) vs. Elective Repeat Cesarean Delivery (ERCD).
TOLAC/VBAC Success Rate: 60-80%.

TOLAC

Pros: Avoids major surgery, ↓ hemorrhage/infection risk, shorter recovery, fewer complications in future pregnancies.
Cons: ~0.5-0.9% risk of uterine rupture (with low transverse scar), risk of emergent C-section if TOLAC fails (higher morbidity than ERCD).

ERCD

Pros: Avoids labor, scheduled procedure, eliminates risk of uterine rupture during labor.
Cons: Higher surgical morbidity (infection, VTE), longer recovery, ↑ risk of placenta accreta/previa in future pregnancies.

⭐ Contraindications to TOLAC are critical. An absolute contraindication is a prior classical, T-shaped, or vertical uterine incision due to a significantly higher rupture risk (4-9%).

Pregnancy and Delivery History Table

TOLAC Candidates - Green Light for Labor?

Ideal Candidate Profile:
- One, prior low-transverse cesarean section.
- Clinically adequate pelvis (assessed via pelvimetry).
- No history of other uterine scars (e.g., myomectomy) or uterine rupture.
- Cephalic presentation.
- Availability of continuous fetal monitoring and emergency C-section resources.
Absolute Contraindications:
- Prior classical, T-shaped, or unknown type of uterine incision.
- History of uterine rupture.
- Placenta previa or other absolute contraindications to vaginal birth.

⭐ The single greatest risk of TOLAC is uterine rupture. The risk is lowest (<1%) with a prior low-transverse incision but rises dramatically with classical incisions or induction of labor.

Uterine Incisions: Low Transverse, Low Vertical, Classical

Uterine Rupture - When the Scar Tears

A full-thickness tear of the uterine wall, typically at the site of a prior cesarean scar.
Risk Factors:
- Prior uterine surgery is the #1 risk. Highest with classical (vertical) incisions.
- Low transverse scar rupture risk is <1% during a Trial of Labor After Cesarean (TOLAC).
- Labor induction/augmentation, especially with prostaglandins (contraindicated in TOLAC).

Types of uterine incisions for cesarean delivery

Clinical Presentation:
- Sudden, severe abdominal pain & cessation of contractions.
- Fetal distress (bradycardia, severe decelerations) is the most common sign.
- Loss of fetal station, palpable fetal parts.
- Maternal hypotension, tachycardia.

⭐ The most reliable and often earliest sign of uterine rupture is a sudden, non-reassuring fetal heart rate pattern, such as prolonged bradycardia or deep, recurrent variable decelerations.

High‑Yield Points - ⚡ Biggest Takeaways

The primary decision is Trial of Labor After Cesarean (TOLAC) vs. Elective Repeat Cesarean Delivery (ERCD).

The biggest risk of TOLAC is uterine rupture, with fetal bradycardia being the most common and reliable sign.

A prior classical (vertical) uterine incision or history of uterine rupture are absolute contraindications to TOLAC.

The ideal candidate for TOLAC has had only one prior low-transverse C-section.

Suspected rupture requires an emergency laparotomy for immediate delivery.

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