WorksheetsNCM109 - Lesson 7
Total questions: 99
Worksheet time: 50mins
Which statement best defines post-partum hemorrhage in clinical terms?
Any genital tract bleeding after six weeks postpartum
Bleeding exceeding 500 ml within 24 hours after birth
Any postpartum spotting within the first two weeks
Bleeding exceeding 250 ml during the second stage of labor
Fill in the blank: Severe post-partum hemorrhage is blood loss greater than or equal to (a) within 24 hours.
Which timing correctly classifies primary post-partum hemorrhage?
Only during the first stage of labor
Between 24 hours and 6 weeks postpartum
Any bleeding beyond six weeks postpartum
During third stage and within 24 hours of delivery
Which change in vital signs commonly indicates deterioration in a mother with post-partum hemorrhage?
Falling pulse with rising blood pressure
Stable pulse with stable blood pressure
Stable pulse with rising blood pressure
Rising pulse with falling blood pressure
Secondary post-partum hemorrhage is also referred to as (a) hemorrhage.
A patient bleeds 600 ml within 12 hours after delivery. How should this be classified?
Primary post-partum hemorrhage
Non-obstetric uterine bleeding
Secondary post-partum hemorrhage
Physiologic postpartum lochia
Which primary cause of postpartum hemorrhage is due to failure of uterine muscle contraction after delivery?
Uterine inversion with fundal collapse
Atonic uterus lacking contraction
Retained placental tissue fragments
Uterine rupture through myometrium
Identify the condition where the uterus turns inside out during or after delivery.
Endometritis causing late bleeding
Subinvolution of placental site
Atonic uterus after placental delivery
Uterine inversion during expulsion
Which item is NOT listed as a primary cause of postpartum hemorrhage?
Cervico-vaginal laceration trauma
Uterine rupture leading bleeding
Blood coagulopathy affecting clotting
Retained product of conception
Name the cause of secondary postpartum hemorrhage characterized by delayed healing at the placental attachment site.
(a)
Which is a recognized cause of secondary postpartum hemorrhage?
Uterine rupture during second stage
Blood coagulopathy post-delivery
Retained bits of cotyledon or membranes
Atonic uterus causing immediate bleed
Select the rare cause linked with secondary postpartum hemorrhage.
Atonic uterus with poor tone
Primary uterine inversion event
Fibroid polyp causing delayed bleeding
Trauma mixed with atony
Which maternal factor increases risk for postpartum hemorrhage due to overdistended uterus?
Prolonged third stage of labor
Grandmultiparity with many births
Multiple delivery causing distension
Placenta previa near cervical os
A patient has a history of postpartum hemorrhage. How does this history affect current risk?
Indicates only secondary PPH risk
No impact on current risk profile
Moderately increases current PPH risk
Eliminates risk with preventive care
Which risk factor is most associated with surgical delivery–related bleeding in the late postpartum period?
Placental abruption before delivery
Episiotomy fetal macrosomia
Pregnancy induced hypertension
Secondary hemorrhage from caesarean section
Prioritize initial suspected cause in immediate heavy bleeding postpartum when uterus is soft and boggy.
Endometritis causing infectious bleeding
Retained membranes causing delayed bleeding
Atonic uterus causing inadequate contraction
Uterine rupture causing concealed bleeding
Which finding best differentiates secondary from primary postpartum hemorrhage?
Timing after 24 hours postpartum
Presence of uterine inversion
Association with macrosomic fetus
Evidence of blood coagulopathy
Which clinical sign most directly indicates hemodynamic compromise in postpartum hemorrhage, as shown in the symptoms diagram?
Mild breast tenderness
Increased heart rate
Improved skin warmth
Normal urine output
In the 4 Ts framework, which category corresponds to uterine atony in postpartum hemorrhage?
Clotting
Tissue
Tone
Trauma
A patient passes large clots and reports dizziness after delivery. Which immediate vital sign change is most consistent with postpartum hemorrhage?
Decreased respiratory rate
Increased oxygen saturation
Decreased blood pressure
Stable heart rhythm
Match each 'T' of postpartum hemorrhage with its example etiology.
Tone → Uterine atony; Tissue → Retained placenta
Clotting → Uterine rupture; Trauma → Coagulopathy
Tone → Retained placenta; Trauma → Uterine atony
Tone → Lacerations; Tissue → Coagulopathy
Which presentation most suggests perineal trauma contributing to postpartum hemorrhage?
Swelling and pain in vaginal and perineal tissues
Improved uterine tone on palpation
Warm, dry skin without tenderness
Clear urine with steady output
In the 4 Ts framework, retained placenta is classified under which category?
Trauma
Tone
Clotting
Tissue
Which etiology aligns with the 'Clotting' category in postpartum hemorrhage?
Uterine rupture
Uterine atony
Retained placenta
Coagulopathy
A patient has decreased blood pressure and lightheadedness after delivery. Which step best prioritizes early recognition of postpartum hemorrhage in this scenario?
Delay assessment until the next scheduled round
Encourage early ambulation and stretching
Administer routine postpartum vaccinations
Identify symptoms consistent with acute blood loss
Which first-line action helps control postpartum hemorrhage due to uterine atony?
Routine antibiotic prophylaxis alone
Rapid hysterectomy without stabilization
Immediate uterine massage with firm pressure
Delayed oxytocin hours after delivery
Which uterotonic is appropriate for persistent uterine atony when oxytocin is insufficient?
Progesterone oral supplementation
Heparin intravenous bolus
Magnesium sulfate infusion
Carboprost intramuscular administration
A patient with heavy bleeding after delivery has a boggy uterus and no retained tissue on ultrasound. Which escalation is most appropriate after uterine massage and oxytocin fail?
Carboprost administration for uterine contraction
Immediate D&C to clear the uterine cavity
Observation with serial hemoglobin checks
Start prophylactic broad-spectrum antibiotics
In surgical management of refractory uterine atony, which option aims to reduce uterine blood flow?
Endometrial ablation for menstrual control
Tubal ligation for contraception only
Uterine artery ligation by experienced surgeon
Cervical cerclage during pregnancy
Which intervention is routinely given alongside D&C for retained products to reduce infection risk?
High-dose oxytocin infusion only
Carboprost repeated every fifteen minutes
Gauze packing without medications
Prophylactic antibiotics before and after
Place the following steps in order for managing retained placental fragments with bleeding: confirm retention, uterotonic therapy, perform D&C, administer prophylactic antibiotics. Which step should occur second?
Uterotonic therapy for contraction
Administer prophylactic antibiotics
Perform D&C procedure
Confirm retention by evaluation
Which postpartum complication is depicted by palpable fetal parts and a tear along a uterine scar?
Uterine rupture with scar dehiscence
Placental abruption with concealed bleed
Uterine atony without structural tear
Cervical laceration with minor bleeding
What is the immediate priority when trauma causes significant blood loss after birth?
Identify and treat the trauma source quickly
Administer oral iron supplementation first
Schedule elective imaging within 24 hours
Observe without intervention for six hours
Vaginal bleeding after delivery may be concealed, leading most commonly to what complication?
Hematoma in surrounding tissue space
Endometritis with fever and pain
Uterine atony causing slow trickle
Retained placenta causing clots
Which supportive measure accompanies surgical control of traumatic postpartum hemorrhage?
Topical estrogen to the cervix
Resuscitation with fluids and blood
Immediate discharge to the ward
Routine diuretics for edema
After delivery, observation for approximately two hours ensures which finding before ward transfer?
Uterus is hard and well contracted
Perineum is entirely pain free
Lochia is completely absent
Hemoglobin level is above baseline
Any derangement of hemostasis in postpartum hemorrhage is most typically defined as what?
Enhanced thrombin generation always
Hyperfibrinolysis without bleeding risk
Excessive platelet production occurs
Impaired clot formation predominates
Which of the following is a recognized cause of hemostasis derangement in obstetrics?
Mild dehydration from breastfeeding
Amniotic fluid embolism leading coagulopathy
Benign uterine fibroid regression
Physiologic leukocytosis after labor
Which antenatal measure most directly reduces modifiable risk for post-partum hemorrhage?
Routine blood group documentation and crossmatch readiness
Universal prophylactic antibiotics throughout pregnancy
General improvement of maternal health status through optimization
Identification and scheduling of high-risk patients for elective delivery
During cesarean section, which intranatal practice helps prevent excessive bleeding?
Continuous uterotonic infusion before fetal delivery
Delayed uterine closure to promote drainage
Spontaneous separation and delivery of the placenta
Manual rapid extraction of placenta without traction
Active management of the third stage of labor typically includes the use of (a) .
Which action best describes active management of the third stage to reduce PPH?
Expectant observation until placenta expels spontaneously
Prophylactic transfusion for all postpartum patients
Controlled cord traction with timely uterotonics administration
Routine uterine packing immediately after delivery
A patient is categorized as high risk for PPH antenatally. Which planning step improves safety intrapartum?
Avoiding oxytocin to prevent uterine tachysystole
Ensuring an expert obstetric anesthetist is present
Scheduling slow delivery regardless of fetal status
Skipping placental examination to shorten third stage
Immediately after birth, which sequence best minimizes missed bleeding sources?
Give antibiotics, discharge early, schedule clinic follow-up
Apply fundal pressure, discharge after one hour observation
Examine placenta, explore utero-vaginal canal, observe two hours
Observe two hours, then examine placenta and canal
Which uterotonic agent and dose is recommended during active management of the third stage of labor when available?
Oxytocin 10 IU IM routinely
Oxytocin 5 IU slow IV
Carbetocin 100 µg IV push
Misoprostol 400 µg orally
When oxytocin is not available or feasible, what is the recommended alternative and dose for prevention of postpartum hemorrhage?
(a)
Which blood loss threshold defines postpartum hemorrhage after cesarean delivery?
Greater than 1 liter of loss
Greater than 500 milliliters
Any visible bleeding at perineum
More than 250 milliliters
A patient has ongoing bleeding after delivery. What is the immediate priority in initial resuscitation?
Secure IV access promptly
Begin uterine tamponade
Order coagulation studies
Administer blood products
Fill in the blank: For fluid resuscitation in ongoing bleeding, aim to keep blood pressure above (a) mm Hg systolic.
Which oxytocin infusion dose range is recommended during ongoing bleeding management?
5–10 IU per liter IV
1–2 IU per hour IV
50–80 IU per liter IV
20–40 IU per liter IV
Which bedside maneuver is indicated to reduce pelvic arterial flow during uncontrolled PPH prior to definitive measures?
Bladder catheter clamping
Uterine inversion reduction
Manual placental removal
Aortic compression technique
Which step helps identify multifactorial causes when bleeding persists despite initial measures?
Examine to determine causes
Increase oxytocin concentration
Start prophylactic antibiotics
Apply fundal pressure continuously
Which cause category in the PPH algorithm is addressed by removing retained tissue with curettage or manual extraction?
Tissue etiology management
Trauma source control
Thrombin pathway correction
Tone restoration approach
Which component of the ‘4 Ts’ corresponds to uterine atony?
(a)
Which product combination is appropriate for coagulopathy management during PPH?
FFP, RBC, cryoprecipitate
Tranexamic acid exclusively
Platelets only, no plasma
Normal saline boluses alone
Which prostaglandin is recommended for refractory atony, including dose and route options?
Misoprostol 200 µg sublingual
Carboprost 250 µg IV bolus
15‑methyl PGF2α 0.25–1 mg IM or intramyometrial
Dinoprostone 3 mg vaginal insert
What should be done immediately for uterine inversion identified postpartum?
Delay reinversion, observe closely
Immediate reinversion and consult
Start oxytocin and wait
Apply fundal massage vigorously
Which advanced interventions are listed when hemorrhage is still not controlled?
Bed rest and serial vitals in recovery
Operating room for arterial ligation or hysterectomy
Increase oxytocin to 100 IU/L on ward
Prolonged external uterine massage only
Which trauma-related sources should be considered and may require surgical repair during PPH?
Ureteral injury primarily
Ovarian torsion assessment
Placenta accreta exclusively
Episiotomy, hematoma, ruptured uterus
During severe hypotension with unstable vitals, which escalation step is appropriate?
Delay surgery preparations
Avoid transfusion products
Switch to oral fluids only
Place central IV line promptly
Which intramuscular dose of ergometrine is recommended during active management of post‑partum hemorrhage?
0.1 mg intramuscularly
0.2 mg intramuscularly
0.5 mg intramuscularly
1.0 mg intramuscularly
Which combination drug can be given intramuscularly as an alternative to ergometrine during active management of bleeding?
Misoprostol 400 micrograms
Syntometrine 1 milliliter
Carbetocin 100 micrograms
Methylergometrine 5 milligrams
During active management, what simple physical maneuver helps stimulate uterine contraction and retraction?
Suprapubic compression
Fundal pressure only
Bimanual uterine massage
Controlled cord traction
When should the placenta be expelled during active management to reduce bleeding?
Following bladder catheterization
After oxytocin infusion starts
With the next uterine contraction
Immediately after delivery
What technique may be used to assist placental expulsion during active management when the uterus contracts?
Vacuum extraction of placenta
Manual removal without traction
Fundal pressure or controlled cord traction
Rapid cord traction
What immediate step helps uterine contraction by removing a factor that impedes it in active management of bleeding?
Apply external aortic compression
Administer tranexamic acid
Empty the urinary bladder by catheterization
Start high‑rate oxytocin infusion
If bleeding persists ten minutes after the first dose, what is the recommended next action regarding ergometrine or syntometrine?
Switch to misoprostol
Stop uterotonics
Repeat a second dose
Increase oxytocin rate
Fill in the blank: An intramuscular alternative to ergometrine during active management is (a) .
Which uterotonic regimen is most appropriate to initiate for true postpartum hemorrhage requiring continuous contraction support?
Oxytocin infusion at titrated rates
Single dose ergometrine only
Prostaglandin gel intrauterine
No uterotonic, just massage
Which statement best represents a reasoned sequence for initial management when heavy bleeding continues after delivery?
Delay uterotonics until hemorrhage stops
Start prostaglandins, ignore massage
Massage uterus, give uterotonic, assist placenta
Catheterize bladder after placenta delivers
Which maneuver correctly describes bimanual uterine massage for an atonic uterus during postpartum hemorrhage?
Both hands on abdomen compressing the fundus
One vaginal hand pushing uterus, other compresses fundus
Abdominal hand pulls fundus upward without vaginal support
Two vaginal hands elevating cervix toward fundus
During bimanual uterine massage, which aspect is massaged by the abdominal hand?
Posterior aspect of uterus
Anterior aspect of uterus
Lateral aspect of uterus
Cervical aspect of uterus
Select the typical intramuscular dose of oxytocin for treating postpartum hemorrhage.
5 IU intramuscularly
10 IU intramuscularly
40 IU intramuscularly
20 IU intramuscularly
What is a recommended oxytocin infusion rate when diluting 20 IU in 1 L normal saline?
500 mL per hour
400 mL per hour
250 mL per hour
100 mL per hour
How much oxytocin-containing fluid can be safely infused rapidly over 10 minutes without complications?
750 mL over 10 minutes
500 mL over 10 minutes
250 mL over 10 minutes
400 mL over 10 minutes
Identify the typical dose and route for methylergonovine used in postpartum hemorrhage.
0.1 mg orally once
0.2 mg intramuscularly, repeat in 2–4 hours
1 mg subcutaneously, repeat every hour
0.5 mg intravenously, continuous infusion
Carboprost for refractory postpartum hemorrhage is given at what dose and interval?
1 mg single dose
0.5 mg every 60 minutes
0.25 mg every 15 minutes
0.1 mg every 30 minutes
What is the maximum total cumulative dose of carboprost typically used?
1 mg total dose
2 mg total dose
3 mg total dose
4 mg total dose
Which route and dose align with FIGO’s recommendation for misoprostol in postpartum hemorrhage?
600 mcg sublingual dose
400 mcg oral dose
800 mcg vaginal dose
1,000 mcg rectal dose
Beyond uterotonics, which procedure addresses bleeding from genital tract lacerations during postpartum hemorrhage management?
External uterine compression only
Expectant management without intervention
Prompt laceration repair with suturing
Immediate hysterectomy without assessment
Which statement best describes the goal when managing lacerations and hematomas from birth trauma during postpartum care?
Delay repair until edema fully resolves
Prioritize cosmetic outcome over hemostasis
Achieve hemostasis and perform timely repair
Observe only if bleeding appears minimal
Fill in the blank with the precise term: (a) is rare in the context of postpartum complications mentioned.
Which statement accurately defines hysterectomy in the context of life‑threatening gynecologic conditions?
Endometrial ablation for heavy periods
Excision of fallopian tubes for menorrhagia
Removal of ovaries during menopause only
Partial or total removal of the uterus surgically
A patient with refractory postpartum hemorrhage and suspected uterine rupture is unstable. Which plan reflects appropriate DoK 3 reasoning for operative management?
Initiate psychotherapy before any surgery
Schedule elective repair after 48 hours
Proceed to surgical repair or hysterectomy urgently
Administer oral iron and discharge home
Which definition of dystocia is correct within labor management?
Postpartum recovery without complications
Long, difficult, or abnormal labor pattern
Elective induction with minimal contractions
Normal labor with rapid progression
Identify the three major components of the labor process used to analyze causes of dystocia.
Provider, protocol, environment
Hormones, nutrition, hydration
Powers, passenger, passageway
Placenta, cervix, perineum
A fetus in malpresentation with narrow maternal pelvis causes slow labor despite adequate contractions. Which component primarily explains the difficulty?
Placental component mainly
Passenger and passageway components
Maternal psychology component
Powers component only
Which factor most directly increases risk for uterine dystocia by causing excessive uterine volume?
Multiple gestation causing overdistention
Electrolyte imbalance causing cramping
Maternal dehydration causing hypoperfusion
Short maternal stature limiting outlet
Cephalopelvic disproportion primarily reflects a mismatch between which two structures?
Fetal head and maternal pelvis
Uterine fundus and lower segment
Placenta and uterine wall
Cervix and amniotic membranes
Which scenario best illustrates pelvic dystocia?
Midpelvis contracture reducing capacity
Overdistended uterus from hydramnios
Uterine overstimulation with oxytocin
Placenta previa obstructing the passage
A primigravid adolescent presents in labor with poor engagement at the inlet. Which pelvic factor increases her risk of dystocia?
Pelvic immaturity with smaller diameters
Uterine fibroid causing obstruction
Maternal fear increasing catecholamines
Ovarian tumor compressing the outlet
Which soft tissue condition most likely prevents the fetal head from entering the bony pelvis?
Oxytocin overstimulation tachysystole
Placenta previa covering the os
Cephalopelvic disproportion mismatch
Maternal short stature alone
Identify a modifiable contributor to uterine dystocia during labor management.
Adolescent pelvic immaturity
Inappropriate timing of analgesic agents
Congenital uterine malformation
Maternal short stature trait
During prolonged labor with a visible abdominal ridge and severe pain, what complication related to a Bandl ring is of greatest concern?
Development of cord prolapse
Increased risk of uterine rupture
Progression to placental abruption
Onset of shoulder dystocia
Which combination best groups soft tissue dystocia causes?
Fibroids, ovarian tumors, full bladder
Hydramnios, multiple gestation, CPD
Fear, fatigue, electrolyte imbalance
Short stature, dehydration, malpresentation
Which anatomical structure most commonly impedes delivery in shoulder dystocia as shown in the diagram?
Ischial spine trapping the posterior arm
Iliac crest compressing the fetal thorax
Pubic bone obstructing the anterior shoulder
Sacral promontory obstructing the fetal head
In the diagram comparing nerve bundles, what injury mechanism to the brachial plexus is depicted in shoulder dystocia?
Stretch causing neuropraxia or axon damage
Ischemia causing nerve infarction
Transection of the upper trunks
Compression leading to demyelination
Which immediate fetal risk is increased when the anterior shoulder is wedged under the pubic bone during delivery?
Umbilical cord compression reducing oxygenation
Rectal laceration increasing infection
Placental abruption causing maternal shock
Uterine rupture causing hemorrhage
Identify the maternal pelvic region highlighted in the small inset that relates to the site of shoulder impaction.
Anterior pelvis near pubic symphysis
Posterior pelvis near sacrum
Lateral pelvis near iliac wings
Pelvic floor near perineum
