Postpartum Care Practice Questions

Q: A woman dies from a heart disease six days after delivery. This would come under the category of :

Indirect maternal death. ***Indirect maternal death*** - An **indirect maternal death** is defined as one resulting from a pre-existing disease or a disease that developed during pregnancy, which was not due to direct obstetric causes but was aggravated by the physiological effects of pregnancy. - Heart disease in this context, especially when occurring six days postpartum, is often a pre-existing condition exacerbated by pregnancy-related cardiovascular demands, fitting this definition. *Direct maternal death* - **Direct maternal deaths** are those resulting from obstetric complications of the pregnant state, from interventions, omissions, incorrect treatment, or from a chain of events resulting from any of these. - Examples include severe hemorrhage, pre-eclampsia/eclampsia, or obstructed labor, which are not described in this scenario. *Unclassified death* - An **unclassified death** is assigned when there is insufficient information to determine the cause of death as direct, indirect, or coincidental. - In this case, the cause of death (heart disease) is known, making classification possible. *Medical (non-maternal) death* - This category usually refers to deaths from medical conditions **unrelated to or unaggravated by pregnancy**. - While heart disease is a medical condition, its occurrence six days postpartum strongly suggests that the physiological changes of pregnancy played a significant role in its exacerbation or presentation, thereby classifying it as a maternal death rather than a coincidental non-maternal death.

Q: Which of the following is an absolute contraindication to breastfeeding according to WHO guidelines?

Active, untreated maternal tuberculosis. ***Active, untreated maternal tuberculosis*** - According to **WHO guidelines**, active, untreated tuberculosis in the mother IS an **absolute contraindication to direct breastfeeding** due to the risk of transmission to the infant through respiratory droplets during close contact. - However, **expressed breast milk** can be given to the infant during this period as TB is not transmitted through breast milk itself. - Once the mother has received **at least 2 weeks of appropriate anti-tubercular treatment** and is no longer infectious, **direct breastfeeding can be safely resumed**. - This is a temporary contraindication that becomes resolved with treatment, but in the untreated state, it is considered absolute for direct breastfeeding. *Maternal diarrhoea* - **Maternal diarrhea** is NOT a contraindication to breastfeeding according to WHO. - Antibodies in breast milk actually help **protect the infant** from gastrointestinal infections. - Mothers should maintain **good hand hygiene** to prevent fecal-oral transmission, but breastfeeding should continue. - Maternal hydration should be maintained to ensure adequate milk production. *1st 24 hours after Caesarean section* - The **first 24 hours after cesarean section** is NOT a contraindication to breastfeeding. - **Early initiation of breastfeeding** within the first hour after delivery is recommended even after C-section to promote bonding and establish milk supply. - While positioning may require adjustment due to surgical pain, this is managed with **proper support and pain relief**, not by withholding breastfeeding. - Skin-to-skin contact and breastfeeding should be facilitated as soon as the mother is alert and responsive. *None of the above* - This is incorrect because active, untreated maternal tuberculosis IS an absolute contraindication to direct breastfeeding according to WHO guidelines, though expressed breast milk can still be provided.

Q: A multiparous woman delivered by a village dai (midwife) presents on the 22nd postnatal day with bleeding per vaginum with clots. On examination, the uterus is 14-16 weeks, the internal os is open, and there is bleeding through the os. The likely cause of this bleeding is

Retained bits of placenta and membranes. ***Retained bits of placenta and membranes*** - Postnatal bleeding with clots on day 22, an enlarged uterus (14-16 weeks size), and an open internal os are **classic features of retained products of conception**. - Retained placental fragments prevent proper **uterine involution** and interfere with myometrial contraction, leading to **secondary postpartum hemorrhage** (PPH occurring after 24 hours up to 12 weeks postpartum). - The open internal os with bleeding through it strongly suggests intrauterine retained tissue. *Perineal tears* - Perineal tears cause **immediate postpartum bleeding**, typically bright red and continuous, identified and repaired at the time of delivery. - They would **not explain** an enlarged uterus, subinvolution, or delayed bleeding with clots on **day 22 postpartum**. *Excessive postnatal physical work* - While physical overexertion may delay recovery or cause fatigue, it does **not directly cause vaginal bleeding with clots** and an enlarged uterus. - This clinical presentation requires an **obstetric pathology** such as retained products. *Uterine atony* - Uterine atony is the most common cause of **primary PPH** (within 24 hours of delivery), presenting with a soft, boggy uterus and profuse bleeding. - However, on day 22 with an **open os and retained tissue**, the primary issue is retained products rather than atony alone.

Q: The following are the predisposing factors for postpartum uterine atony except

Pre-eclampsia. ***Pre-eclampsia*** - Pre-eclampsia is a condition of **hypertension** and **proteinuria during pregnancy**; it does not directly predispose to uterine atony. - While it can be associated with other obstetric complications, it is not a direct risk factor for the uterus's inability to contract effectively postpartum. *Oxytocin induced labour* - Prolonged or high-dose oxytocin administration can lead to **receptor desensitization** in the myometrium, potentially leading to uterine exhaustion and atony. - The uterus may become fatigued and less responsive to endogenous oxytocin after extensive stimulation. *Multiple pregnancy* - Multiple pregnancies lead to **overdistension of the uterus**, which can stretch the myometrial fibers beyond their optimal contractile capacity. - This overstretching reduces the uterus's ability to contract effectively after birth, increasing the risk of atony. *Hydramnios* - **Hydramnios (polyhydramnios)**, an excessive amount of amniotic fluid, also causes significant uterine overdistension. - Similar to multiple pregnancies, this overstretching compromises the myometrium's ability to contract and retract postpartum, contributing to atony.

Q: In the puerperium, which of the following hormonal changes are responsible for lactogenesis? 1. A sudden fall in the oestrogen levels after delivery 2. Reduction of prolactin inhibiting factor from the hypothalamus 3. Release of prolactin from the anterior pituitary 4. Release of oxytocin from the posterior pituitary Select the correct answer using the code given below :

1, 2 and 3. ***1, 2 and 3*** - **Lactogenesis** (milk production) critically depends on the **sudden drop in estrogen** after delivery, which removes the inhibitory effect on prolactin. - This, combined with the **release of prolactin from the anterior pituitary** (due to reduced **prolactin-inhibiting factor**, or dopamine, from the hypothalamus), stimulates the glandular cells in the breast to produce milk. *1 and 2 only* - This option correctly identifies the sudden fall in **estrogen** and reduction of **prolactin-inhibiting factor**'s influence but omits the direct action of **prolactin** release from the anterior pituitary, which is essential for milk synthesis. - While estrogen decline and reduced PIF are crucial, they lead to the **release of prolactin**, which is the direct stimulus for lactogenesis. *1 and 4* - While the sudden fall in **estrogen** is critical for initiating lactogenesis, **oxytocin** (released from the posterior pituitary) is primarily responsible for **milk ejection (let-down)**, not milk production (lactogenesis). - Oxytocin acts on myoepithelial cells to contract and expel milk, whereas prolactin stimulates milk synthesis. *2, 3 and 4* - This option correctly identifies the reduction of **prolactin-inhibiting factor** and the release of **prolactin**, which are essential for lactogenesis. However, it incorrectly includes **oxytocin**, which is involved in milk ejection, and misses the crucial role of the **fall in estrogen levels** that permits prolactin to act. - The elevated **estrogen levels during pregnancy** inhibit the action of prolactin, so their drop is a prerequisite for effective milk production.

Q: A 32 year old woman is noted to have 1200 cc of blood loss following a spontaneous vaginal delivery and delivery of placenta. The uterine fundus is palpated and noted to be firm. Which of the following is the most likely treatment for this patient?

Surgical repair of cervical tear. **Surgical repair of cervical tear** - The patient presents with **postpartum hemorrhage** (over 1000 mL blood loss) despite a **firm uterine fundus**, which indicates that **uterine atony** is unlikely to be the cause. - A firm uterus in the presence of continuous bleeding suggests a **genital tract laceration**, with a cervical tear being a common site. Surgical repair is necessary to stop the bleeding. *Replacement of inverted uterus* - **Uterine inversion** is characterized by the collapse of the uterine fundus into or through the cervix, which would present as a **soft, non-palpable fundus** or a mass in the vagina. - This patient's fundus is noted to be **firm**, ruling out uterine inversion as the cause of her hemorrhage. *Intramuscular prostaglandin* - **Prostaglandins** (like carboprost tromethamine) are used to treat **uterine atony**, which is characterized by a **soft, boggy uterus**. - The patient's uterus is described as **firm**, indicating that uterine atony is not the primary cause of her hemorrhage. *B-Lynch suture* - The **B-Lynch suture** is a surgical technique primarily used to manage **refractory uterine atony** that has not responded to medical management. - Since the uterus is firm and not atonic, this intervention would not be appropriate for the underlying cause of bleeding in this patient.

Q: Most probable cause of heavy bleeding in a P2L2 during tenth day post partum is:

Retained bits of cotyledons and membranes. ***Retained bits of cotyledons and membranes*** - **Retained placental fragments** prevent the uterus from contracting effectively, leading to uterine atony and heavy bleeding. - This typically presents as secondary postpartum hemorrhage, which occurs **24 hours to 6 weeks postpartum**, consistent with bleeding on the tenth day. *Infected episiotomy wound* - An infected episiotomy wound would primarily cause **local pain**, **swelling**, **redness**, and **purulent discharge**, not heavy uterine bleeding. - While infection can exacerbate pain and discomfort, it does not directly lead to **prolonged or excessive uterine hemorrhage**. *Resumption of menstruation* - Menstruation typically resumes much later postpartum, especially in breastfeeding individuals, often **months after delivery**. - Bleeding on the tenth day is likely related to the **postpartum state** and not a return to normal menstrual cycles. *Subinvolution of placental site* - Subinvolution refers to the failure of the uterus to return to its normal size and state, which can cause **prolonged lochia** and bleeding. - While a possible cause of later postpartum bleeding, **retained placental tissue** is a more direct and common cause for significant hemorrhage on the tenth day.

Q: During immediate puerperium,

the number of white cells increases. ***the number of white cells increases*** - Leukocytosis, or an increase in the number of **white blood cells**, is a common and normal physiological response during the **immediate puerperium**. - This rise in white blood cell count, primarily **neutrophils**, is a protective mechanism against potential infection and aids in the healing process following childbirth. *the number of lymphocytes increases* - While other immune cells contribute to postpartum recovery, a significant increase in **lymphocytes** is not the primary expected change in the immediate puerperium. - Lymphocyte counts may fluctuate but do not typically show the same dramatic immediate increase as neutrophils. *the number of white cells decreases* - A decrease in the number of **white cells** during the immediate puerperium would be an abnormal finding and could indicate a developing complication, such as **immunosuppression** or a severe infection. - Normal physiological changes post-delivery involve an **increase** in white blood cell count as part of the body's recovery and protective mechanisms. *the number of eosinophils increases* - An increase in **eosinophils** is usually associated with **allergic reactions**, parasitic infections, or certain autoimmune conditions. - It is not a typical or expected physiological finding in the immediate postpartum period, and a significant rise might warrant further investigation.

Q: Ideal time to perform post partum sterilization as per Government of India guidelines is:

From 12 hours to 7 days of delivery. ***From 12 hours to 7 days of delivery*** - The **Government of India guidelines** recommend performing postpartum sterilization between **12 hours and 7 days after delivery**. - This timing is considered ideal as the **uterus is still enlarged**, making the fallopian tubes easier to locate for the procedure. *From 24 hours to 7 days of delivery* - While part of the recommended window, starting at **24 hours excludes the crucial 12-24 hour period** immediately after delivery when the procedure is also safely and effectively done. - This option is **less comprehensive** than the established guideline, which begins earlier. *Within 7 days of delivery* - This option is too broad as it includes the **initial 0-12 hour period**, which is generally discouraged due to increased risk of hemorrhage or other complications immediately post-delivery. - The **first 12 hours** are often a period of significant physiological changes and recovery for the mother. *From 48 hours to 7 days of delivery* - This timing omits the **first two days post-delivery**, which are often very convenient for the patient and clinician while the patient is still hospitalized. - Waiting until 48 hours might mean missing an opportunity to perform the procedure while the patient is already in the **hospital setup**, potentially increasing follow-up visits or logistical challenges.

Question 1

A woman dies from a heart disease six days after delivery. This would come under the category of :

Accepted Answer

Indirect maternal death

Answer

Direct maternal death

Answer

Unclassified death

Answer

Medical (non-maternal) death

Question 2

Which of the following is an absolute contraindication to breastfeeding according to WHO guidelines?

Accepted Answer

Active, untreated maternal tuberculosis

Answer

Maternal diarrhoea

Answer

None of the above

Answer

1st 24 hours after Caesarean section

Question 3

A 20-year-old young woman, who was delivered two months ago at home by a nurse, presents with a complaint of something protruding through the vulva. The clinical examination reveals a cystocele, rectocele, and the cervix 1 cm above the introitus. The most appropriate management will be

Accepted Answer

Anterior colporrhaphy, posterior colporrhaphy and perineal repair

Answer

Sling operation

Answer

Fothergill's operation

Answer

Vaginal hysterectomy

Question 4

A multiparous woman delivered by a village dai (midwife) presents on the 22nd postnatal day with bleeding per vaginum with clots. On examination, the uterus is 14-16 weeks, the internal os is open, and there is bleeding through the os. The likely cause of this bleeding is

Accepted Answer

Retained bits of placenta and membranes

Answer

Perineal tears

Answer

Excessive postnatal physical work

Answer

Uterine atony

Question 5

The following are the predisposing factors for postpartum uterine atony except

Accepted Answer

Pre-eclampsia

Answer

Oxytocin induced labour

Answer

Multiple pregnancy

Answer

Hydramnios

Question 6

In the puerperium, which of the following hormonal changes are responsible for lactogenesis?

1. A sudden fall in the oestrogen levels after delivery
2. Reduction of prolactin inhibiting factor from the hypothalamus
3. Release of prolactin from the anterior pituitary
4. Release of oxytocin from the posterior pituitary
Select the correct answer using the code given below :

Accepted Answer

1, 2 and 3

Answer

1 and 2 only

Answer

1 and 4

Answer

2, 3 and 4

Question 7

A 32 year old woman is noted to have 1200 cc of blood loss following a spontaneous vaginal delivery and delivery of placenta. The uterine fundus is palpated and noted to be firm. Which of the following is the most likely treatment for this patient?

Accepted Answer

Surgical repair of cervical tear

Answer

Replacement of inverted uterus

Answer

Intramuscular prostaglandin

Answer

B-Lynch suture

Question 8

Most probable cause of heavy bleeding in a P2L2 during tenth day post partum is:

Accepted Answer

Retained bits of cotyledons and membranes

Answer

Infected episiotomy wound

Answer

Resumption of menstruation

Answer

Subinvolution of placental site

Question 9

During immediate puerperium,

Accepted Answer

the number of white cells increases

Answer

the number of lymphocytes increases

Answer

the number of white cells decreases

Answer

the number of eosinophils increases

Question 10

Ideal time to perform post partum sterilization as per Government of India guidelines is:

Accepted Answer

From 12 hours to 7 days of delivery

Answer

From 24 hours to 7 days of delivery

Answer

Within 7 days of delivery

Answer

From 48 hours to 7 days of delivery

Postpartum Care — MCQs

Postpartum Care — MCQs

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