Molly is a 20-year-old gravida 1, para

Molly is a 20-year-old gravida 1, para 1 who gave birth to a term, healthy baby boy, weighing 9 lbs 1 oz (4.1 kg) at 23:32 hours. She received an epidural for labor pain control, pushed for 3 hours, and required a vacuum assisted delivery. Her perineum required repair of a third-degree laceration. After birth, the nurse discontinued the continuous epidural pump, placed ice on the perineum, completed the required 15-minute checks (x5), helped Molly breastfeed, and assisted Molly’s boyfriend in holding the baby and taking pictures. On arrival to the mother-baby unit, Molly requests pain medication and states that the ice is helping some but that she wants to “stay on top of it.” She rates the pain as a 5 on a 10-point scale. The admission vital signs and fundal location are within normal limits. An examination of Molly’s perineum reveals mild swelling and a normal amount of vaginal bleeding. Molly is tired and asks that she be allowed to sleep. Her boyfriend goes home to sleep, and the baby is taken to the nursery. Two hours later, Molly calls for her nurse and complains of intense burning, pain, and pressure “where I had my stitches.” You examine her perineum and note an 8 cm bulging mass on her left vulva. When you touch it with a gloved hand, Molly says, “Oh, that is so tender!

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