Patient is a 41 y.o. female who presented for a scheduled repeat cesarean section. Patient had completed childbearing and desired permanent sterilization via cesarean section. Her pregnancy was additionally complicated by history of two prior cesarean sections, advanced maternal age, obesity with BMI 38 and recent diagnosis of COVID-19 on POD 2.  Surgery was complicated by postpartum hemorrhage due to bleeding from hysterotomy. EBL was 1700 ml and patient received 1g TXA intraoperatively. Hemoglobin post-op was 9.0 compared to 12.0 prior to surgery. Patient remained asymptomatic for anemia. She met postpartum milestones and was discharged home in stable condition on post-operative day #3. PO Iron supplement prescribed upon discharge.  She is to follow up with her OB in 6 weeks for a postpartum visit.    Postpartum depression screening: Edinburgh Edinburgh Postnatal Depression Scale Total: 10 The patient was taken to the operating room, where spinal anesthesia was obtained without difficulty.  She was placed in a dorsal, supine position with a leftward tilt. A Foley catheter was sterilely inserted and SCDs were placed on her lower legs bilaterally. She was then prepped and draped in the normal sterile fashion. Anesthesia was tested and determined to be adequate.  A low transverse skin incision was made with a scalpel and carried through to the underlying layer of the fascia. The fascia was scored on each side of the linea alba with the underlying rectus muscle visualized. The fascial incision was then extended bilaterally with Mayo scissors. The cephalad aspect of the fascial incision was grasped with the Kocher clamps, elevated and the rectus muscles dissected off sharply and bluntly.  Similarly, the caudal aspect of the fascial incision was grasped with Kocher clamps, elevated and the rectus muscles were dissected off sharply and bluntly. The rectus muscles were separated in the midline.  The peritoneum was identified and entered bluntly.  The peritoneal window was extended using blunt countertraction, avoiding the bladder. The DeLee retractor was inserted and the vesicouterine peritoneum identified.   The Alexis retractor was inserted and the lower uterine segment was identified. Bladder was adhered to lower uterine segment, so mid-transverse incision was made on uterus. Brisk bleeding was noted on entry into uterus due to large vessels. The incision was extended bluntly. The infant was in a cephalic presentation.  The infant?s head was delivered atraumatically with fundal pressure from the first assistant.  The remainder of the infant was easily delivered. The infant was vigorous at birth.  Cord clamping was delayed for 60 seconds and then the umbilical cord was clamped with two clamps and cut. The infant was handed off to the awaiting nurses at the warmer. Mixed cord blood was obtained.   The placenta was removed spontaneously and the uterus cleared of all clots and debris.  The uterus was exteriorized.  The uterine incision was repaired with 0 Monocryl in a running stitch in a single layer. Brisk bleeding was noted during hysterotomy closure due to large sinuses near hysterotomy. A second 0 Monocryl was used in running fashion along the right side of the hysterotomy due to venous sinus bleeding.  1g TXA IV was given intraoperatively. Excellent hemostasis was obtained after hysterotomy closure.    The tubal ligation was then performed.  The left tube was identified and followed out to the fimbriated edge.  The tube was grasped with a Percy clamp, elevated, and a 1 cm portion of the tube was suture ligated with 0 Plain x 2.  The tube was excised.   The tube ends were inspected and were hemostatic.  Attention was then turned to the right tube, the tube was followed out to the fimbriated edge.  The tubal was done in the same manner as the other side.  Each tube was inspected and was hemostatic.  The uterus was replaced into the abdomen.  The bladder was backfilled using methylene blue, 90cc, to evaluate for injury.  No leakage or evidence of injury was noted.    The gutters were cleared of all clots and debris. The peritoneum and rectus muscles were inspected and found to be hemostatic.  The fascia was reapproximated using 0 PDS in a running stitch from each corner. The subcutaneous layer was irrigated and reapproximated using 3-0 Vicryl in running fashion.  The skin was reapproximated using 3-0 STRATA FIX  suture.  Skin glue was applied.   The patient tolerated the procedure well. Sponge, lap and needle counts correct x2.  The patient received 2 g of Ancef prior to beginning of the procedure.  The patient was transferred to the recovery room in stable condition.