Postpartum Care — MCQs

A 35-year-old grand multipara starts bleeding profusely soon after delivery. Following steps were done: IV lines secured, resuscitation commenced, oxytocins given, and balloon tamponade done. While these steps were being done, 4 units of blood were transfused. However, her vitals remain: BP = 80/50 mm of Hg, Pulse Rate = 130 beats/minute. What is the next step in management?

Q88Easy

What is the likely size of the uterus at 8 weeks postpartum?

Q89Easy

What is the recommended dose of anti-D immunoglobulin administered postpartum to an Rh-negative mother with an Rh-positive infant?

Q90Easy

Breast feeding is contraindicated if the mother is taking which of the following medications?

Postpartum Care Indian Medical PG Practice Questions and MCQs

Question 81: All of the following are causes of secondary postpartum hemorrhage except?

A. Retained cotyledon
B. Endometritis
C. Placental polyp
D. Placenta previa (Correct Answer)

Explanation: **Explanation:** Postpartum Hemorrhage (PPH) is classified based on timing: **Primary PPH** occurs within 24 hours of delivery, while **Secondary PPH** occurs between 24 hours and 12 weeks postpartum. **Why Placenta Previa is the correct answer:** Placenta previa is a condition where the placenta implants in the lower uterine segment. It is a classic cause of **antepartum hemorrhage (APH)**. While it can predispose a patient to primary PPH (due to poor contractility of the lower uterine segment), it does not cause secondary PPH. By the time the secondary postpartum period begins, the placenta has already been delivered. **Analysis of Incorrect Options (Causes of Secondary PPH):** * **Retained Cotyledon/Membranes:** This is the **most common cause** of secondary PPH. Small fragments of placental tissue prevent proper uterine involution and lead to delayed bleeding. * **Endometritis:** Infection of the uterine lining causes inflammation and sloughing of the decidua, leading to secondary PPH, typically occurring 1–2 weeks after delivery. * **Placental Polyp:** This forms when a retained piece of placenta becomes organized and vascularized. When it eventually separates, it causes brisk secondary hemorrhage. **NEET-PG High-Yield Pearls:** * **Definition:** Secondary PPH is bleeding from the genital tract occurring >24 hours up to 12 weeks (6 weeks in older texts) post-delivery. * **Peak Incidence:** Most commonly occurs between **8–14 days** postpartum. * **Management:** The first-line investigation is a **Pelvic Ultrasound** to look for retained products of conception (RPOCs). * **Other Causes:** Subinvolution of the placental site, Choriocarcinoma, and Dehiscence of a Cesarean scar.

Question 82: Which drug is contraindicated in a patient with rheumatic heart disease experiencing postpartum hemorrhage (PPH)?

A. Oxytocin infusion
B. Methylergometrine (Correct Answer)
C. Misoprostol
D. Carboprost

Explanation: **Explanation:** In the management of Postpartum Hemorrhage (PPH), the choice of uterotonic is dictated by the patient’s underlying comorbidities. **Why Methylergometrine is contraindicated:** Methylergometrine (Methergine) is an ergot alkaloid that causes generalized vasoconstriction and a sudden increase in peripheral vascular resistance. In patients with **Rheumatic Heart Disease (RHD)**—particularly those with mitral stenosis—this leads to a rapid increase in venous return (preload) and a sudden rise in blood pressure. This "autotransfusion" effect can cause acute pulmonary edema and heart failure in a compromised cardiac patient. Therefore, it is strictly contraindicated in patients with heart disease and hypertension. **Analysis of Incorrect Options:** * **Oxytocin (Option A):** This is the first-line drug for PPH in cardiac patients. While rapid boluses can cause hypotension, a slow intravenous infusion is safe and effective. * **Misoprostol (Option C):** A PGE1 analog that is generally safe in cardiac patients. Its primary side effects are shivering and pyrexia, but it does not significantly impact hemodynamics. * **Carboprost (Option D):** A PGF2α analog. While it is contraindicated in **Asthma** (due to bronchoconstriction), it is not specifically contraindicated in heart disease, though it should be used with caution if pulmonary hypertension is present. **High-Yield Clinical Pearls for NEET-PG:** * **Methergine:** Contraindicated in **Heart Disease** and **Hypertension/Preeclampsia**. * **Carboprost (PGF2α):** Contraindicated in **Asthma**. * **Misoprostol (PGE1):** Safest in asthmatics; no major cardiac contraindications. * **Active Management of Third Stage of Labor (AMTSL):** The most important step to prevent PPH in cardiac patients is the use of Oxytocin.

Question 83: Which of the following drugs is used to decrease postpartum hemorrhage in a normotensive woman?

A. Oxytocin
B. Methergine (Correct Answer)
C. Progesterone
D. Prostaglandins

Explanation: **Explanation:** The management of Postpartum Hemorrhage (PPH) involves the use of various uterotonic agents. **Methergine (Methylergonovine)**, an ergot alkaloid, is a potent uterotonic that causes sustained, tetanic uterine contractions. It is highly effective in controlling PPH by compressing intramyometrial blood vessels. However, its use is strictly contraindicated in women with hypertension (including Preeclampsia/Eclampsia) because it causes peripheral vasoconstriction, which can lead to a hypertensive crisis or stroke. Therefore, in a **normotensive woman**, it is a preferred second-line agent after Oxytocin. **Analysis of Options:** * **Oxytocin (Option A):** While Oxytocin is the first-line drug for the *prevention* and *treatment* of PPH (Active Management of Third Stage of Labor), the question specifically highlights the "normotensive" status to point toward Methergine, which is the classic "distractor" or "specific choice" in exams when hypertension is ruled out. * **Progesterone (Option C):** This hormone is used for maintaining pregnancy and preventing preterm labor; it has no role in the acute management of PPH. * **Prostaglandins (Option D):** Drugs like Carboprost (PGF2α) or Misoprostol (PGE1) are used in PPH, but Carboprost is contraindicated in asthmatics, and they are typically used if Oxytocin and Methergine fail. **High-Yield Clinical Pearls for NEET-PG:** * **Methergine Dose:** 0.2 mg IM (Never IV, as it causes sudden severe hypertension). * **Contraindications for Methergine:** Hypertension, Heart Disease, and Raynaud’s phenomenon. * **Carboprost (15-methyl PGF2α):** Contraindicated in **Asthma**. * **Misoprostol:** Best for PPH prophylaxis in low-resource settings (heat stable, oral/rectal route).

Question 84: A patient, after a normal vaginal delivery, inquires about perineal strengthening exercises. When should she be advised to start Kegel's exercises?

A. 1st week in a normal delivery, 6 weeks if instrumental
B. After 3 weeks
C. Immediately (Correct Answer)
D. After 6 weeks

Explanation: **Explanation:** **1. Why "Immediately" is Correct:** Kegel’s exercises (pelvic floor muscle training) are designed to strengthen the *Levator ani* muscle group. During a vaginal delivery, these muscles and the pudendal nerve undergo significant stretching and potential micro-trauma. Starting exercises **immediately** (within 24–48 hours) post-delivery—provided there is no severe perineal pain or extensive third/fourth-degree tears—promotes healing by increasing blood flow to the perineum, reduces edema, and hastens the recovery of urinary continence. Early initiation is crucial to prevent long-term complications like Pelvic Organ Prolapse (POP) and Stress Urinary Incontinence (SUI). **2. Analysis of Incorrect Options:** * **Option A & B:** Waiting for 1 to 3 weeks unnecessarily delays the rehabilitation of the pelvic floor. While pain might be a limiting factor initially, patients are encouraged to perform gentle contractions as soon as they feel comfortable. * **Option D:** 6 weeks marks the end of the puerperium. While this is the traditional time for a postnatal check-up, waiting this long misses the critical window for early neuromuscular retraining. **3. Clinical Pearls for NEET-PG:** * **Primary Muscle Targeted:** Pubococcygeus (part of the Levator ani). * **Indications:** Prevention and treatment of Stress Urinary Incontinence (SUI) and early-stage Pelvic Organ Prolapse. * **Technique:** Patients should be taught to "contract and lift" the pelvic floor without co-contracting the abdominals or gluteal muscles. * **Post-Cesarean:** Even after a C-section, Kegel's should be started early because the pregnancy itself (weight of the gravid uterus) weakens the pelvic floor, regardless of the mode of delivery.

Question 85: Which of the following complications during pregnancy does NOT increase the risk of postpartum hemorrhage (PPH)?

A. Hypertension (Correct Answer)
B. Macrosomia
C. Twin pregnancy
D. Hydramnios

Explanation: To understand this question, we must look at the primary cause of Postpartum Hemorrhage (PPH): **Uterine Atony** (failure of the uterus to contract after delivery). ### 1. Why Hypertension is the Correct Answer **Hypertension** (including Preeclampsia) is generally associated with a hypercoagulable state and peripheral vasoconstriction. While it increases the risk of placental abruption (which can lead to PPH via DIC), hypertension itself does not cause uterine atony. In fact, some antihypertensives or the pathology of preeclampsia do not inherently prevent the uterus from contracting. Therefore, among the given options, it is the least likely to be a direct risk factor for atonic PPH. ### 2. Why the Other Options are Incorrect The other three options are classic causes of **Uterine Overdistension**, which is a major risk factor for atonic PPH. When the uterine muscle fibers are stretched beyond their physiological limit, they lose the ability to contract effectively (the "snap-back" mechanism) after the placenta separates. * **Macrosomia:** A large baby (>4kg) overstretches the myometrium. * **Twin Pregnancy:** Multiple gestations significantly increase uterine volume. * **Hydramnios:** Excessive amniotic fluid causes rapid distension and often leads to sudden decompression, both of which predispose to atony. ### 3. NEET-PG High-Yield Pearls * **The 4 T’s of PPH:** Tone (Atony - 70%), Trauma (Lacerations), Tissue (Retained products), and Thrombin (Coagulopathy). * **Most Common Cause:** Uterine Atony is the #1 cause of PPH worldwide. * **Management Tip:** While hypertension isn't a risk for atony, remember that **Methylergometrine** (an oxytocic) is strictly **contraindicated** in hypertensive patients as it can cause a hypertensive crisis or stroke. Use Oxytocin or Misoprostol instead.

Question 86: What is true regarding the use of bromocriptine for suppression of lactation?

A. It can cause deep vein thrombosis.
B. It can cause hypotension. (Correct Answer)
C. Metoclopramide potentiates the action of bromocriptine.
D. It is given for 1 week only.

Explanation: **Explanation:** Bromocriptine is a dopamine agonist (D2 receptor agonist) that inhibits the release of prolactin from the anterior pituitary. While it was historically the drug of choice for lactation suppression, its use has significantly declined due to its side effect profile. **Why Option B is Correct:** Bromocriptine causes peripheral vasodilation and inhibits the sympathetic nervous system, frequently leading to **orthostatic hypotension** and dizziness. In severe cases, it can cause significant drops in blood pressure, which is particularly concerning in the immediate postpartum period when hemodynamic shifts are already occurring. **Analysis of Incorrect Options:** * **Option A:** Bromocriptine is actually associated with an increased risk of **thromboembolic events** (like stroke and myocardial infarction) and hypertension/seizures in postpartum women, rather than DVT specifically. However, the risk of cardiovascular accidents led the FDA to withdraw its indication for routine lactation suppression. * **Option C:** Metoclopramide is a **dopamine antagonist**. Therefore, it antagonizes (blocks) the effect of bromocriptine rather than potentiating it. * **Option D:** To prevent rebound lactation, bromocriptine must be administered for **14 days (2 weeks)**. A 1-week course is insufficient. **NEET-PG High-Yield Pearls:** * **Drug of Choice:** Currently, **Cabergoline** (a long-acting D2 agonist) is the preferred drug for lactation suppression because it is more effective, has a longer half-life, and carries fewer side effects than bromocriptine. * **Dosage:** Cabergoline is typically given as a single dose (1 mg) within 24 hours of delivery. * **Non-Pharmacological:** For many women, breast binding, ice packs, and avoiding nipple stimulation are safer alternatives for suppression.

Question 87: A 35-year-old grand multipara starts bleeding profusely soon after delivery. Following steps were done: IV lines secured, resuscitation commenced, oxytocins given, and balloon tamponade done. While these steps were being done, 4 units of blood were transfused. However, her vitals remain: BP = 80/50 mm of Hg, Pulse Rate = 130 beats/minute. What is the next step in management?

A. Insert B-Lynch suture
B. Ligate internal iliac artery
C. Perform hysterectomy (Correct Answer)
D. Transfuse factor VIIa

Explanation: ### Explanation **Correct Answer: C. Perform hysterectomy** The patient is experiencing **Refractory Postpartum Hemorrhage (PPH)**. Despite aggressive resuscitation (4 units of blood), medical management (oxytocics), and mechanical intervention (balloon tamponade), she remains hemodynamically unstable (BP 80/50, Pulse 130). In a **grand multipara**, the risk of uterine atony is high, and the uterus often fails to respond to conservative measures. When a patient is in **decompensated shock** despite resuscitative efforts, the priority is "life over limb" (or life over uterus). At this stage, surgical intervention is mandatory. While B-Lynch or devascularization are options, in an unstable grand multipara who has already failed balloon tamponade, **emergency hysterectomy** is the definitive, life-saving step to stop the hemorrhage immediately. **Why other options are incorrect:** * **A. Insert B-Lynch suture:** This is a conservative surgical compression suture. While useful, it requires a laparotomy and is less likely to succeed if balloon tamponade has already failed in a hemodynamically unstable patient. * **B. Ligate internal iliac artery:** This is a technically demanding, time-consuming procedure. In a patient with a pulse of 130 and BP of 80/50, there is no time for complex dissections; rapid control via hysterectomy is preferred. * **D. Transfuse factor VIIa:** This is an expensive, last-resort medical adjunct for coagulopathy. It does not address the primary surgical/mechanical cause of bleeding in this scenario. **Clinical Pearls for NEET-PG:** * **Definition of PPH:** Blood loss >500 ml (Vaginal) or >1000 ml (LSCS). * **First-line management:** Uterine massage and Oxytocin. * **Bakri Balloon:** Maximum volume is 500 ml; it is the "tamponade test"—if bleeding continues despite placement, proceed to laparotomy. * **Stepwise Devascularization:** 1. Uterine artery $\rightarrow$ 2. Ovarian artery $\rightarrow$ 3. Internal Iliac artery (Internal iliac ligation reduces pelvic pulse pressure by 85%). * **Ultimate Management:** Hysterectomy is the definitive treatment for intractable PPH.

Question 88: What is the likely size of the uterus at 8 weeks postpartum?

A. 100 gm (Correct Answer)
B. 500 gm
C. 700 gm
D. 900 gm

Explanation: **Explanation:** The question tests the knowledge of **uterine involution**, the physiological process by which the uterus returns to its non-pregnant state following delivery. This process involves the contraction of interlacing muscle fibers and the autolysis of protein within uterine myocytes. **1. Why Option A is Correct:** Immediately after delivery, the uterus weighs approximately **1000 gm**. It undergoes rapid reduction in size and weight: * **End of 1 week:** ~500 gm * **End of 2 weeks:** ~300 gm * **End of 6 to 8 weeks:** **60–100 gm** (The non-pregnant weight). By 8 weeks postpartum, the process of involution is complete, and the uterus has returned to its baseline pre-pregnancy weight of roughly 100 gm. **2. Why Incorrect Options are Wrong:** * **Option B (500 gm):** This is the weight of the uterus at the end of the **first week** postpartum. * **Option C & D (700 gm / 900 gm):** These weights are seen within the **first 24–48 hours** after delivery. At these stages, the fundus is still palpable at or near the level of the umbilicus. **3. High-Yield Clinical Pearls for NEET-PG:** * **Rate of Descent:** The fundus descends at a rate of approximately **1 cm (one fingerbreadth) per day**. * **Pelvic Organ Status:** The uterus becomes a pelvic organ (no longer palpable abdominally) by the **12th day** postpartum. * **Breastfeeding Effect:** Involution is generally **faster** in breastfeeding mothers due to the release of endogenous oxytocin, which promotes uterine contractions. * **Histology:** While the number of myocytes does not decrease significantly, the individual cells decrease markedly in size (atrophy/autolysis).

Question 89: What is the recommended dose of anti-D immunoglobulin administered postpartum to an Rh-negative mother with an Rh-positive infant?

A. 50 micrograms
B. 200 micrograms
C. 300 micrograms (Correct Answer)
D. 100 micrograms

Explanation: **Explanation:** The administration of Anti-D immunoglobulin is a critical step in preventing **Rh isoimmunization**. When an Rh-negative mother carries an Rh-positive fetus, fetal red blood cells can enter the maternal circulation (fetomaternal hemorrhage), leading to the production of anti-D antibodies. These antibodies can cross the placenta in subsequent pregnancies, causing Hemolytic Disease of the Fetus and Newborn (HDFN). **Why 300 micrograms is correct:** The standard recommended dose for postpartum prophylaxis (within 72 hours of delivery) is **300 micrograms (1500 IU)**. This dose is pharmacologically calculated to neutralize up to **30 mL of Rh-positive whole blood** (or 15 mL of packed red cells). This is sufficient to cover the majority of standard delivery scenarios. **Analysis of Incorrect Options:** * **50 micrograms:** This "mini-dose" is typically reserved for first-trimester events (e.g., abortion or ectopic pregnancy occurring before 12 weeks), where the fetal blood volume is very small. * **100/200 micrograms:** These are sub-therapeutic doses for a full-term delivery and do not meet the international standard guidelines (ACOG/RCOG) for routine postpartum prophylaxis. **High-Yield Clinical Pearls for NEET-PG:** * **Timing:** Anti-D should ideally be given within **72 hours** of delivery. However, it can still provide some benefit if given up to 13–28 days later. * **Antenatal Prophylaxis:** A routine dose is also given at **28 weeks** of gestation to prevent sensitization during the third trimester. * **Kleihauer-Betke Test:** If a massive fetomaternal hemorrhage (>30 mL) is suspected, this test is used to quantify fetal cells in maternal blood to calculate if additional doses of Anti-D are required. * **Route:** It is usually administered via **Intramuscular (IM)** injection.

Question 90: Breast feeding is contraindicated if the mother is taking which of the following medications?

A. Iron tonics
B. Iron tonics
C. Crystalline penicillin
D. Phenytoin (Correct Answer)

Explanation: **Explanation:** The correct answer is **Phenytoin**. While many medications are secreted in breast milk, only a few are absolute contraindications. Phenytoin is an antiepileptic drug that is excreted in breast milk in significant concentrations. It can cause **sedation, poor sucking reflex, and potential methemoglobinemia** in the neonate. Furthermore, it may interfere with the neonate's vitamin K metabolism, increasing the risk of hemorrhage. **Analysis of Options:** * **Iron Tonics:** These are not only safe but often recommended postpartum to replenish maternal iron stores lost during delivery. Iron does not enter breast milk in quantities that would harm the infant. * **Crystalline Penicillin:** Most penicillins are considered safe during breastfeeding. While trace amounts may enter the milk (potentially causing minor flora changes or allergic sensitization), they are not a contraindication. * **Phenytoin:** Due to its potential for neonatal CNS depression and its long half-life, it is generally avoided if safer alternatives are available, or the infant must be closely monitored for toxicity. **NEET-PG High-Yield Pearls:** * **Absolute Contraindications to Breastfeeding (Maternal Drugs):** Radioactive isotopes, Antimetabolites (Methotrexate), Lithium, Ergotamine, and certain illicit drugs (Cocaine, Heroin). * **Maternal Infections:** Breastfeeding is contraindicated in **HIV** (in developed settings) and **HTLV-1**. * **Infant Contraindication:** **Galactosemia** is the classic absolute neonatal contraindication. * **Safe Anticonvulsant:** Valproate and Carbamazepine are generally considered safer than Phenytoin during lactation as they have lower milk-to-plasma ratios.

Practice by Chapter

Normal Puerperium

Practice Questions

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

Practice Questions

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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