Postpartum Care — MCQs

A woman complains of severe pain in the vagina after vaginal delivery. On examination, she is pale, her pulse rate is 110 beats per minute, and her blood pressure is 100/60 mm of Hg. Vaginal examination reveals a large, soft, boggy mass on the right lateral vaginal wall. What is the most appropriate treatment?

Q224

In a multipara, the most common cause of postpartum hemorrhage is?

Q225

Which of the following is NOT a cause of postpartum hemorrhage in a well-contracted uterus?

Postpartum Care Indian Medical PG Practice Questions and MCQs

Question 221: Most common cause of postpartum haemorrhage (PPH) is

A. Atonic uterus (Correct Answer)
B. Cervical tears
C. Episiotomy wound
D. Vaginal tears

Explanation: ***Atonic uterus*** - An **atonic uterus** fails to contract adequately after birth, leading to **poor compression of blood vessels** at the placental site, which is the most common cause of **Postpartum Haemorrhage (PPH)**. - Risk factors include **uterine overdistension** (e.g., multifetal pregnancy, polyhydramnios), prolonged labor, rapid labor, and grand multiparity. *Cervical tears* - **Cervical tears** can cause significant bleeding, but they are less common than uterine atony as a primary cause of PPH. - Typically, bleeding from cervical tears is continuous and often **bright red**, sometimes occurring even with a well-contracted uterus. *Episiotomy wound* - An **episiotomy wound** can bleed, but the amount is usually limited and rarely causes severe PPH unless it's poorly repaired or extends. - It is a controlled incision and generally less likely to lead to massive hemorrhage compared to uterine atony. *Vaginal tears* - **Vaginal tears** (lacerations) can contribute to postpartum bleeding, especially if deep or extensive. - While they require repair, **vaginal tears** are generally not the most common or significant cause of severe PPH compared to an atonic uterus.

Question 222: Kegel's exercises should begin after?

A. 24 hours after delivery
B. 3 weeks after delivery
C. 6 weeks after delivery
D. Immediately after delivery (Correct Answer)

Explanation: ***Immediately after delivery*** - **Kegel's exercises** can be initiated as soon as possible after delivery, provided the woman feels comfortable and there are no contraindications. - Early commencement helps **restore pelvic floor muscle tone**, reduce urinary incontinence, and promote healing. *24 hours after delivery* - While it is not strictly incorrect to start at 24 hours, waiting unnecessarily delays the potential benefits of **pelvic floor muscle training** for postpartum recovery. - The goal is to start as early as comfort allows, which can often be within the first few hours. *3 weeks after delivery* - Waiting three weeks to begin **Kegel's exercises** would be a significant delay in postpartum recovery. - Early engagement is crucial for **optimal rehabilitation** of the pelvic floor and prevention of long-term issues. *6 weeks after delivery* - Six weeks after delivery is typically the time for the **postpartum check-up**, but it is too late to *begin* Kegel's exercises for optimal benefit. - By this point, opportunities for **early muscle re-education** and symptom prevention would have been missed.

Question 223: A woman complains of severe pain in the vagina after vaginal delivery. On examination, she is pale, her pulse rate is 110 beats per minute, and her blood pressure is 100/60 mm of Hg. Vaginal examination reveals a large, soft, boggy mass on the right lateral vaginal wall. What is the most appropriate treatment?

A. Drain and insert a figure of 8 suture (Correct Answer)
B. Analgesics and monitoring
C. Vaginal packing
D. Conservative management with ice packs

Explanation: ***Drain and insert a figure of 8 suture*** - The symptoms of severe pain, pale appearance, tachycardia, hypotension, and a large, soft, boggy mass on the vaginal wall are indicative of a **vaginal hematoma**, which requires immediate surgical intervention. - The most appropriate treatment for a growing vaginal hematoma is **surgical incision, evacuation of the clot, identification and ligation of the bleeding vessel**, and closure with a figure-of-eight or continuous locking suture to achieve hemostasis. - This comprehensive approach addresses both the accumulated blood and the source of bleeding. *Analgesics and monitoring* - While pain relief is necessary, merely administering analgesics and monitoring would not address the underlying **active bleeding** and growing hematoma, which can lead to significant blood loss and hypovolemic shock. - This approach would be insufficient for a patient presenting with signs of **hemodynamic instability** (tachycardia, hypotension, pallor). *Vaginal packing* - Vaginal packing might temporarily tamponade minor bleeding in small, stable hematomas (<3-5 cm) without signs of expansion. - However, it is generally **ineffective for a rapidly expanding hematoma** from an actively bleeding vessel in a hemodynamically compromised patient. - Packing can also obscure ongoing bleeding and contribute to infection or tissue necrosis. *Conservative management with ice packs* - Conservative management with ice packs may be appropriate only for **small, non-expanding hematomas** (<3 cm) in hemodynamically stable patients. - In this case, the patient has a **large hematoma** with signs of ongoing bleeding and hemodynamic compromise (tachycardia, hypotension, pallor), making conservative management inappropriate and potentially dangerous. - Delaying surgical intervention could lead to severe hemorrhage, hypovolemic shock, and increased maternal morbidity.

Question 224: In a multipara, the most common cause of postpartum hemorrhage is?

A. Retained placenta
B. Uterine atonicity (Correct Answer)
C. Uterine perforation
D. Fibroid in the uterus

Explanation: ***Uterine atonicity*** - This is the **most common cause** of postpartum hemorrhage, especially in multiparous women, where the uterus may have lost some of its tone from previous pregnancies. - After delivery, the uterus normally contracts to compress blood vessels and prevent excessive bleeding; **uterine atony** prevents this essential contraction. *Retained placenta* - While a significant cause of postpartum hemorrhage, it is less common than uterine atony overall and often presents with a **non-contracted uterus** despite attempts at fundal massage. - The placenta or fragments of it remain in the uterus, preventing complete uterine contraction and leading to continuous bleeding. *Uterine perforation* - This is a rare and usually iatrogenic cause of postpartum hemorrhage, often associated with operative procedures during delivery or uterine instrumentation. - It involves a tear in the uterine wall, leading to bleeding into the abdominal cavity, which is distinct from the typical presentation of postpartum hemorrhage. *Fibroid in the uterus* - Uterine fibroids can contribute to postpartum hemorrhage by interfering with the uterus's ability to contract effectively after delivery. - However, they are **not the most common cause**; their presence increases the risk, but uterine atony remains the predominant reason for excessive bleeding.

Question 225: Which of the following is NOT a cause of postpartum hemorrhage in a well-contracted uterus?

A. Vaginal tear
B. Cervical laceration
C. Atony of uterus (Correct Answer)
D. Retained placenta

Explanation: ***Atony of uterus*** - **Uterine atony** is the **most common cause of postpartum hemorrhage** overall, accounting for 70-80% of cases - Atony **by definition** means a **poorly contracted, soft, boggy uterus** - If the uterus is **well-contracted and firm**, atony is **completely ruled out** as the cause of bleeding - The presence of a well-contracted uterus on palpation definitively excludes atony *Vaginal tear* - **Vaginal tears** can cause significant PPH even with a **well-contracted uterus** - Represents **genital tract trauma** independent of uterine tone - Bleeding is typically **bright red**, continuous, and occurs despite a **firm uterus** on examination - Part of the "Trauma" category in the 4 T's of PPH (Tone, Trauma, Tissue, Thrombin) *Cervical laceration* - **Cervical lacerations** lead to considerable blood loss **independently of uterine contraction status** - Damage to **cervical blood vessels** causes persistent bleeding - Clinical clue: **Bright red bleeding** with a **firm, well-contracted uterus** on palpation - Also part of the "Trauma" category; requires direct visualization and repair *Retained placenta* - **Retained placental tissue** typically **prevents adequate uterine contraction**, leading to a soft, poorly contracted uterus - While small fragments might coexist with a seemingly firm uterus on external palpation, **significant retained tissue** would prevent complete myometrial contraction - In the context of a **truly well-contracted uterus**, retained placenta is an unlikely primary cause of PPH - However, it remains a possible cause if only examining the fundus while fragments remain in the lower segment

Practice by Chapter

Normal Puerperium

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Lactation and Breastfeeding

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Postpartum Complications

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Postpartum Depression and Psychiatric Disorders

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Contraception After Delivery

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Postpartum Infections

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Secondary Postpartum Hemorrhage

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Recovery After Cesarean Delivery

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Postpartum Exercise and Rehabilitation

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Follow-up and Future Pregnancy Planning

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