Labor and Delivery — MCQs

Question 1: A multipara developed postpartum hemorrhage (PPH) during her 3rd child birth. What is the most probable cause for her PPH?

• A. Fibroid
• B. Retained placenta
• C. Uterine atony (Correct Answer)
• D. Uterine perforation

Explanation: **Explanation:** **1. Why Uterine Atony is the Correct Answer:** Uterine atony refers to the failure of the myometrium to contract effectively after the delivery of the placenta. In a normal delivery, the contraction of interlacing muscle fibers (the "living ligatures") compresses the spiral arteries to prevent bleeding. **Uterine atony is the most common cause of primary Postpartum Hemorrhage (PPH), accounting for approximately 70-80% of cases.** Multiparity is a significant risk factor because repeated stretching of the uterine muscle fibers leads to reduced muscle tone and contractility. **2. Analysis of Incorrect Options:** * **Fibroid (Option A):** While intramural or submucosal fibroids can interfere with uterine contractions and increase the risk of PPH, they are a much less common cause than simple atony. * **Retained Placenta (Option B):** This is the second most common cause of PPH (part of the "4 Ts" - Tissue). However, statistically, atony remains more prevalent, especially in the absence of specific history suggesting placental adherence issues. * **Uterine Perforation (Option D):** This is typically an iatrogenic complication associated with procedures like D&C or manual removal of the placenta, rather than a primary cause of spontaneous PPH in a multipara. **3. High-Yield Clinical Pearls for NEET-PG:** * **The 4 Ts of PPH:** **T**one (Atony - 70%), **T**issue (Retained products - 20%), **T**rauma (Lacerations - 10%), and **T**hrombin (Coagulopathy - 1%). * **Management Priority:** The first step in managing atonic PPH is **Uterine Massage** followed by oxytocics (Oxytocin is the drug of choice). * **Risk Factors for Atony:** Multiparity, overdistension (polyhydramnios, twins, macrosomia), prolonged labor, and use of uterine relaxants (magnesium sulfate). * **Active Management of Third Stage of Labor (AMTSL):** The most effective way to prevent atonic PPH.