T he patient was a 17-year-old unmarried, primi- gravida who delivered via vacuum-assisted vaginal extraction two days previously. In the course of the delivery, a significant midline and extensive right lateral wall vaginal tear occurred. The patient was discharged on the first postpartum day; however, she represented herself to the clinic 24 h later with shaking chills, a temperature of 103.3Β°F, and bilaterally costovertebral angle (CVA) tenderness. The patient denied any dysuria, vomiting, episiotomy pain, abdominal pain, foul smelling discharge, or breast tenderness.
Physical examination revealed a temperature of 103.3Β°F, pulse 110, respirations 16, blood pressure 110/70. Pertinent physical findings were limited to the abdominal and pelvic examinations. The abdomen was soft and nontender. No masses were present. Bowel sounds were present. The fundus was firm, 3 cm below the umbilicus, and nontender. The patient had marked CVA tenderness to minimal palpation. The remainder of the physical examination was unremarkable. Laboratory evaluation reveals a white count of 18,700, hematocrit 20.6, platelets 215,000. Urinalysis revealed 50-90 WBCs with positive nitrite and WBC esterase as well as many bacteria were seen.