📘 Postpartum Hemorrhage (PPH)

(Important for OBG Nursing, GNM/BSc Nursing, NHM, AIIMS, NORCET, GPSC Staff Nurse Exams)

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✅ 1. Introduction / Definition:

Postpartum hemorrhage (PPH) is defined as blood loss of ≥500 mL after vaginal delivery or ≥1000 mL after cesarean section, within 24 hours (primary PPH) or after 24 hours up to 6 weeks postpartum (secondary PPH).

It is a leading cause of maternal mortality, especially in developing countries.

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✅ 2. Classification:

1. Primary (Early) PPH: Occurs within first 24 hours after birth
2. Secondary (Late) PPH: Occurs after 24 hours to 6 weeks postpartum

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✅ 3. Causes / Risk Factors:

📌 Remember the 4 Ts — major causes of PPH:

1. Tone – Uterine atony (most common cause)
2. Tissue – Retained placental tissue
3. Trauma – Genital tract lacerations, uterine rupture
4. Thrombin – Coagulopathy or clotting disorders

🔹 Risk Factors:

• Prolonged labor or precipitate labor
• Overdistended uterus (twins, polyhydramnios)
• High parity (grand multipara)
• Manual removal of placenta
• Operative delivery (forceps, vacuum, C-section)
• Infection
• Previous history of PPH

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✅ 4. Pathophysiology:

• After delivery, the uterus should contract to compress blood vessels.
• In PPH, failure of uterine contraction (atony) or other factors like trauma, retained tissue, or coagulation defects cause continued bleeding.

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✅ 5. Clinical Manifestations / Signs & Symptoms:

• Excessive vaginal bleeding (>1 pad soaked in 15 min)
• Uterus feels soft and boggy (in uterine atony)
• Pallor, cold and clammy skin
• Tachycardia, hypotension
• Dizziness, fainting
• Oozing from IV sites (if DIC)

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✅ 6. Diagnostic Evaluation:

• Clinical observation of blood loss
• Fundal examination – to detect uterine tone and height
• CBC, hemoglobin – for anemia and blood loss
• Coagulation profile – if bleeding is unresponsive
• Ultrasound – to detect retained placenta or clots

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✅ 7. Management:

🔹 Immediate First Response:

• Call for help – obstetric and emergency team
• Assess ABCs – Airway, Breathing, Circulation
• Fundal massage – Stimulate uterine contraction
• Ensure IV access, start 2 large-bore IV lines
• Monitor vitals every 5–15 minutes

🔹 Medical Management:

• Uterotonics:
  • Oxytocin (Pitocin) – First-line drug
  • Methylergometrine – Avoid in hypertension
  • Carboprost (Prostodin) – Avoid in asthma
  • Misoprostol – Oral, sublingual, or rectal
• Tranexamic acid (TXA) – Antifibrinolytic

🔹 Mechanical/Surgical Measures:

• Uterine tamponade – e.g., Bakri balloon
• Uterine artery ligation
• Uterine compression sutures (B-Lynch)
• Hysterectomy – Last resort in uncontrolled bleeding

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✅ 8. Complications:

• Hypovolemic shock
• Disseminated intravascular coagulation (DIC)
• Renal failure
• Sheehan’s syndrome (postpartum pituitary necrosis)
• Maternal death

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✅ 9. Nurse’s Role:

• Identify early signs of PPH
• Perform fundal massage immediately
• Monitor bleeding and vital signs closely
• Ensure uterotonics are administered
• Prepare for blood transfusion if needed
• Provide emotional support to the mother
• Document all interventions accurately
• Educate on danger signs and importance of postnatal visits

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✅ 10. Golden One-Liners for Quick Revision:

• PPH = >500 mL (vaginal) or >1000 mL (cesarean) blood loss
• Uterine atony is the most common cause
• First-line management = uterine massage + oxytocin
• Use 4 Ts to remember causes: Tone, Tissue, Trauma, Thrombin
• B-Lynch suture is a uterine-saving surgery for atonic PPH

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✅ 11. MCQs for Practice:

Q1. What is the most common cause of primary postpartum hemorrhage?
a) Cervical tear
b) Uterine atony
c) Retained placenta
d) Coagulation disorder
Correct Answer: b) Uterine atony
Rationale: Atony is the failure of uterine contraction and accounts for ~70–80% of PPH.

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Q2. Which uterotonic drug is contraindicated in a patient with high blood pressure?
a) Oxytocin
b) Misoprostol
c) Methylergometrine
d) Carboprost
Correct Answer: c) Methylergometrine
Rationale: It causes vasoconstriction and can worsen hypertension.

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Q3. Which of the following is the first step in PPH management?
a) Laparotomy
b) Fundal massage
c) Antibiotics
d) Foley catheter
Correct Answer: b) Fundal massage
Rationale: Massaging the uterus stimulates contraction and helps control bleeding.

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Q4. Which surgical technique is used to preserve the uterus in severe PPH?
a) Cesarean section
b) B-Lynch suture
c) Episiotomy
d) Hysterectomy
Correct Answer: b) B-Lynch suture
Rationale: B-Lynch compression suture is applied to stop uterine bleeding and save the uterus.

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Q5. Which of the following drugs is an antifibrinolytic used in PPH?
a) Tranexamic acid
b) Oxytocin
c) Ergometrine
d) Dinoprostone
Correct Answer: a) Tranexamic acid
Rationale: TXA reduces bleeding by stabilizing clots.

📘 Retained Placenta

(Important for OBG Nursing, GNM/BSc Nursing, NHM, AIIMS, NORCET, GPSC Staff Nurse Exams)

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✅ 1. Introduction / Definition:

Retained placenta is defined as failure to expel the placenta within 30 minutes after the birth of the baby, despite active management of the third stage of labor.

It is a significant cause of primary postpartum hemorrhage (PPH) and may require manual or surgical removal.

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✅ 2. Classification / Types:

1. Trapped Placenta – Placenta is detached but trapped in uterus or cervix due to constriction ring or closed cervix.
2. Adherent Placenta – Placenta is partially attached to the uterine wall (may be due to uterine atony).
3. Placenta Accreta Spectrum (Abnormally Adherent Placenta)
   • Placenta accreta: Chorionic villi attach to the myometrium
   • Placenta increta: Villi invade into the myometrium
   • Placenta percreta: Villi penetrate through the uterine wall

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✅ 3. Causes / Risk Factors:

• Previous retained placenta
• Previous cesarean section
• Uterine curettage or surgery
• Placenta previa
• Preterm birth
• Multiparity
• Uterine abnormalities
• Manual removal of placenta in previous delivery
• Use of oxytocin during labor (causing trapped placenta)

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✅ 4. Pathophysiology:

• Normal third stage of labor involves placental separation and expulsion.
• In retained placenta, this process is disrupted due to mechanical entrapment, failure of separation, or abnormal placental adherence.
• Risk of continued bleeding, infection, and uterine inversion increases.

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✅ 5. Clinical Manifestations / Signs & Symptoms:

• Failure of placenta delivery within 30 minutes
• Continued vaginal bleeding
• Signs of uterine atony (soft, boggy uterus)
• Feeling of fullness or mass in uterus
• Hypovolemic shock in severe cases
• Pain and discomfort

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✅ 6. Diagnostic Evaluation:

• Clinical diagnosis based on time and palpation
• Ultrasound – to confirm retained placental tissue or abnormal adherence
• CBC and hemoglobin – to assess blood loss
• Coagulation profile – if excessive bleeding
• Histopathology (if removed surgically) for suspected placenta accreta

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✅ 7. Management:

🔹 Initial Measures:

• Uterine massage
• Controlled cord traction (with counter-traction on uterus)

🔹 Manual Removal of Placenta (MRP):

• Done under anesthesia (spinal or general)
• Maintain aseptic technique
• Administer antibiotics prophylactically

🔹 For Placenta Accreta Spectrum:

• May require surgical intervention
  • Uterine artery embolization
  • Partial myometrial resection
  • Hysterectomy in severe cases (especially placenta percreta)

🔹 Supportive Care:

• IV fluids and blood transfusion if needed
• Antibiotics to prevent infection
• Oxytocin or other uterotonics to contract uterus

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✅ 8. Complications:

• Postpartum hemorrhage
• Infection / endometritis
• Shock and anemia
• Uterine rupture or inversion
• Hysterectomy
• Infertility (if uterus is removed)

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✅ 9. Nurse’s Role:

• Monitor the third stage of labor closely
• Count time from birth to placental delivery
• Observe for signs of retained placenta (bleeding, soft uterus)
• Prepare for MRP and assist with equipment
• Start IV line and fluids, monitor vital signs
• Administer prescribed uterotonics and antibiotics
• Provide emotional support
• Educate mother about importance of follow-up and next pregnancy planning

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✅ 10. Golden One-Liners for Quick Revision:

• Retained placenta = no placenta expelled within 30 minutes post-delivery
• Most common cause = uterine atony or trapped placenta
• First step = uterine massage + controlled cord traction
• Manual removal is done under anesthesia
• Placenta accreta may require hysterectomy

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✅ 11. MCQs for Practice:

Q1. Retained placenta is defined when placenta is not delivered within:
a) 10 minutes
b) 20 minutes
c) 30 minutes
d) 60 minutes
Correct Answer: c) 30 minutes
Rationale: Failure to deliver the placenta within 30 minutes is considered retained.

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Q2. What is the most common cause of retained placenta?
a) Cervical tear
b) Uterine inversion
c) Uterine atony
d) Placenta accreta
Correct Answer: d) Placenta accreta
Rationale: Abnormal adherence is a leading cause of true retained placenta.

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Q3. What is the first line of management in retained placenta?
a) Hysterectomy
b) Manual removal
c) Fundal massage and controlled cord traction
d) Laparotomy
Correct Answer: c) Fundal massage and controlled cord traction
Rationale: These are initial non-invasive methods to assist expulsion.

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Q4. Which of the following is a serious complication of placenta percreta?
a) Prolonged labor
b) Hypertension
c) Uterine rupture
d) Constipation
Correct Answer: c) Uterine rupture
Rationale: In percreta, placenta invades through the uterine wall, risking rupture.

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Q5. Which of the following drugs helps contract the uterus in PPH due to retained placenta?
a) Diazepam
b) Methylergometrine
c) Paracetamol
d) Nifedipine
Correct Answer: b) Methylergometrine
Rationale: Ergot derivatives like methylergometrine induce strong uterine contractions.

📘 Morbidly Adherent Placenta (MAP)

(Important for OBG Nursing, GNM/BSc Nursing, NHM, AIIMS, NORCET, GPSC Staff Nurse Exams)

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✅ 1. Introduction / Definition:

Morbidly Adherent Placenta (MAP) refers to a group of abnormal placental attachment disorders where the placenta abnormally adheres to or invades the uterine wall due to defective decidua basalis.

It is a life-threatening obstetric condition, often associated with severe postpartum hemorrhage (PPH).

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✅ 2. Classification (Placenta Accreta Spectrum):

1. Placenta Accreta
   • Chorionic villi attach directly to the myometrium (no invasion)
   • Most common type (~75%)
2. Placenta Increta
   • Chorionic villi invade into the myometrium
3. Placenta Percreta
   • Chorionic villi penetrate through the myometrium, possibly reaching serosa, bladder, or adjacent organs
   • Most severe form

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✅ 3. Causes / Risk Factors:

• Previous cesarean section (most important risk factor)
• Placenta previa, especially with prior C-section
• Previous uterine surgery or curettage
• Multiparity
• Advanced maternal age (>35 years)
• Asherman’s syndrome (intrauterine adhesions)
• IVF conception

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✅ 4. Pathophysiology:

• Normal placenta implants into the decidua basalis, which prevents deep invasion.
• In MAP, the decidua is absent or deficient, allowing chorionic villi to abnormally adhere/invade the myometrium and beyond.
• The placenta fails to separate properly after delivery, resulting in severe hemorrhage and requiring surgical intervention.

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✅ 5. Clinical Manifestations / Signs & Symptoms:

• Often asymptomatic antenatally
• May present with:
  • Antepartum hemorrhage (in case of previa)
  • Failure of placental separation after delivery
  • Severe postpartum hemorrhage
  • Bladder symptoms (if percreta involves bladder)

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✅ 6. Diagnostic Evaluation:

🔹 Ultrasound (USG):

• Loss of clear placental-myometrial interface
• Placental lacunae (vascular spaces)
• Thinning of myometrium under placenta

🔹 Color Doppler / MRI:

• Better delineation of invasion depth
• MRI is preferred for suspected placenta increta or percreta

🔹 Antenatal suspicion is key in women with:

• Placenta previa + previous C-section

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✅ 7. Management:

🔹 Antenatal Planning:

• Admit at 34–36 weeks in high-risk cases
• Multidisciplinary team: obstetrician, anesthetist, urologist, hematologist
• Plan elective cesarean delivery at 36–37 weeks

🔹 Operative Delivery:

• Cesarean hysterectomy (without attempting placental removal) is standard in accreta/increta/percreta
• Prepare blood products in advance (major hemorrhage risk)
• In percreta with bladder involvement, partial cystectomy may be required

🔹 Conservative Management (selected cases):

• Leave placenta in situ
• Monitor with methotrexate and serial β-hCG
• Reserved for women desiring future fertility and without bleeding

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✅ 8. Complications:

🔸 Maternal:

• Massive hemorrhage
• Shock
• DIC (disseminated intravascular coagulation)
• Urologic injury (bladder involvement)
• Need for hysterectomy
• Death (if not managed timely)

🔸 Fetal:

• Preterm birth
• Fetal distress due to hemorrhage
• Low birth weight

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✅ 9. Nurse’s Role:

• Identify high-risk mothers during antenatal care
• Ensure early referral for high-risk cases (previa + scar)
• Prepare for operative delivery and blood transfusion
• Monitor vitals, bleeding, and urine output closely
• Provide postoperative care and emotional support
• Educate about future pregnancy risks and importance of early booking

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✅ 10. Golden One-Liners for Quick Revision:

• Morbidly adherent placenta = Placenta deeply attached or invaded
• Placenta accreta spectrum includes accreta, increta, percreta
• Previous C-section + previa = highest risk
• Cesarean hysterectomy is often required
• Early antenatal diagnosis reduces maternal mortality

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✅ 11. MCQs for Practice:

Q1. Which type of morbidly adherent placenta penetrates the uterine serosa and beyond?
a) Placenta accreta
b) Placenta increta
c) Placenta percreta
d) Placenta previa
Correct Answer: c) Placenta percreta
Rationale: Percreta invades through the uterus to adjacent structures like the bladder.

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Q2. What is the most significant risk factor for placenta accreta?
a) Maternal anemia
b) Primigravida
c) Previous cesarean section
d) Uterine fibroid
Correct Answer: c) Previous cesarean section
Rationale: Scarring from cesarean disrupts normal decidualization.

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Q3. Which investigation is most helpful to diagnose placenta percreta antenatally?
a) X-ray
b) MRI
c) CT scan
d) Blood test
Correct Answer: b) MRI
Rationale: MRI clearly delineates depth of placental invasion.

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Q4. What is the standard management of placenta increta discovered intraoperatively?
a) Try to remove placenta manually
b) Wait for spontaneous separation
c) Cesarean hysterectomy
d) Conservative treatment
Correct Answer: c) Cesarean hysterectomy
Rationale: Manual removal can cause fatal hemorrhage; hysterectomy is safer.

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Q5. In placenta accreta, the placenta is:
a) Attached to endometrium
b) Penetrating myometrium partially
c) Attached directly to myometrium
d) Free floating in amniotic sac
Correct Answer: c) Attached directly to myometrium
Rationale: Accreta involves superficial invasion without full penetration.

📘 Puerperal Inversion of Uterus

(Important for OBG Nursing, GNM/BSc Nursing, NHM, AIIMS, NORCET, GPSC Staff Nurse Exams)

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✅ 1. Introduction / Definition:

Uterine inversion is a rare but life-threatening obstetric emergency in which the fundus of the uterus turns inside out, usually after delivery of the placenta, and protrudes into or outside the vagina.

It most commonly occurs in the puerperal period (immediately postpartum).

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✅ 2. Classification (Types):

1. Incomplete Inversion: Uterine fundus is inverted but remains inside the uterine cavity.
2. Complete Inversion: Fundus passes through the cervix but remains within the vagina.
3. Prolapsed Inversion: Fundus protrudes outside the vaginal introitus.
4. Total Inversion: Uterus and vagina both are inverted (very rare).

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✅ 3. Causes / Risk Factors:

• Excessive traction on the umbilical cord during third stage of labor
• Fundal pressure before placental separation (Crede’s maneuver)
• Uterine atony
• Abnormally adherent placenta (e.g., placenta accreta)
• Short umbilical cord
• Excessive manual removal of placenta
• Multiparity
• Previous history of uterine inversion

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✅ 4. Pathophysiology:

• When traction is applied to the cord or pressure to the fundus before the placenta is separated, the uterine wall turns inside out.
• Uterus loses tone (atony) and invaginates through the cervix.
• This leads to shock, hemorrhage, and uterine ischemia.

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✅ 5. Clinical Manifestations / Signs & Symptoms:

• Sudden onset of severe lower abdominal pain
• Shock (disproportionate to blood loss)
• Profuse vaginal bleeding
• Palpable mass in or outside the vagina
• Absent uterine fundus on abdominal palpation
• Uterus visible at vaginal introitus (in complete or prolapsed inversion)
• Anxiety, pallor, hypotension, tachycardia

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✅ 6. Diagnostic Evaluation:

• Clinical diagnosis is usually enough based on:
  • Visible mass at vaginal opening
  • Uterus not palpable abdominally
• Ultrasound – May confirm inversion in unclear cases
• CBC and coagulation profile – To evaluate blood loss and complications

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✅ 7. Management:

🔹 Emergency Measures:

• Call for immediate help (Obstetric, Anesthesia, Blood bank)
• Start IV fluids and blood transfusion
• Oxygen administration
• Trendelenburg position (head low)

🔹 Uterine Repositioning:

1. Manual Repositioning (Johnson’s Method):
   • Immediate attempt to push fundus back through the cervix into correct position
   • Done under general or regional anesthesia
2. Hydrostatic Method (O’Sullivan’s technique):
   • Warm saline infusion via a vaginal cannula to push the uterus back
3. Surgical Management (if manual fails):
   • Huntington’s procedure – via laparotomy
   • Haultain’s operation – incision on cervical ring to reposition uterus

🔹 After Repositioning:

• Administer uterotonics (e.g., oxytocin, misoprostol) to prevent recurrence
• Give broad-spectrum antibiotics
• Monitor for shock, infection, and recurrence

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✅ 8. Complications:

• Hemorrhagic shock
• Uterine rupture (if forceful attempts made)
• Sepsis
• DIC (Disseminated Intravascular Coagulation)
• Infertility or future uterine inversion
• Death (if not managed urgently)

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✅ 9. Nurse’s Role:

• Recognize early signs (shock with absent fundus)
• Call for immediate help
• Maintain IV access, begin fluid resuscitation
• Assist during manual repositioning or surgery
• Monitor vital signs and uterine tone
• Administer uterotonics and antibiotics
• Provide psychological support and postpartum care
• Educate mother for future pregnancy care

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✅ 10. Golden One-Liners for Quick Revision:

• Uterine inversion = fundus turns inside out after delivery
• Classic sign = absent fundus + vaginal mass + shock
• Caused by fundal pressure or cord traction
• Managed with manual repositioning (Johnson’s method)
• Always start uterotonics only after repositioning

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✅ 11. MCQs for Practice:

Q1. What is the most common cause of puerperal uterine inversion?
a) Cord prolapse
b) Placenta previa
c) Fundal pressure or cord traction
d) Cervical tear
Correct Answer: c) Fundal pressure or cord traction
Rationale: Premature traction or pressure can pull the uterine fundus inside out.

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Q2. Which of the following is a classic sign of uterine inversion?
a) Hypertension
b) Foul-smelling lochia
c) Shock with absent uterine fundus
d) Cervical dilation
Correct Answer: c) Shock with absent uterine fundus
Rationale: The uterus becomes non-palpable abdominally and may be visible vaginally.

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Q3. What is the immediate treatment for uterine inversion?
a) Hysterectomy
b) Oxytocin injection
c) Manual repositioning of uterus
d) Antibiotics
Correct Answer: c) Manual repositioning of uterus
Rationale: Repositioning is priority before administering uterotonics.

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Q4. When should oxytocin be administered in uterine inversion?
a) Before repositioning
b) During repositioning
c) After repositioning
d) Never
Correct Answer: c) After repositioning
Rationale: Giving it before may prevent successful repositioning.

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Q5. Which surgical method is used if manual reposition fails?
a) B-Lynch suture
b) Dilation and curettage
c) Haultain’s procedure
d) Cesarean section
Correct Answer: c) Haultain’s procedure
Rationale: Involves incision in cervical ring to allow repositioning.

📘 Atonic Uterus

(Important for OBG Nursing, GNM/BSc Nursing, NHM, AIIMS, NORCET, GPSC Staff Nurse Exams)

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✅ 1. Introduction / Definition:

An atonic uterus refers to a failure of the uterus to contract effectively after delivery of the placenta, leading to uterine atony, which is the most common cause of primary postpartum hemorrhage (PPH).

It is a life-threatening obstetric emergency due to risk of massive blood loss and shock.

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✅ 2. Classification:

It is not classified into types but is a major cause under the “Tone” category of the 4 Ts of PPH:

• Tone – Atonic uterus
• Tissue – Retained placenta
• Trauma – Lacerations
• Thrombin – Coagulation disorders

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✅ 3. Causes / Risk Factors:

• Overdistended uterus:
  • Multiple gestation
  • Polyhydramnios
  • Macrosomia
• Prolonged or precipitate labor
• High parity (grand multipara)
• Injudicious use of oxytocin
• Magnesium sulfate therapy
• Chorioamnionitis (infection)
• Retained placental fragments
• Uterine fibroids
• Previous history of uterine atony

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✅ 4. Pathophysiology:

• After delivery, uterine muscle fibers should contract to compress blood vessels.
• In atony, the uterus fails to contract, leading to uncontrolled bleeding from the placental site.
• Uterine blood sinuses remain open, causing massive hemorrhage.

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✅ 5. Clinical Manifestations / Signs & Symptoms:

• Excessive vaginal bleeding (bright red, continuous)
• Soft, boggy uterus on palpation
• Uterus may be higher than expected in the abdomen
• Signs of hypovolemic shock:
  • Tachycardia
  • Hypotension
  • Pallor
  • Cold, clammy skin
• Decreased urine output

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✅ 6. Diagnostic Evaluation:

• Clinical diagnosis based on:
  • Palpation of a soft uterus
  • Excessive bleeding after delivery
• CBC, hemoglobin – to assess blood loss
• Coagulation profile – rule out DIC
• Ultrasound – rule out retained placental fragments

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✅ 7. Management:

🔹 Immediate Management:

1. Call for help – Obstetric and anesthetic team
2. Fundal massage – Stimulate uterine contraction
3. Ensure two large-bore IV lines, start IV fluids
4. Monitor vital signs, bleeding, and urine output
5. Insert Foley catheter – assess urine output

🔹 Medical Management:

• Uterotonics (in order of use):
  • Oxytocin – First-line, IV infusion or IM
  • Methylergometrine – Avoid in hypertensive patients
  • Carboprost (15-methyl PGF2α) – Avoid in asthma
  • Misoprostol – Rectal or oral
• Tranexamic Acid (TXA) – antifibrinolytic to reduce bleeding

🔹 Surgical Management (if unresponsive to drugs):

• Uterine tamponade (Bakri balloon)
• Uterine compression sutures (B-Lynch)
• Uterine artery ligation
• Internal iliac artery ligation
• Hysterectomy (last resort)

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✅ 8. Complications:

• Severe postpartum hemorrhage
• Hypovolemic shock
• Disseminated intravascular coagulation (DIC)
• Renal failure
• Need for hysterectomy
• Death

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✅ 9. Nurse’s Role:

• Early recognition of excessive bleeding
• Perform uterine (fundal) massage
• Administer uterotonics as prescribed
• Maintain strict input/output charting
• Monitor vital signs and uterine tone
• Assist in resuscitation and surgical procedures
• Provide emotional support to mother and family
• Ensure documentation and blood availability

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✅ 10. Golden One-Liners for Quick Revision:

• Atonic uterus = most common cause of primary PPH
• Uterus feels soft, boggy, enlarged
• First-line drug = Oxytocin
• Do not give methylergometrine in hypertension
• B-Lynch suture used surgically to control bleeding

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✅ 11. MCQs for Practice:

Q1. The most common cause of postpartum hemorrhage is:
a) Cervical tear
b) Uterine rupture
c) Uterine atony
d) Coagulopathy
Correct Answer: c) Uterine atony
Rationale: Atonic uterus is responsible for ~70–80% of primary PPH.

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Q2. What is the first line of management in atonic uterus?
a) Hysterectomy
b) Uterine artery ligation
c) Fundal massage
d) Uterine packing
Correct Answer: c) Fundal massage
Rationale: Immediate stimulation of uterus helps initiate contraction.

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Q3. Which drug is used first to manage uterine atony?
a) Carboprost
b) Misoprostol
c) Oxytocin
d) Methylergometrine
Correct Answer: c) Oxytocin
Rationale: Oxytocin is the first-line uterotonic for PPH management.

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Q4. Which uterotonic is contraindicated in hypertension?
a) Oxytocin
b) Methylergometrine
c) Misoprostol
d) Tranexamic acid
Correct Answer: b) Methylergometrine
Rationale: It causes vasoconstriction and can raise BP dangerously.

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Q5. The definitive surgical management of atonic uterus refractory to medical therapy is:
a) Cesarean section
b) Cervical cerclage
c) Hysterectomy
d) Episiotomy
Correct Answer: c) Hysterectomy
Rationale: When all conservative measures fail, hysterectomy is done to save the mother.