Uterine rupture US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Uterine rupture. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Uterine rupture US Medical PG Question 1: A 37-year-old G4P3 presents to her physician at 20 weeks gestation for routine prenatal care. Currently, she has no complaints; however, in the first trimester she was hospitalized due to acute pyelonephritis and was treated with cefuroxime. All her past pregnancies required cesarean deliveries for medical indications. Her history is also significant for amenorrhea after weight loss at 19 years of age and a cervical polypectomy at 30 years of age. Today, her vital signs are within normal limits and a physical examination is unremarkable. A transabdominal ultrasound shows a normally developing male fetus without morphologic abnormalities, anterior placement of the placenta in the lower uterine segment, loss of the retroplacental hypoechoic zone, and visible lacunae within the myometrium. Which of the following factors present in this patient is a risk factor for the condition she has developed?
- A. A history of amenorrhea
- B. Genitourinary infections during pregnancy
- C. Multiple cesarean deliveries (Correct Answer)
- D. Intake of antibiotics in the first trimester
- E. Cervical surgery
Uterine rupture Explanation: ***Multiple cesarean deliveries***
- The ultrasound findings of an **anterior low-lying placenta**, **loss of the retroplacental hypoechoic zone**, and **visible lacunae within the myometrium** are classic signs of **placenta accreta spectrum (PAS)**.
- Previous uterine surgeries, particularly **cesarean deliveries**, are the most significant risk factor for PAS, as they can cause defects in the uterine wall that allow the placenta to abnormally implant.
*A history of amenorrhea*
- **Amenorrhea** after weight loss at a young age suggests a potential history of **hypothalamic amenorrhea** or other ovulatory dysfunction, which is not a direct risk factor for placenta accreta.
- This condition primarily affects **fertility** and menstrual regularity, not placental implantation depth.
*Genitourinary infections during pregnancy*
- While **pyelonephritis** in pregnancy is a serious condition, it is an **infection** and does not directly cause abnormal placental implantation or placenta accreta.
- Infections can lead to other complications like **preterm labor** or sepsis, but not PAS.
*Intake of antibiotics in the first trimester*
- **Antibiotic use** for treating infections like pyelonephritis does not contribute to the development of placenta accreta.
- Antibiotics are used to resolve bacterial infections and have no known mechanistic link to placental adherence disorders.
*Cervical surgery*
- **Cervical polypectomy** is a minor surgical procedure involving the cervix, not the uterine corpus.
- While other uterine surgeries (e.g., myomectomy) can be risk factors for PAS, a cervical polypectomy typically does not affect the myometrium or increase the risk of abnormal placental adherence.
Uterine rupture US Medical PG Question 2: A 27-year-old woman, gravida 3, para 2, at 41 weeks' gestation is admitted to the hospital in active labor. Her pregnancy has been uncomplicated. Both of her prior children were delivered by vaginal birth. She has a history of asthma. Current medications include iron and vitamin supplements. After a prolonged labor, she undergoes vaginal delivery. Shortly afterwards, she begins to have heavy vaginal bleeding with clots. Her temperature is 37.2°C (98.9°F), pulse is 90/min, respirations are 17/min, and blood pressure is 130/72 mm Hg. Examination shows a soft, enlarged, and boggy uterus on palpation. Laboratory studies show:
Hemoglobin 10.8 g/dL
Hematocrit 32.3%
Leukocyte Count 9,000/mm3
Platelet Count 140,000/mm3
Prothrombin time 14 seconds
Partial thromboplastin time 38 seconds
Her bleeding continues despite bimanual uterine massage and administration of oxytocin. Which of the following is the most appropriate next step in management?
- A. Administer methylergonovine (Correct Answer)
- B. Transfuse blood
- C. Perform hysterectomy
- D. Administer carboprost tromethamine
- E. Perform curettage
Uterine rupture Explanation: ***Administer methylergonovine***
- The patient is likely experiencing **postpartum hemorrhage (PPH)** due to **uterine atony**, characterized by a soft, enlarged, and boggy uterus after delivery, with continued bleeding despite initial measures (massage, oxytocin).
- Given her history of **asthma**, carboprost tromethamine (prostaglandin F2-alpha) is **contraindicated** due to its potential to cause severe bronchospasm, making methylergonovine (an ergot alkaloid) the appropriate next uterotonic agent.
*Transfuse blood*
- While blood transfusions may eventually be necessary if bleeding is severe and leads to significant hemodynamic instability or severe anemia, it is **not the immediate next step** in managing the underlying cause of the hemorrhage (uterine atony).
- **Uterotonic agents** should be tried first to contract the uterus and stop the bleeding, as indicated by the patient's current vital signs being relatively stable (pulse 90/min, BP 130/72 mm Hg).
*Perform hysterectomy*
- **Hysterectomy** is a drastic measure considered only after all less invasive medical and surgical interventions (e.g., uterotonic agents, uterine tamponade, suturing techniques) have failed to control severe PPH.
- It would be **premature** to proceed directly to hysterectomy without attempting additional medical management for uterine atony.
*Administer carboprost tromethamine*
- **Carboprost tromethamine** is a prostaglandin analog that is effective in treating uterine atony but is **contraindicated in patients with asthma** due to its known side effect of inducing bronchospasm.
- The patient's history of asthma makes this a **dangerous option**, and an alternative uterotonic like methylergonovine should be chosen.
*Perform curettage*
- **Curettage** (removing retained placental fragments) would be appropriate if the cause of PPH was **retained placental tissue**.
- However, the examination finding of a **soft, enlarged, and boggy uterus** is characteristic of uterine atony, not retained placenta, and the initial management of atony involves uterotonic agents.
Uterine rupture US Medical PG Question 3: 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?
- A. Intramuscular carboprost
- B. Manual exploration of the uterus
- C. Discontinuing oxytocin
- D. Intravenous methylergonovine
- E. Uterine fundal massage (Correct Answer)
Uterine rupture Explanation: ***Uterine fundal massage***
- The patient presents with **postpartum hemorrhage** indicated by vaginal bleeding and a **soft, enlarged fundus** after placental delivery, suggesting **uterine atony**.
- **Uterine fundal massage** is the **first-line intervention** to encourage uterine contraction and reduce bleeding by expelling clots and compressing vessels.
*Intramuscular carboprost*
- **Carboprost** is a **prostaglandin F2 alpha analog** used to treat **uterine atony** when initial measures like uterine massage and oxytocin are insufficient.
- It is contraindicated in patients with **asthma** due to its bronchoconstrictive effects, which this patient has.
*Manual exploration of the uterus*
- **Manual exploration of the uterus** is indicated when there is suspicion of **retained placental fragments** or **uterine rupture**.
- While these can cause postpartum hemorrhage, the primary finding of a soft, boggy uterus points more strongly to atony, making massage the immediate priority.
*Discontinuing oxytocin*
- The patient is already on an **intravenous oxytocin infusion**, which is a uterotonic agent used to prevent and treat uterine atony.
- Discontinuing it would worsen **uterine atony** and increase blood loss, directly contradicting the goal of management.
*Intravenous methylergonovine*
- **Methylergonovine** is an **ergot alkaloid** used to treat **uterine atony**, but it is contraindicated in patients with **hypertension**, which is not explicitly present here, but it is a potent vasoconstrictor and second-line.
- It is often used as a **second-line agent** if oxytocin and massage are ineffective and there are no contraindications.
Uterine rupture US Medical PG Question 4: A 32-year-old woman, gravida 2, para 1, at 38 weeks' gestation comes to the emergency department because of vaginal bleeding for the past hour. The patient reports that she felt contractions prior to the onset of the bleeding, but the contractions stopped after the bleeding started. She also has severe abdominal pain. Her first child was delivered by lower segment transverse cesarean section because of a nonreassuring fetal heart rate. Her pulse is 110/min, respirations are 17/min, and blood pressure is 90/60 mm Hg. Examination shows diffuse abdominal tenderness with no rebound or guarding; no contractions are felt. The fetal heart rate shows recurrent variable decelerations. Which of the following is the most likely diagnosis?
- A. Uterine inertia
- B. Amniotic fluid embolism
- C. Uterine rupture (Correct Answer)
- D. Vasa previa
- E. Abruptio placentae
Uterine rupture Explanation: ***Uterine rupture***
- The patient's history of a prior **cesarean section**, sudden onset of **vaginal bleeding** and **severe abdominal pain**, resolution of contractions, and signs of **hypovolemic shock** (tachycardia, hypotension) coupled with fetal distress (variable decelerations) are highly indicative of uterine rupture.
- Diffuse abdominal tenderness without rebound or guarding, and no palpable contractions, are also consistent with rupture.
*Uterine inertia*
- This condition is characterized by **weak or uncoordinated uterine contractions** leading to prolonged labor, but it does not typically present with acute vaginal bleeding, sudden severe abdominal pain, or hypovolemic shock.
- Fetal distress in uterine inertia would more likely be due to prolonged labor rather than acute compromise following a sudden event.
*Amniotic fluid embolism*
- This is a rare, life-threatening obstetric emergency characterized by sudden **cardiovascular collapse, respiratory distress**, and **coagulopathy**, often occurring during labor or immediately postpartum.
- While it can cause fetal distress, vaginal bleeding and severe abdominal pain are not primary presenting symptoms.
*Vasa previa*
- Characterized by **painless vaginal bleeding** when fetal vessels within the membranes cross the internal cervical os, making them vulnerable to rupture during cervical dilation or amniotomy.
- The bleeding is typically fetal blood, and fetal distress occurs rapidly, but the mother would not experience severe abdominal pain or signs of hypovolemic shock unless the bleeding is substantial and prolonged.
*Abruptio placentae*
- This involves the **premature separation of the placenta**, causing painful vaginal bleeding, uterine tenderness, and frequent, strong contractions.
- While it can cause hypovolemic shock and fetal distress, the description of contractions stopping after bleeding started, along with a previous C-section scar, points more specifically to uterine rupture rather than an abruption.
Uterine rupture US Medical PG Question 5: A 29-year-old G2P1 at 35 weeks gestation presents to the obstetric emergency room with vaginal bleeding and severe lower back pain. She reports the acute onset of these symptoms 1 hour ago while she was outside playing with her 4-year-old son. Her prior birthing history is notable for an emergency cesarean section during her first pregnancy. She received appropriate prenatal care during both pregnancies. She has a history of myomectomy for uterine fibroids. Her past medical history is notable for diabetes mellitus. She takes metformin. Her temperature is 99.0°F (37.2°C), blood pressure is 104/68 mmHg, pulse is 120/min, and respirations are 20/min. On physical examination, the patient is in moderate distress. Large blood clots are removed from the vaginal vault. Contractions are occurring every 2 minutes. Delayed decelerations are noted on fetal heart monitoring. Which of the following is the most likely cause of this patient's symptoms?
- A. Premature separation of a normally implanted placenta (Correct Answer)
- B. Amniotic sac rupture prior to the start of uterine contractions
- C. Placental implantation over internal cervical os
- D. Chorionic villi attaching to the myometrium
- E. Chorionic villi attaching to the decidua basalis
Uterine rupture Explanation: ***Premature separation of a normally implanted placenta***
- The acute onset of **vaginal bleeding**, **severe lower back pain**, frequent uterine contractions, and **fetal decelerations** in a patient with risk factors like a prior cesarean section and diabetes mellitus are highly suggestive of **abruptio placentae**.
- **Uterine tenderness** and a **firm, rigid uterus** (though not explicitly stated, implied by contractions and pain) are also characteristic findings.
*Amniotic sac rupture prior to the start of uterine contractions*
- This condition presents with a gush of fluid from the vagina, often without significant bleeding or severe pain unless associated with other complications.
- While it can lead to preterm labor, it doesn't directly cause the severe back pain, heavy bleeding with clots, and fetal distress seen here.
*Placental implantation over internal cervical os*
- This describes **placenta previa**, which typically presents with **painless vaginal bleeding**, often bright red, without severe abdominal or back pain.
- The presence of severe abdominal pain and uterine contractions makes placenta previa less likely.
*Chorionic villi attaching to the myometrium*
- This describes **placenta accreta**, a condition where the placenta abnormally adheres to the myometrium. It is typically diagnosed postnatally with **difficulty in placental separation** and severe hemorrhage.
- While a prior C-section is a risk factor, the acute presentation of pain and bleeding in the antepartum period is not the classic presentation of accreta alone.
*Chorionic villi attaching to the decidua basalis*
- This describes the **normal implantation** of the placenta into the decidua basalis of the uterus.
- This is the physiological process of pregnancy and would not cause the symptoms of vaginal bleeding, severe pain, and fetal distress described.
Uterine rupture US Medical PG Question 6: A 28-year-old woman at 30 weeks gestation is rushed to the emergency room with the sudden onset of vaginal bleeding accompanied by intense abdominopelvic pain and uterine contractions. The intensity and frequency of pain have increased in the past 2 hours. This is her 1st pregnancy and she was diagnosed with gestational diabetes several weeks ago. Her vital signs include a blood pressure of 124/68 mm Hg, a pulse of 77/min, a respiratory rate of 22/min, and a temperature of 37.0°C (98.6°F). The abdominal examination is positive for a firm and tender uterus. An immediate cardiotocographic evaluation reveals a fetal heart rate of 150/min with prolonged and repetitive decelerations and high-frequency and low-amplitude uterine contractions. Your attending physician warns you about delaying the vaginal physical examination until a quick sonographic evaluation is completed. Which of the following is the most likely diagnosis in this patient?
- A. Miscarriage
- B. Vasa previa
- C. Placenta abruption (Correct Answer)
- D. Placenta previa
- E. Uterine rupture
Uterine rupture Explanation: **Placenta abruption**
- The sudden onset of **vaginal bleeding** with **intense abdominopelvic pain**, **uterine contractions**, and a **firm, tender uterus** strongly suggests **placental abruption**.
- **Fetal decelerations** and the physician's warning against immediate vaginal examination (due to potential for exacerbating hemorrhage if it were placenta previa) further support this diagnosis.
*Miscarriage*
- This patient is at **30 weeks gestation**, whereas a miscarriage is defined as pregnancy loss before **20 weeks of gestation**.
- While bleeding and pain occur, the gestational age rules against a diagnosis of miscarriage.
*Vasa previa*
- **Vasa previa** is characterized by rupture of fetal vessels, leading to **fetal bleeding** and **sudden, painless vaginal bleeding**.
- The patient's presentation includes **intense abdominopelvic pain** and **uterine contractions**, which are not typical of vasa previa.
*Placenta previa*
- **Placenta previa** typically presents with **painless vaginal bleeding** and usually does not involve intense abdominal pain or a **firm, tender uterus**.
- The patient's symptoms of significant pain and uterine contractions are inconsistent with placenta previa.
*Uterine rupture*
- **Uterine rupture** is a catastrophic event, often preceded by a history of **uterine surgery** or trauma, and presents with sudden, severe pain, **fetal distress**, and a **palpable fetal parts** outside the uterus.
- While there is pain and fetal distress, the presence of a **firm, tender uterus** and the absence of a history of uterine surgery make abruption a more likely diagnosis.
Uterine rupture US Medical PG Question 7: A 32-year-old G2P1 female at 30 weeks gestation presents to the emergency department with complaints of vaginal bleeding and severe abdominal pain. She states that she began feeling poorly yesterday with a stomach-ache, nausea, and vomiting. She first noted a small amount of spotting this morning that progressed to much larger amounts of vaginal bleeding with worsened abdominal pain a few hours later, prompting her to come to the emergency department. Her previous pregnancy was without complications, and the fetus was delivered at 40 weeks by Cesarean section. Fetal heart monitoring shows fetal distress with late decelerations. Which of the following is a risk factor for this patient's presenting condition?
- A. Singleton pregnancy
- B. Hyperlipidemia
- C. Patient age
- D. Hypertension (Correct Answer)
- E. Prior Cesarean section
Uterine rupture Explanation: ***Hypertension***
- The presenting symptoms of **vaginal bleeding**, **severe abdominal pain**, and **fetal distress** in a pregnant woman are highly suggestive of **placental abruption**.
- **Chronic hypertension** is a well-established and significant risk factor for placental abruption, increasing the risk by two to three times.
*Singleton pregnancy*
- This is typical for most pregnancies and does not increase the risk of placental abruption.
- **Multiple gestations** (twins, triplets) are actually associated with an increased risk of placental abruption, not singleton pregnancies.
*Hyperlipidemia*
- **Hyperlipidemia** is generally not considered a direct risk factor for placental abruption.
- While it can be associated with other cardiovascular issues, its link to placental abruption is not significant in the way hypertension is.
*Patient age*
- At 32 years old, the patient is not at an extremely advanced maternal age, which typically refers to 35 years or older.
- While **advanced maternal age** can be a slight risk factor for some pregnancy complications, it is not as strong a risk factor for placental abruption as hypertension in this context.
*Prior Cesarean section*
- A **prior Cesarean section** is a risk factor for conditions like **placenta previa** and **placenta accreta**, where the placenta implants abnormally.
- It is not a primary risk factor for **placental abruption**, which involves premature separation of a normally implanted placenta.
Uterine rupture US Medical PG Question 8: A 46-year-old woman presents to the clinic complaining that she “wets herself.” She states that over the past year she has noticed increased urinary leakage. At first it occurred only during her job, which involves restocking shelves with heavy appliances. Now she reports that she has to wear pads daily because leakage of urine will occur with simply coughing or sneezing. She denies fever, chills, dysuria, hematuria, or flank pain. She has no significant medical or surgical history, and takes no medications. Her last menstrual period was 8 months ago. She has 3 healthy daughters that were born by vaginal delivery. Which of the following tests, if performed, would most likely identify the patient’s diagnosis?
- A. Methylene blue dye
- B. Post-void residual volume
- C. Urodynamic testing
- D. Estrogen level
- E. Q-tip test (Correct Answer)
Uterine rupture Explanation: ***Q-tip test***
- The patient's symptoms (leakage with coughing/sneezing, lifting heavy objects, vaginal deliveries, recent cessation of menses) are classic for **stress urinary incontinence**, often due to **urethral hypermobility**.
- The **Q-tip test** assesses urethral hypermobility by measuring the angle of deflection of a sterile cotton swab inserted into the urethra during a Valsalva maneuver. An angle >30 degrees from the horizontal indicates hypermobility.
*Methylene blue dye*
- **Methylene blue dye** is primarily used to identify **vesicovaginal or ureterovaginal fistulas**, where dye would be seen leaking into the vagina.
- The patient's symptoms do not suggest a fistula, but rather a problem with sphincter control during increased abdominal pressure.
*Post-void residual volume*
- **Post-void residual volume (PVR)** measures the amount of urine left in the bladder after urination, primarily used to diagnose **overflow incontinence** or **urinary retention**.
- The patient's symptoms are inconsistent with overflow incontinence, which typically involves frequent dribbling or incomplete emptying rather than leakage specifically with physical exertion.
*Urodynamic testing*
- **Urodynamic testing** is a more comprehensive and invasive evaluation that includes cystometry, pressure-flow studies, and electromyography, often used to differentiate types of incontinence when the diagnosis is unclear.
- While it can diagnose stress incontinence, less invasive tests like the Q-tip test are typically preferred as a first step for **urethral hypermobility** before proceeding to complex urodynamic studies.
*Estrogen level*
- An **estrogen level** might be relevant if **atrophic vaginitis** or **urethritis** due to estrogen deficiency were suspected, which can contribute to urgency or mixed incontinence.
- While the patient is peri-menopausal, her primary symptoms (leakage with exertion) are more indicative of structural weakness (stress incontinence) rather than estrogen-related tissue atrophy or inflammation.
Uterine rupture US Medical PG Question 9: A 62-year-old woman makes an appointment with her primary care physician because she recently started experiencing post-menopausal bleeding. She states that she suffered from anorexia as a young adult and has been thin throughout her life. She says that this nutritional deficit is likely what caused her to not experience menarche until age 15. She used oral contraceptive pills for many years, has never been pregnant, and experienced menopause at age 50. A biopsy of tissue inside the uterus reveals foci of both benign and malignant glandular cells. Which of the following was a risk factor for the development of the most likely cause of her symptoms?
- A. Menopause at age 50
- B. Never becoming pregnant (Correct Answer)
- C. Using oral contraceptive pills
- D. Menarche at age 15
- E. Being underweight
Uterine rupture Explanation: ***Never becoming pregnant***
- **Nulliparity** is a significant risk factor for **endometrial cancer** as it implies longer exposure to unopposed estrogen, which stimulates endometrial proliferation.
- The diagnosis of malignant glandular cells in the context of post-menopausal bleeding strongly suggests **endometrial carcinoma**, where nulliparity contributes to increased estrogen exposure over time.
*Menopause at age 50*
- **Later age of menopause** (e.g., after 52) is a risk factor for endometrial cancer, as it prolongs the duration of estrogen exposure.
- Menopause at age 50 is considered within the **average range**, thus not typically an independent risk factor for endometrial cancer.
*Using oral contraceptive pills*
- **Combined oral contraceptive pills** (estrogen and progestin) actually **reduce the risk** of endometrial cancer.
- The progestin component in OCPs counteracts the proliferative effects of estrogen on the endometrium, offering protection.
*Menarche at age 15*
- **Early menarche** (before age 12) is a risk factor for endometrial cancer due to a longer lifetime exposure to estrogen.
- Menarche at age 15 is considered **later than average**, which would typically be a protective factor against endometrial cancer, as it shortens the duration of estrogen exposure.
*Being underweight*
- **Obesity** is a major risk factor for endometrial cancer because adipose tissue converts androgens to estrogens, leading to higher levels of circulating estrogen.
- Being underweight or having a history of anorexia does not increase the risk of endometrial cancer; in fact, it may be associated with **lower estrogen levels**, which could be protective.
Uterine rupture US Medical PG Question 10: A 25-year-old G2P1001 at 32 weeks gestation presents to the hospital with painless vaginal bleeding. The patient states that she was taking care of laundry at home when she experienced a sudden sensation of her water breaking and saw that her groin was covered in blood. Her prenatal history is unremarkable according to the clinic records, but she has not seen an obstetrician for the past 14 weeks. Her previous delivery was by urgent cesarean section for placenta previa. Her temperature is 95°F (35°C), blood pressure is 125/75 mmHg, pulse is 79/min, respirations are 18/min, and oxygen saturation is 98% on room air. Cervical exam shows gross blood in the vaginal os. The fetal head is not palpable. Fetal heart rate monitoring demonstrates decelerations and bradycardia. Labs are pending. IV fluids are started. What is the best next step in management?
- A. Cesarean section (Correct Answer)
- B. Betamethasone
- C. Red blood cell transfusion
- D. Vaginal delivery
- E. Lumbar epidural block
Uterine rupture Explanation: ***Cesarean section***
- This patient presents with signs highly suggestive of **placenta previa with possible vasa previa or placental abruption**, with life-threatening complications for both mother and fetus. The presence of **painless vaginal bleeding**, a prior **cesarean section for placenta previa**, and **fetal heart rate decelerations/bradycardia** necessitate immediate delivery via cesarean section to prevent **fetal demise** and severe **maternal hemorrhage**.
- The rapid deterioration of the fetal status, indicated by **decelerations and bradycardia**, confirms the urgency. A **cesarean section** is the quickest and safest way to deliver the baby and address the underlying obstetric emergency.
*Betamethasone*
- **Betamethasone** is administered to promote **fetal lung maturity** in cases of preterm delivery. While this patient is preterm at 32 weeks, the critical nature of the fetal distress and bleeding requires immediate delivery, making the delay for betamethasone administration inappropriate.
- The benefits of steroids for lung maturity are outweighed by the **immediate risk of fetal demise** and severe maternal complications if delivery is delayed.
*Red blood cell transfusion*
- While the patient is actively bleeding and may eventually require a **blood transfusion**, starting IV fluids and proceeding with an **immediate cesarean section** are higher priorities to stabilize the mother and rescue the fetus.
- Transfusions are supportive measures once the source of hemorrhage is addressed and vital signs are stabilized during or after surgery.
*Vaginal delivery*
- Given the patient's history of **placenta previa**, current **painless vaginal bleeding**, and signs of **fetal distress**, a vaginal delivery is contraindicated due to the high risk of **exsanguinating hemorrhage** for the mother and severe fetal compromise.
- The prior **cesarean section for placenta previa** also increases the risk of recurrent previa and **placenta accreta spectrum**, further contraindicating vaginal delivery.
*Lumbar epidural block*
- A **lumbar epidural block** is used for pain management during labor, but in this emergent situation with active bleeding and fetal distress, immediate delivery is paramount.
- The time required to safely administer an **epidural**, along with the potential for **hypotension** in a hypovolemic patient, makes it an inappropriate next step.
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