OG17.1-3,OG18.1-4,OG19.{1-2,4} | Postnatal Care — Graded Quiz

Correct. Bromocriptine is a dopamine D2-receptor agonist. Dopamine is the primary prolactin-inhibiting factor (PIF) from the hypothalamus. By mimicking dopamine, bromocriptine suppresses prolactin secretion from anterior pituitary lactotrophs, abolishing milk synthesis. This is the mechanism used deliberately to suppress lactation (though WHO no longer recommends routine pharmacological lactation suppression).

Dopamine (from hypothalamus) inhibits prolactin. Dopamine agonists (bromocriptine, cabergoline) suppress lactation. Dopamine antagonists (metoclopramide, domperidone) enhance milk supply. This axis is clinically relevant in galactagogue use and in managing pituitary adenomas postpartum.

Bromocriptine acts via dopamine receptor agonism at the pituitary, suppressing prolactin. It has no direct effect on oxytocin, oestrogen, or progesterone pathways. Understanding the dopamine-prolactin axis explains how drugs (metoclopramide, domperidone) enhance milk supply and how bromocriptine/cabergoline suppress it.

Correct. The signs described — clicking, maternal pain, unsatisfied baby, shallow attachment — all indicate poor latch. The correct action is to gently break the suction (with a clean finger in the corner of the mouth), reposition, and achieve a deep latch: baby's mouth wide open, most of the areola in the mouth (not just the nipple), chin touching the breast, lips flanged outward. Limiting feed duration treats the symptom (pain) while perpetuating the cause (poor latch).

A correct latch involves: wide mouth opening (≥120°), ≥2 cm areola in the mouth, chin touching the breast, asymmetric latch (more lower areola visible), no audible clicking. Poor latch is the root cause of nipple trauma, poor milk transfer, and early cessation.

Limiting feed duration, nipple shields as a first-line measure, and switching to bottle all address symptoms without correcting the root cause (shallow latch). Proper latch correction resolves all the described signs — clicking (air intake), pain (nipple compression), unsatisfied baby (poor milk transfer).

Correct. Confirmed breast abscess (fluctuance + ultrasound hypoechoic collection) requires drainage — either ultrasound-guided needle aspiration (preferred for <5 cm, well-defined, non-multiloculated collections; may need repeat) or surgical incision and drainage (for larger, multiloculated, or failed aspiration). Continued breastfeeding (or expression if too painful) is part of management, not a contraindication. Antibiotics continue but drainage is the definitive step.

Breast abscess = pus collection requiring drainage. Prefer ultrasound-guided aspiration over open I&D (better cosmesis, no general anaesthesia, allows continued breastfeeding). Continue appropriate antibiotics alongside drainage. Continue or express from the affected breast.

Antibiotics alone cannot resolve a formed abscess — there is no vascular supply to deliver the drug to the pus collection. Stopping breastfeeding worsens milk stasis. Mastectomy is never indicated for uncomplicated breast abscess.

Correct. At ~34 weeks: neuromuscular maturity shows some posture/flexion but not complete (popliteal angle ~90-100°, scarf sign may cross midline), physical maturity shows plantar creases over anterior 2/3 only, some lanugo, pinna soft but with slow recoil, skin still somewhat smooth. Option A describes term (38-40 weeks). Option C describes post-term. Option D describes very preterm (~24-26 weeks).

NBS is the standard tool for gestational age estimation from examination. At 34 weeks: plantar creases anterior 2/3, pinna with slow recoil, lanugo abundant on back, neuromuscular tone partly mature. Total NBS score of ~20-25 corresponds to ~34 weeks.

NBS scores neuromuscular (posture, arm recoil, popliteal angle, scarf sign, heel to ear) and physical maturity (skin, lanugo, plantar surface, breast, ear, genitalia) criteria. At 34 weeks, findings are intermediate — some maturity markers present but not complete-term findings.

Correct. Before escalating to chest compressions, the NRP mandates a ventilation corrective steps check — the MR. SOPA mnemonic: Mask adjustment (seal), Reposition (head), Suction, Open mouth, Pressure increase, Airway alternative (intubation). The most common reason PPV fails is a leaky mask seal, not inadequate pressure. Compressions on a baby with inadequately ventilated lungs are ineffective.

HR <60 after 30 seconds of PPV → check EFFECTIVENESS of PPV first (MR. SOPA corrective steps) before adding chest compressions. The most common reason for failed PPV is a leaky mask seal. Chest compressions on un-ventilated lungs are ineffective.

Term gestational age is assessed at the very start (before initiating any NRP steps), not at this point. Maternal blood group is irrelevant to acute resuscitation. Supplemental oxygen is used but is secondary — ensuring effective ventilation (mask seal and chest movement) takes priority before adding compressions.

Correct. The 2015 NRP revision (and subsequent guidelines) abandoned routine intubation for endotracheal suctioning in VIGOROUS meconium-stained babies (HR >100, strong cry, good tone), as it was not shown to reduce meconium aspiration syndrome and caused harm by delaying resuscitation. Vigorous babies with meconium receive routine initial steps. Only NON-VIGOROUS babies (depressed, low HR, poor tone) receive intubation and tracheal suctioning.

Meconium-stained amniotic fluid + vigorous baby → routine NRP initial steps, NO routine ET suctioning. Non-vigorous baby with MSAF → intubation and tracheal suctioning. This is a high-yield post-2015 change that is frequently examined.

Pre-2015 practice of routine intubation for ET suctioning in all meconium-stained babies was abandoned because it did not reduce MAS and caused harm. Intrapartum oropharyngeal suctioning at the perineum was also abandoned as it did not reduce MAS. Cord clamping delay decisions are separate from meconium management.

Correct. Puerperal psychosis (postpartum psychosis) typically presents within the first 2 weeks postpartum (peak days 3-10), with rapid onset of manic or psychotic features: elation, grandiosity, decreased need for sleep, pressured speech, irritability, thought disorder. It is a psychiatric emergency requiring urgent evaluation and often inpatient treatment. It differs from blues (mild, transient, days 3-5, weeping, no psychotic features) and PPD (gradual onset after 2 weeks, depressive features).

Three postpartum psychiatric entities: (1) Blues: days 3-5, mild, tearful, self-limiting. (2) PPD: after 2 weeks, persistent low mood, requires treatment. (3) Puerperal psychosis: days 3-10, rapid onset, manic/psychotic features, psychiatric emergency. Each has a distinct time course and severity.

Postpartum blues occurs days 3-5, is mild, self-limiting, and characterised by tearfulness, not mania. PPD has a later onset (typically >2 weeks) and depressive (not manic/elated) features. Fever is absent here, making puerperal pyrexia with delirium unlikely. The manic picture with early onset = puerperal psychosis.

Correct. Secondary PPH (haemorrhage occurring 24 hours to 12 weeks postpartum) with an intrauterine echogenic mass strongly suggests retained products of conception (RPOC). Management is surgical evacuation — manual vacuum aspiration (MVA) or hysteroscopic guided removal — under antibiotic cover, as RPOC are invariably infected. Ergometrine or misoprostol alone without evacuation is inadequate when RPOC are confirmed on ultrasound.

Secondary PPH causes by frequency: RPOC (most common), endometritis (often coexists), subinvolution, coagulopathy, rare trophoblastic disease. Ultrasound-confirmed RPOC = surgical evacuation + antibiotics. β-hCG should be checked if RPOC are not confirmed to exclude GTD.

A fibroid would typically be known antenatally and would not appear as an echogenic mass at 3 weeks postpartum. While gestational trophoblastic disease (hydatidiform mole, choriocarcinoma) can present similarly, it would be very rare and β-hCG would be checked only after RPOC are excluded. The most common cause of secondary PPH is RPOC.

Correct. For breastfeeding women who are less than 6 weeks postpartum, the progestogen-only pill is WHO MEC category 2 (generally usable; benefits generally outweigh risks — theoretical concern about minimal progestogen in breast milk in the first 6 weeks). After 6 weeks, it becomes MEC 1. There is no absolute contraindication (MEC 4) for POP in breastfeeding women at any time postpartum. Combined pill (with oestrogen) is MEC 4 in the first 6 weeks.

Breastfeeding postpartum contraception WHO MEC summary: COC = MEC 4 (<6 weeks), MEC 3 (6 weeks-6 months), MEC 2 (>6 months). POP = MEC 2 (<6 weeks), MEC 1 (>6 weeks). DMPA injectable = MEC 2 (<6 weeks), MEC 1 (>6 weeks). PPIUCD = MEC 1 (postplacental/immediate).

POP is not MEC 1 in the first 6 weeks (that applies after 6 weeks postpartum in breastfeeding women). It is not MEC 3 or MEC 4 — those categories apply to the combined pill (oestrogen-containing) in this setting. POP = MEC 2 from birth to 6 weeks, then MEC 1 after 6 weeks in breastfeeding women.

Correct. PPIUCD insertion uses a modified technique because the uterine cavity is large and the standard inserter tube would not reach the fundus. For vaginal delivery: the IUCD is loaded on ring forceps and placed at the fundus under direct bimanual guidance, then confirmed by gently pushing the strings back into the cavity. At caesarean section it is placed directly by hand at the fundus. The standard withdrawal technique used for interval insertion does not achieve fundal placement in the large postpartum uterus and leads to malposition and expulsion.

PPIUCD insertion technique: ring-forceps placement to the fundus (vaginal delivery) or hand placement (CS). Fundal placement is critical — midcavity or low placement leads to higher expulsion rates. Strings are tucked into the cavity at postplacental insertion (not visible at the os until involution).

The standard insertion technique is inappropriate for postplacental insertion because the postpartum uterine cavity is much larger — a standard tube will deposit the device in the lower cavity, not the fundus, leading to expulsion. Insertion is NOT contraindicated at 20 minutes — this is within the 10-minute immediate window AND within the 48-hour immediate postpartum window.

Correct. In the NRP algorithm, if HR remains <60 bpm after 30 seconds of confirmed effective PPV + coordinated chest compressions (3:1), epinephrine is indicated. Dose: 0.01-0.03 mg/kg of 1:10,000 solution IV (preferred — via UVC) or 0.05-0.1 mg/kg endotracheal (ET route requires higher dose, less reliable). Sodium bicarbonate is a later consideration (after adequate ventilation established, prolonged resuscitation). Continuing compressions without escalation after failed response is not the algorithm.

NRP medication threshold: HR <60 bpm after effective PPV + chest compressions → epinephrine. IV route (UVC) preferred: 0.1-0.3 mL/kg of 1:10,000 (= 0.01-0.03 mg/kg). ET route: 0.5-1 mL/kg of 1:10,000 (higher dose needed). Normal saline 10 mL/kg for suspected hypovolaemia.

After failed PPV + compressions, the NRP algorithm mandates epinephrine. Sodium bicarbonate is not a first-line medication and should only be considered after prolonged resuscitation with confirmed metabolic acidosis and adequate ventilation. Prognosis should not be determined at this stage without a full resuscitation attempt.

Correct. Short feeding times (5 minutes), baby falling asleep at the breast, and poor weight gain despite on-demand feeding suggest ineffective milk transfer — the baby is not drawing enough milk per feed, leading to: incomplete breast drainage, accumulation of feedback inhibitor of lactation (FIL) in the alveoli, which down-regulates milk synthesis. The solution is to improve latch and ensure effective milk removal (longer active feeds, breast compression, expressing to stimulate supply).

Low milk supply is almost always secondary to inadequate drainage rather than a primary supply problem. FIL (whey protein) accumulates in undrained alveoli and locally suppresses milk synthesis. Improving latch and drainage corrects supply. Galactagogues (domperidone, metoclopramide) are adjuncts, not first-line.

Primary lactation failure (insufficient glandular tissue) is rare (<5% of women). Excessive milk supply would cause choking, fast letdown, not poor gain. Neonatal hypothyroidism causes poor feeding but would also present with other signs (prolonged jaundice, hypotonia, poor cry) and is tested at birth. The described picture (short feeds, sleepy baby, poor gain) is classic for latch/transfer problem.