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

   A. Vaginal hematoma

2. B

   B. Perineal tear

3. C

   C. Bartholin's cyst

4. D

   D. Cystocoele

Appeared in: INI-CET EXAM -2026

Explanation

• A vaginal hematoma is a collection of blood in the vaginal tissues, which is a known complication of trauma from an instrumental delivery.
• The collection of blood forms a mass that presents as a 'cystic swelling' and appears 'bluish' or dusky due to the blood under the mucosa.
• This mass can exert significant pressure on the adjacent urethra, leading to obstruction and causing acute urinary retention.
• The patient's history and physical findings align perfectly with the classic presentation of a puerperal hematoma.

Why Other Options Were Wrong

• Option B: A perineal tear is a laceration or an open wound of the perineum, not a cystic swelling within the vaginal wall. While it can cause pain and bleeding, its appearance is distinctly different.
• Option C: A Bartholin's cyst is a blocked gland located at the posterior vaginal introitus. It is typically not bluish (unless there is hemorrhage into it) and is less commonly associated with acute urinary retention immediately postpartum compared to a large vaginal wall hematoma.
• Option D: A cystocele is a chronic prolapse of the bladder into the vagina due to weakened pelvic floor muscles. It is not an acute event that develops within hours of delivery and would not have a bluish appearance.

Related Visual

Clinical Relevance

• Nursing practice connection: Safe nursing care depends on performing Diagnosis of acute postpartum complications following instrumental delivery in the correct sequence, documenting the action clearly, and monitoring for the expected response.
• Postpartum hematomas are an obstetric emergency. While vulvar hematomas are visible, vaginal and retroperitoneal hematomas can be concealed, leading to significant, hidden blood loss and hypovolemic shock.
• A key nursing responsibility is to assess for disproportionate pain. A patient complaining of severe, persistent perineal or rectal pressure/pain that seems out of proportion to the expected postpartum discomfort should be immediately evaluated for a hematoma.
• Management depends on size and stability. Small, non-expanding hematomas (less than 5 cm) may be managed conservatively with ice packs and observation. Large or expanding hematomas require surgical incision and drainage.

How to Approach the Question

• First, identify the key elements of the clinical scenario: a patient who is 4 hours postpartum after an instrumental delivery.
• Next, analyze the presenting signs and symptoms: 1) inability to pass urine, and 2) a bluish cystic swelling in the vagina.
• Synthesize these findings. The instrumental delivery is a major risk factor for trauma. The 'bluish cystic swelling' strongly suggests a collection of blood (a hematoma). The 'inability to pass urine' indicates a mass effect compressing the urethra.
• Evaluate each option against this synthesis. Vaginal hematoma is the only option that explains all three components: the cause (trauma), the appearance (bluish cyst), and the complication (urinary retention).
• Rule out the other options. A perineal tear is a laceration, not a cyst. A Bartholin's cyst is in a specific location and not typically blue. A cystocele is a chronic prolapse, not an acute, hemorrhagic event.

Concept Tested & Keywords

• Concept Tested: Diagnosis of acute postpartum complications following instrumental delivery.
• 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 (risk factor for trauma), a bluish cystic swelling (sign of hemorrhage), and urinary retention (sign of mass effect) is highly specific for a vaginal hematoma.

Question ID

QFBDSAveRRqW5GqFYEUEth

Copy ID

Reference Book

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

E6 Obstetrics Williams p. 53-72