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OG16.1-3 | Third Stage Complications — Assignment
CLINICAL SCENARIO
Postpartum haemorrhage remains the leading direct cause of maternal mortality in India and globally. This assignment asks you to construct a structured clinical management plan for a specific PPH scenario, critically evaluate the uterotonic choices in that patient context (applying contraindication reasoning), describe the stepwise escalation of mechanical and surgical interventions, and reflect on systems-level factors that contribute to PPH-related mortality in low-resource settings.
Instructions
You are the registrar on call. A 30-year-old G4P3 woman with no documented antenatal care has just delivered vaginally at a district hospital. Within 10 minutes of delivery, she has bled approximately 900 mL. The placenta has been delivered and is complete. The uterus is soft and poorly contracted despite vigorous bimanual massage. Her observations: BP 88/58 mmHg, HR 126/min, SpO2 95% on air, RR 22/min. Write a structured clinical management plan for this patient, critically justifying each decision. Your assignment must address all four sections below.
Length: 1200–1600 words (excluding references). Bullet points are acceptable in Sections 1 and 3; full sentences required in Sections 2 and 4.
What to Submit
Section 1: Immediate Diagnosis and Assessment (20 marks)
Guidance: Classify this PPH using the 4 T framework — identify the most likely T in this patient and explain your reasoning using the clinical signs. Calculate the shock index and classify the haemodynamic severity. List the four actions that must happen simultaneously in the first 5 minutes (resuscitation/assessment/communication/uterotonic). Explain why waiting for laboratory results before starting treatment is incorrect.
Section 2: Uterotonic Therapy — Decision and Contraindication Reasoning (25 marks)
Guidance: List the four major uterotonics (oxytocin, ergometrine, carboprost, misoprostol) and their mechanisms of action. For each, state the principal contraindications. This patient has no documented comorbidities — identify which of the four you would use as first-, second-, and third-line agents in this patient and justify your sequencing. Then address this variation: the patient's relative mentions she has been using a salbutamol inhaler for the last three months. How would this information change your third-line uterotonic choice, and why? Be specific about the mechanism of contraindication.
Section 3: Escalation — Mechanical and Surgical Interventions (25 marks)
Guidance: Despite optimal uterotonic therapy (all three second-line agents given), bleeding continues at 200 mL/15 minutes. Describe in logical sequence the non-surgical mechanical interventions you would now initiate (bimanual compression, intrauterine balloon, NASG — describe how each works and the clinical endpoint/criterion for escalation beyond it). If the intrauterine balloon tamponade test is negative, outline the surgical options available at a district hospital with a general surgeon (B-Lynch compression suture, devascularisation, hysterectomy). What is the role of tranexamic acid in this escalation, and when should it be given?
Section 4: Blood Product Management and Systems Reflection (30 marks)
Guidance: The haemoglobin returns at 6.8 g/dL, platelets 72,000/mm³, INR 2.1, fibrinogen 0.8 g/L. Interpret this coagulation profile (what complication has developed?) and describe the blood component therapy you would initiate, with target thresholds for each parameter during active haemorrhage. Finally, write a short reflective paragraph (150–200 words) addressing: what antenatal, intrapartum, and systems-level factors most commonly delay recognition or treatment of PPH in district hospitals in India, and what single change would have the greatest impact on outcome in this patient's case.
Grading Rubric — Third Stage Complications — Assignment Marking Rubric
| Criterion | Points | Full-marks descriptor |
|---|---|---|
| Accurate PPH classification using 4 T framework, correct shock index calculation and haemodynamic severity staging, and correct identification of simultaneous first-5-minute actions | 20 pts | 4 T classification fully correct with explicit reasoning; shock index correctly calculated (SI=1.44) and mapped to Class III/severe shock; all four simultaneous actions correctly listed with brief rationale |
| Accuracy of uterotonic mechanisms and contraindications; correct sequencing for this patient; correct identification of carboprost contraindication in asthma with mechanistic explanation | 25 pts | All four uterotonics with mechanisms correct; all principal contraindications stated; logical sequencing with justification; carboprost-asthma bronchoconstriction mechanism fully explained with PGF2α receptor reference; ergometrine-hypertension trap also discussed |
| Logical stepwise escalation of non-surgical and surgical interventions with correct mechanism/endpoint for each; appropriate timing of tranexamic acid | 25 pts | Bimanual compression technique correctly described with endpoint; tamponade balloon mechanism and tamponade test (positive/negative significance) correctly explained; NASG mechanism and use-case correctly stated; B-Lynch, devascularisation, hysterectomy in logical sequence with district hospital context; tranexamic acid given within 3 hours, mechanism stated |
| Correct identification of DIC, accurate target-based blood component therapy, and quality of systems-level reflection | 30 pts | DIC correctly identified with all three criteria (thrombocytopenia + prolonged PT/INR + low fibrinogen); correct component therapy with explicit targets (Hb≥8, platelets≥50,000, INR<1.5, fibrinogen≥2 g/L); 1:1:1 massive transfusion protocol mentioned; reflection is thoughtful, identifies specific antenatal/intrapartum/systems barriers (unbooked, distance, blood bank access), and proposes a specific evidence-based intervention |
PEER REVIEW
Read your peer's assignment carefully. Using the marking rubric as your guide, provide structured feedback on: (1) Is the 4 T classification and haemodynamic staging correct? (2) Are the uterotonic contraindications accurately explained — specifically, is the carboprost-asthma mechanism explained with pharmacological reasoning? (3) Is the escalation sequence logical and complete? (4) Is the DIC identified and component targets specified? Your feedback should include at least one specific strength and at least one specific constructive suggestion per section.