After a forceps delivery of a 4.2 kg baby, bright red blood trickles steadily from the vagina. The uterus is firm and at the umbilicus, the placenta and membranes are complete, the bladder is empty and the blood is clotting normally. The most likely cause of the bleeding is:

Disseminated intravascular coagulation

A woman with severe pre-eclampsia (BP 166/112 mmHg) has atonic bleeding 20 minutes after birth. Which uterotonic order should the nurse clarify before giving it?

Oxytocin 20 IU in 500 mL infusion

Misoprostol 800 micrograms sublingual

Antepartum and postpartum haemorrhage

18 AIIMS NORCET (Nursing Officer) practice questions on Antepartum and postpartum haemorrhage, part of Obstetric and Gynaecological Nursing. The first 18 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Hard
After a forceps delivery of a 4.2 kg baby, bright red blood trickles steadily from the vagina. The uterus is firm and at the umbilicus, the placenta and membranes are complete, the bladder is empty and the blood is clotting normally. The most likely cause of the bleeding is:
1. AGenital tract laceration
2. BAtony of the uterus
3. CRetained placental cotyledon
4. DDisseminated intravascular coagulation
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Answer: A · Genital tract laceration
Work through the four Ts. Tone is good (firm uterus), tissue is excluded (placenta and membranes complete) and thrombin is normal (blood clots). That leaves trauma, made likely by an instrumental delivery of a big baby, and the steady bright red trickle with a contracted uterus is its classic sign. The cervix, vagina and perineum are inspected under good light and the tear is sutured.
- B: Atony gives a soft, boggy uterus, but this uterus is firm.
- C: A retained cotyledon is unlikely when the placenta is complete, and the uterus usually relaxes.
- D: DIC is excluded because the blood is clotting normally.
Question 2 · Easy
The most common cause of primary postpartum haemorrhage is:
1. AAtony of the uterus
2. BMaternal coagulation failure
3. CLaceration of the cervix
4. DRetained placental tissue
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Answer: A · Atony of the uterus
Of the four Ts of PPH (tone, trauma, tissue, thrombin), poor uterine tone causes most cases. After the placenta separates, bleeding from the placental bed is stopped mainly by the crossed myometrial fibres contracting around the vessels, the so-called living ligatures. A soft, boggy uterus therefore bleeds freely. This is why every woman is given a uterotonic and has her uterine tone checked after birth.
- B: Coagulopathy is the least common of the four Ts.
- C: Genital tract trauma is the second commonest cause, usually with a well-contracted uterus.
- D: Retained tissue causes fewer cases and is checked by examining the placenta for completeness.
Question 3 · Easy
Painless, causeless and recurrent bright red vaginal bleeding in the third trimester is the classic presentation of:
1. ACervical carcinoma
2. BPlacenta praevia
3. CAbruptio placentae
4. DRupture of the uterus
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Answer: B · Placenta praevia
In placenta praevia the placenta lies wholly or partly in the lower uterine segment. As the lower segment forms and stretches in late pregnancy, the placenta shears off its attachment and maternal sinuses open, giving painless bleeding without any obvious trigger. The first bleed is often small (a warning haemorrhage) and bleeding tends to recur. The uterus is soft and non-tender, and the presenting part is often high or malpresenting.
- A: Cervical cancer bleeding is usually contact bleeding and is not tied to the third trimester.
- C: Abruption usually causes pain with a tense, tender uterus.
- D: Uterine rupture presents with pain, shock and loss of fetal parts' outline, usually in labour.
Question 4 · Medium
A woman with severe pre-eclampsia (BP 166/112 mmHg) has atonic bleeding 20 minutes after birth. Which uterotonic order should the nurse clarify before giving it?
1. AOxytocin 20 IU in 500 mL infusion
2. BMisoprostol 800 micrograms sublingual
3. CCarboprost 250 micrograms IM
4. DMethylergometrine 0.2 mg IM
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Answer: D · Methylergometrine 0.2 mg IM
Ergot alkaloids such as methylergometrine constrict vascular smooth muscle and can raise blood pressure sharply, risking eclampsia, stroke or heart failure. They are therefore contraindicated in hypertension, pre-eclampsia and heart disease. Oxytocin, misoprostol and carboprost do not raise blood pressure in this way. Carboprost is the drug to avoid in asthma, because it causes bronchospasm.
- A: Oxytocin infusion is the main treatment of atonic PPH and is safe in hypertension.
- B: Misoprostol causes shivering and fever but does not cause a hypertensive crisis.
- C: Carboprost is contraindicated in asthma, not in pre-eclampsia.
Question 5 · Easy
The most common site of an ectopic pregnancy is the:
1. AAmpulla of the fallopian tube
2. BInterstitial part of the tube
3. CSurface of the ovary
4. DIsthmus of the fallopian tube
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Answer: A · Ampulla of the fallopian tube
About 95% of ectopic pregnancies are tubal, and most of these lie in the ampulla, the widest and longest part of the tube where fertilisation normally occurs. Ampullary pregnancies tend to end as tubal abortion or rupture later than isthmic ones. Isthmic pregnancies rupture early because the lumen is narrow. Interstitial (cornual) pregnancy is rare but bleeds torrentially when it ruptures.
- B: Interstitial pregnancy is rare and ruptures late with heavy bleeding.
- C: Ovarian pregnancy is uncommon.
- D: The isthmus is the second commonest tubal site and ruptures early.
Question 6 · Medium
For a woman with postpartum haemorrhage, WHO recommends that intravenous tranexamic acid 1 g be started:
1. AWithin 24 hours of birth
2. BWithin 3 hours of birth
3. CWithin 6 hours of birth
4. DWithin 12 hours of birth
Answer and explanation in LearnFree account
Question 7 · Hard
A woman with postpartum haemorrhage has a pulse of 126/min and a blood pressure of 84/50 mmHg. What is her shock index, and what does it mean?
1. A1.0, showing a mild loss that needs observation only
2. B0.67, within the normal range for a postpartum woman
3. C1.5, showing major blood loss needing urgent resuscitation
4. D42, showing a compensated loss with stable circulation
Answer and explanation in LearnFree account
Question 8 · Medium
At 10 weeks of pregnancy a woman has heavy vaginal bleeding and painful cramps. The internal os is open, no tissue has been passed yet and the gestational sac lies low in the uterus. This is:
1. AMissed abortion
2. BInevitable abortion
3. CThreatened abortion
4. DIncomplete abortion
Answer and explanation in LearnFree account
Question 9 · Medium
A woman with a ruptured tubal pregnancy complains of pain at the tip of her right shoulder. This pain is caused by:
1. ABlood in the peritoneal cavity irritating the diaphragm
2. BSpasm of the fallopian tube spreading up the chest
3. CPressure of the enlarged uterus on the liver
4. DReferred pain from the stretched round ligament
Answer and explanation in LearnFree account
Question 10 · Medium
A primigravida at 34 weeks with pre-eclampsia has sudden severe abdominal pain and a small dark vaginal bleed. Her uterus is hard and tender, fetal parts cannot be felt and the fetal heart rate is 100/min. The most likely diagnosis is:
1. AAbruptio placentae
2. BVasa praevia
3. CPlacenta praevia
4. DPreterm labour
Answer and explanation in LearnFree account
Question 11 · Hard
An Rh-negative woman (indirect Coombs test negative) married to an Rh-positive man has suction evacuation for an incomplete abortion at 9 weeks. The correct anti-D immunoglobulin dose is:
1. A50 micrograms IM after 7 days
2. B50 micrograms IM within 72 hours
3. C300 micrograms IM within 72 hours
4. DNo anti-D is needed before 12 weeks
Answer and explanation in LearnFree account
Question 12 · Medium
After suction evacuation of a complete hydatidiform mole, the most important part of the woman's follow-up is:
1. ARepeat suction curettage at six weeks
2. BMonthly pelvic ultrasound for a year
3. CSerial serum beta-hCG until normal
4. DMonthly serum alpha-fetoprotein levels
Answer and explanation in LearnFree account
Question 13 · Medium
Ten minutes after the placenta is delivered, the nurse finds the uterus soft and boggy above the umbilicus with brisk vaginal bleeding. The first nursing action is to:
1. AApply firm traction to the umbilical cord
2. BRaise the head end of the bed to 45 degrees
3. CMassage the uterine fundus until it is firm
4. DPack the vagina tightly with sterile gauze
Answer and explanation in LearnFree account
Question 14 · Medium
A woman at 33 weeks is admitted with painless bright red bleeding of about 100 mL; her vital signs and fetal heart are normal. Which order should the nurse question before carrying it out?
1. AUltrasound scan to localise the placenta
2. BGroup and cross-match two units of blood
3. CDigital vaginal examination to assess the cervix
4. DContinuous fetal heart rate monitoring
Answer and explanation in LearnFree account
Question 15 · Hard
A woman at 16 weeks has brownish vaginal bleeding and severe vomiting. Her uterus is the size of 22 weeks, BP is 150/100 mmHg with proteinuria, no fetal heart is heard on Doppler and serum beta-hCG is very high. The most likely diagnosis is:
1. AUterine fibroid with pregnancy
2. BTwin pregnancy with pre-eclampsia
3. CMissed abortion
4. DComplete hydatidiform mole
Answer and explanation in LearnFree account
Question 16 · Easy
After a vaginal birth, primary postpartum haemorrhage is defined as blood loss within 24 hours of birth of at least:
1. A1500 mL
2. B250 mL
3. C1000 mL
4. D500 mL
Answer and explanation in LearnFree account
Question 17 · Medium
A haemodynamically stable woman has an unruptured right tubal pregnancy, and medical treatment with methotrexate is being considered. Which finding makes her unsuitable for this treatment?
1. ANo free fluid in the pouch of Douglas
2. BAdnexal mass measuring 2.5 cm
3. CFetal cardiac activity seen in the tubal mass
4. DSerum beta-hCG of 1,800 mIU/mL
Answer and explanation in LearnFree account
Question 18 · Easy
For the prevention of postpartum haemorrhage in the third stage, WHO recommends as the first-choice uterotonic:
1. AMethylergometrine 0.2 mg IV
2. BOxytocin 10 IU IM or IV
3. CCarboprost 250 micrograms IM
4. DDinoprostone 0.5 mg gel
Answer and explanation in LearnFree account

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Antepartum and postpartum haemorrhage

After a forceps delivery of a 4.2 kg baby, bright red blood trickles steadily from the vagina. The uterus is firm and at the umbilicus, the placenta and membranes are complete, the bladder is empty and the blood is clotting normally. The most likely cause of the bleeding is:

The most common cause of primary postpartum haemorrhage is:

Painless, causeless and recurrent bright red vaginal bleeding in the third trimester is the classic presentation of:

A woman with severe pre-eclampsia (BP 166/112 mmHg) has atonic bleeding 20 minutes after birth. Which uterotonic order should the nurse clarify before giving it?

The most common site of an ectopic pregnancy is the:

For a woman with postpartum haemorrhage, WHO recommends that intravenous tranexamic acid 1 g be started:

A woman with postpartum haemorrhage has a pulse of 126/min and a blood pressure of 84/50 mmHg. What is her shock index, and what does it mean?

At 10 weeks of pregnancy a woman has heavy vaginal bleeding and painful cramps. The internal os is open, no tissue has been passed yet and the gestational sac lies low in the uterus. This is:

A woman with a ruptured tubal pregnancy complains of pain at the tip of her right shoulder. This pain is caused by:

A primigravida at 34 weeks with pre-eclampsia has sudden severe abdominal pain and a small dark vaginal bleed. Her uterus is hard and tender, fetal parts cannot be felt and the fetal heart rate is 100/min. The most likely diagnosis is:

An Rh-negative woman (indirect Coombs test negative) married to an Rh-positive man has suction evacuation for an incomplete abortion at 9 weeks. The correct anti-D immunoglobulin dose is:

After suction evacuation of a complete hydatidiform mole, the most important part of the woman's follow-up is:

Ten minutes after the placenta is delivered, the nurse finds the uterus soft and boggy above the umbilicus with brisk vaginal bleeding. The first nursing action is to:

A woman at 33 weeks is admitted with painless bright red bleeding of about 100 mL; her vital signs and fetal heart are normal. Which order should the nurse question before carrying it out?

A woman at 16 weeks has brownish vaginal bleeding and severe vomiting. Her uterus is the size of 22 weeks, BP is 150/100 mmHg with proteinuria, no fetal heart is heard on Doppler and serum beta-hCG is very high. The most likely diagnosis is:

After a vaginal birth, primary postpartum haemorrhage is defined as blood loss within 24 hours of birth of at least:

A haemodynamically stable woman has an unruptured right tubal pregnancy, and medical treatment with methotrexate is being considered. Which finding makes her unsuitable for this treatment?

For the prevention of postpartum haemorrhage in the third stage, WHO recommends as the first-choice uterotonic: