OG16.1-3 | Third Stage Complications — Practice Quiz

Correct. PPH is defined as ≥500 mL blood loss after vaginal delivery, or ≥1000 mL after caesarean section, within 24 hours of delivery.

Standard definition of PPH: ≥500 mL (vaginal) or ≥1000 mL (caesarean section) within 24 hours of delivery, or any blood loss causing haemodynamic compromise.

PPH threshold differs by route of delivery: ≥500 mL (vaginal) or ≥1000 mL (caesarean). Any haemodynamically significant loss also qualifies regardless of volume.

Correct. The 4 Ts are Tone (uterine atony — most common, 70–80%), Trauma (genital tract lacerations, uterine rupture), Tissue (retained placenta, membranes), and Thrombin (coagulopathy).

The 4 Ts mnemonic: Tone (uterine atony — 70-80%), Trauma, Tissue, Thrombin. Identifying the correct T directs appropriate management.

The 4 Ts framework: Tone (atony), Trauma (lacerations/rupture), Tissue (retained products), Thrombin (coagulopathy). Atony is responsible for ~80% of PPH cases.

Correct. Carboprost (15-methyl PGF2α) causes potent bronchoconstriction and is absolutely contraindicated in asthma. It can precipitate a life-threatening bronchospasm.

PPH uterotonic contraindications — KEY TRAP: Carboprost is contraindicated in asthma (bronchospasm); Ergometrine/methylergometrine is contraindicated in hypertension (vasoconstriction causing BP surge). Always screen before prescribing.

Carboprost (15-methyl PGF2α) is contraindicated in asthma due to bronchoconstriction. Oxytocin and misoprostol are safe. Tranexamic acid is an antifibrinolytic adjunct, not a uterotonic.

Correct. AMTSL — specifically the administration of oxytocin 10 IU IM within 1 minute of baby delivery — reduces PPH incidence by approximately 40%.

AMTSL with oxytocin 10 IU IM within 1 minute of delivery is the single most important PPH prevention measure, reducing incidence by ~40%.

AMTSL with oxytocin 10 IU IM within 1 minute of delivery reduces PPH by ~40%. The three components of AMTSL are: (1) uterotonic within 1 min, (2) controlled cord traction, (3) uterine massage.

Correct. Ergometrine causes intense peripheral vasoconstriction and is absolutely contraindicated in hypertension (PIH, preeclampsia) as it can trigger a hypertensive crisis, stroke, or myocardial infarction.

Ergometrine/methylergometrine: contraindicated in hypertension, heart disease, peripheral vascular disease. Carboprost: contraindicated in asthma. Know both traps for MCQs and clinical practice.

Ergometrine/methylergometrine causes vasoconstriction — contraindicated in hypertension. Carboprost is contraindicated in asthma. Oxytocin and misoprostol are safe in hypertension.

Correct. Bimanual compression: one fist (or closed fingers) in the anterior vaginal fornix elevates the uterus, while the other hand on the abdomen compresses the uterine fundus from above, sandwiching the uterus between both hands.

Bimanual uterine compression: vaginal fist (or closed fingers) in anterior fornix + abdominal hand over fundus. Compresses the uterus between two hands. First and most immediately available PPH technique.

Bimanual compression uses both hands: vaginal fist elevates and supports from below, abdominal hand compresses the fundus from above. This mechanical compression occludes the spiral arteries at the placental bed.

Correct. A positive tamponade test — bleeding ceases after balloon inflation — predicts that haemorrhage is controllable by hydrostatic pressure, often avoiding the need for surgical intervention.

Positive tamponade test = bleeding stops after intrauterine balloon inflation → likely avoids surgery. Negative test (bleeding continues) = proceed to surgical options (B-Lynch suture, haemostatic sutures, or hysterectomy).

A positive tamponade test means bleeding has stopped with the balloon in place, suggesting the haemorrhage is atony-driven and controllable without surgery. The balloon can be left 24 hours and slowly deflated.

Correct. The NASG applies circumferential external compression to the lower limbs and abdomen, auto-transfusing approximately 500–1000 mL of blood to the central circulation, supporting BP and perfusion while definitive treatment is arranged.

NASG: non-pneumatic, circumferential lower-body compression. Provides ~500-1000 mL auto-transfusion effect. First-responder device, particularly useful in resource-limited settings or during transfer.

The NASG is a non-pneumatic (no pump needed) compression device that increases central blood volume by squeezing the lower body. It is particularly valuable in resource-limited settings as a bridge to definitive care.

Correct. Grade 2 (second-degree) inversion: the inverted fundus passes through the cervix and lies in the vagina but does not protrude beyond the introitus. Grade 1 = within cavity; Grade 3 = beyond introitus; Grade 4 = vaginal walls inverted too.

Four grades of uterine inversion: 1st (fundal dimple in cavity), 2nd (fundus in vagina, not beyond introitus), 3rd (fundus beyond introitus), 4th (uterus + vaginal walls inverted). Grade determines urgency and route of reduction.

Inversion grades: Grade 1 = fundal dimple within cavity; Grade 2 = fundus in vagina (not beyond introitus); Grade 3 = beyond introitus; Grade 4 = uterus + vaginal walls prolapsed outside.

Correct. NEVER remove the placenta before reduction — this causes massive haemorrhage from the exposed placental bed. Reduce the inversion first with placenta in situ, THEN remove the placenta after the fundus is repositioned. Also give tocolytics, NOT oxytocin, before reduction.

Uterine inversion with attached placenta: REDUCE FIRST, remove placenta after. The placenta tamponades the raw placental bed. Premature removal causes catastrophic haemorrhage. Tocolysis relaxes the cervical ring to facilitate reduction.

Critical rule: never remove the attached placenta before reducing a uterine inversion. The placenta acts as a tamponade over the open spiral arteries. Remove only after full reduction. Tocolysis (not uterotonic) is given to relax the cervical ring.