A patient is unable to pass urine four hours after an instrumental vaginal delivery. Examination reveals a bluish cystic swelling in the vaginal wall. What is the most likely diagnosis?

1. A

   Vaginal hematoma

2. B

   Perineal tear

3. C

   Bartholin's cyst

4. D

   Cystocoele

Appeared in: AIIMS Rishikesh NO - 2019

Explanation

• A vaginal hematoma is a collection of blood in the vaginal wall, a known complication of traumatic or instrumental delivery.
• The bluish discoloration is characteristic of blood under the tissue, and the mass effect of the hematoma can compress the urethra, leading to acute urinary retention.
• The patient's history of instrumental delivery significantly increases the risk for this type of soft tissue injury and bleeding.
• The presentation of a tense, painful, cystic swelling with urinary retention is a classic sign of a significant puerperal hematoma.

Why Other Options Were Wrong

• Option B: A perineal tear is a laceration or open wound, not a contained, cystic swelling. While a hematoma can occur with a tear, the primary finding described is the hematoma itself.
• Option C: A Bartholin's cyst is a blockage of a gland near the vaginal opening. It is not typically bluish and is less likely to be an acute complication of delivery causing urinary retention.
• Option D: A cystocele is a prolapse of the bladder into the vagina due to weakened pelvic support. It does not present as an acute, painful, bluish mass following delivery.

Related Visual

Clinical Relevance

• Nursing practice connection: Safe nursing care depends on performing The user is being tested on their ability to diagnose postpartum complications based on clinical signs and symptoms, specifically identifying a vaginal hematoma in the correct sequence, documenting the action clearly, and monitoring for the expected response.
• Nurses must be vigilant in assessing postpartum patients for signs of hematoma, including severe pain disproportionate to the expected discomfort, a palpable mass, and signs of urinary retention or hypovolemia.
• Promptly reporting these findings is critical, as large or expanding hematomas can lead to significant blood loss and hemodynamic instability, requiring urgent surgical intervention.
• Nursing care for a patient with a suspected hematoma includes frequent monitoring of vital signs, assessing pain levels, monitoring for swelling, and preparing for potential surgical drainage.

How to Approach the Question

• First, analyze the key elements of the clinical scenario: the patient is postpartum after an instrumental delivery.
• Identify the primary signs and symptoms: inability to urinate and a 'bluish cystic swelling' in the vagina.
• Consider the pathophysiology of each option. 'Bluish' strongly suggests blood. 'Cystic swelling' suggests a collection of fluid (in this case, blood).
• Evaluate how each option aligns with the patient's history and presentation. Instrumental delivery is a major risk factor for trauma and bleeding.
• Correlate the urinary retention with the other findings. A mass in the vaginal wall can easily compress the urethra.
• Conclude that a vaginal hematoma is the only diagnosis that explains all the key features: the cause (trauma from instrumental delivery), the appearance (bluish cystic swelling), and the associated symptom (urinary retention).

Concept Tested & Keywords

• Concept Tested: The user is being tested on their ability to diagnose postpartum complications based on clinical signs and symptoms, specifically identifying a vaginal hematoma.
• Stem keywords: instrumental vaginal delivery, unable to pass urine, bluish cystic swelling, vaginal wall
• Lead-in keywords: most likely diagnosis
• Clinical cues: The combination of recent instrumental delivery, urinary retention, and a bluish swelling is a classic triad for a puerperal hematoma.

Question ID

Qn_Ac7vpak0VMbBqFn4N4b

Copy ID

Reference Book

E6 Midwifery Obstetrics and Gynecology Nursing Sandeep Kaur p. 5-10

E6 Obstetrics Williams p. 53-72