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OG17.1-3,OG18.1-4,OG19.{1-2,4} | Postnatal Care — Practice Quiz
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Which hormone is primarily responsible for milk ejection (let-down reflex) during breastfeeding?
Correct. Oxytocin, released from the posterior pituitary in response to suckling, causes myoepithelial cells around the alveoli and ductules to contract, propelling milk toward the nipple. This is the milk-ejection (let-down) reflex.
Oxytocin drives milk ejection via the neuroendocrine let-down reflex; prolactin drives milk synthesis. The reflex is inhibited by pain and stress — important counselling point.
Prolactin stimulates milk synthesis (lactogenesis), not ejection. Oestrogen and progesterone suppress lactation during pregnancy. Milk ejection is mediated by oxytocin.
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A mother on postpartum day 4 reports that her milk has not come in despite frequent breastfeeding. Examination reveals a soft, non-tender uterus that is larger than expected. Which of the following is the MOST likely cause of delayed lactogenesis II in this mother?
Correct. A retained placental fragment continues to secrete progesterone, which suppresses lactogenesis II (the onset of copious milk production). The clue is delayed milk on day 4 despite frequent feeding AND a larger-than-expected uterus suggesting retained tissue.
Lactogenesis II (copious milk onset, days 2-4) requires the progesterone drop that follows complete placental expulsion. Retained placental fragments are an under-recognised cause of lactation failure.
While inadequate suckling and flat nipples impair milk transfer, they do not explain the uterine finding. Hypothyroidism can cause supply issues but not this acutely. A retained placenta fragment maintains progesterone levels, blocking lactogenesis II.
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A breastfeeding mother presents on day 10 postpartum with a 2-day history of fever (38.5°C), painful right breast erythema, and flu-like symptoms. Examination reveals a localised tender, indurated area without fluctuance. What is the MOST appropriate immediate management?
Correct. This presentation is infective mastitis (no fluctuance, so no abscess yet). Management is: appropriate antibiotic (flucloxacillin or co-amoxiclav for Staphylococcus aureus), continued and effective breastfeeding/expression from the affected breast (cessation is the main preventable cause of abscess formation), and analgesia/supportive care.
Mastitis management rests on three simultaneous pillars: effective breast drainage (continue breastfeeding), appropriate antibiotics (anti-staphylococcal), and supportive care. Stopping breastfeeding converts mastitis to abscess.
Stopping breastfeeding causes milk stasis, increasing the risk of abscess formation — the opposite of what is needed. I&D is reserved for confirmed breast abscess (fluctuance/pus on ultrasound). Analgesics alone without antibiotics and drainage will allow progression to abscess.
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A newborn is assessed at 1 minute of life: heart rate 90 bpm, irregular gasping respirations, blue hands and feet with pink trunk, minimal flexion, grimace only on stimulation. What is this baby's APGAR score?
Correct. Scoring: Colour — blue hands/feet (acrocyanosis), pink body = 1 point; Pulse — HR 90 bpm (>100 = 2; 60-99 = 1; <60 = 0) = 1 point; Grimace — grimace on stimulation = 1 point; Activity/tone — minimal flexion = 1 point; Respiration — gasping = 1 point. Total = 5.
APGAR is scored at 1 and 5 minutes. 7-10 = normal; 4-6 = moderate depression (stimulate, give O2); 0-3 = severe (immediate resuscitation). Never confuse APGAR (birth condition) with Ballard (gestational maturity).
Review APGAR scoring: each of the 5 parameters scores 0-2. Colour: pink all over=2, acrocyanosis=1, blue=0. Pulse: >100=2, 60-99=1, absent=0. Grimace: cry=2, grimace=1, none=0. Activity: active=2, some flexion=1, limp=0. Respiration: strong cry=2, gasping=1, absent=0. Sum here = 1+1+1+1+1 = 5.
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Which of the following umbilical cord blood gas findings is MOST consistent with birth asphyxia?
Correct. Birth asphyxia produces a mixed (respiratory + metabolic) acidosis: low pH (<7.0 or at least ≤7.1), high CO2 (respiratory component), and elevated base deficit (metabolic lactic acidosis from tissue hypoxia). A base deficit ≥12 mEq/L on arterial cord blood is a marker of significant metabolic acidosis consistent with clinically significant asphyxia.
Birth asphyxia is defined by: failure to establish adequate respiration + evidence of metabolic acidosis (umbilical arterial pH <7.0, base deficit ≥12 mEq/L) + neonatal encephalopathy or multi-organ dysfunction. All three criteria together = HIE.
Option A is normal. Option C is mild respiratory acidosis only. Option D is borderline. Birth asphyxia is characterised by severe mixed acidosis — low pH, elevated CO2, AND elevated base deficit — reflecting both respiratory failure and anaerobic metabolism.
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In the NRP algorithm, chest compressions are initiated when, after 30 seconds of effective positive-pressure ventilation, the heart rate remains below which threshold?
Correct. In the NRP algorithm: if HR <100 bpm after initial steps → start PPV; if HR <60 bpm after 30 seconds of EFFECTIVE PPV → add chest compressions at a 3:1 ratio (3 compressions : 1 breath, 90 compressions + 30 breaths/minute = 120 events/minute).
NRP decision points: HR <100 → PPV; HR <60 after effective PPV → add chest compressions (3:1 ratio); HR <60 after compressions + PPV → epinephrine. The 3:1 ratio optimises ventilation in neonatal asphyxia.
The NRP threshold for beginning chest compressions is HR <60 bpm after 30 seconds of confirmed effective PPV. Compressions are NOT started at HR <100 (that threshold triggers PPV) or <80. The 3:1 ratio differs from adult CPR (30:2).
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On postpartum day 5, a primipara develops fever 38.8°C, uterine tenderness, and offensive lochia. Blood cultures are pending. Which organism is MOST commonly responsible for puerperal sepsis in India?
This is a well-known area of uncertainty — there is no single universally agreed 'most common' organism. Globally and in Indian data, the principal organisms are Group A Streptococcus (most virulent, fulminant sepsis), E. coli (particularly after caesarean section and urinary source), and anaerobes. Group B Streptococcus causes neonatal disease more than maternal puerperal sepsis. Empirical management covers Gram-positive, Gram-negative, and anaerobes.
Puerperal sepsis is often polymicrobial. Empirical therapy must cover Group A Streptococcus, E. coli, and anaerobes (e.g. IV ampicillin + gentamicin + metronidazole or piperacillin-tazobactam). Offensive lochia + uterine tenderness = endometritis until proven otherwise.
Puerperal sepsis microbiology is polymicrobial. Group A Streptococcus (Lancefield A) is the classically dreaded causative agent (Semmelweis era) and can cause rapidly fatal sepsis. E. coli is common, particularly post-CS. No single organism is universally 'most common' across all Indian centres — empirical broad-spectrum cover is always appropriate pending cultures.
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A woman is seen at 6 weeks postpartum. She delivered vaginally at term. Her uterus is still palpable per abdomen. This finding is MOST consistent with which diagnosis?
Correct. By 6 weeks (42 days) postpartum, uterine involution should be complete — the uterus should be non-palpable per abdomen and have returned to approximately its pre-pregnant size and weight (~60-80g). A uterus still palpable at 6 weeks indicates subinvolution. Causes include retained products of conception, endometritis, and uterine fibroid.
Subinvolution = failure of the uterus to return to normal size by 6 weeks. Key causes: retained products, endometritis, fibroids. Management: exclude retained products (ultrasound), treat infection if present.
Normal involution: uterus descends approximately 1 cm/day from the umbilicus and should be non-palpable abdominally by day 10-14, and completely involuted by 6 weeks. A palpable uterus at 6 weeks is abnormal = subinvolution.
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A breastfeeding mother, 4 weeks after normal vaginal delivery, requests contraception. She has no medical contraindications. Which contraceptive is categorised as WHO MEC Category 4 (contraindicated) in her situation?
Correct. Combined oral contraceptives contain oestrogen, which significantly reduces breast milk volume and quality, and exposes the infant to oestrogen via milk. Oestrogen also increases the already-elevated postpartum thrombotic risk. WHO MEC 4 (contraindicated) for COC in the first 6 weeks postpartum in breastfeeding women. This is the most common and consequential error in postpartum contraception practice.
COC is WHO MEC category 4 (absolute contraindication) in breastfeeding women <6 weeks postpartum. POP is the preferred hormonal option. This rule is routinely tested in final MBBS and is clinically critical.
LAM and condoms are safe and non-hormonal. The progestogen-only pill is WHO MEC 2 (generally usable, benefits outweigh risks) after 6 weeks in breastfeeding women. The COMBINED pill (containing oestrogen) is WHO MEC 4 in breastfeeding women in the first 6 weeks — absolutely contraindicated.
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Under the Government of India's PPIUCD programme, what is the correct timing for 'immediate' postplacental IUCD insertion?
Correct. Under the MoHFW PPIUCD programme, 'immediate postplacental' insertion is defined as within 10 minutes of placental delivery (either after vaginal delivery or during caesarean section). This window is preferred because the cervix is dilated, the uterus is large and fundal placement is easy, and the woman is already in the facility.
PPIUCD timing: immediate postplacental (within 10 min) or immediate postpartum (within 48 h). The 48h-to-6-week interval is avoided due to high expulsion rates due to uterine involution. After 6 weeks is the standard interval insertion.
PPIUCD timing categories: (1) Immediate postplacental = within 10 minutes of placental delivery; (2) Immediate postpartum = within 48 hours; (3) Early postpartum = 48 hours to 6 weeks (AVOIDED due to high expulsion risk); (4) Interval = after 6 weeks. The 'within 6 hours' option is not a defined category.
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