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

Correct. This is PPH with atony unresponsive to first-line IM oxytocin. The next step is second-line uterotonic therapy: misoprostol 800 mcg sublingually (fast absorption) plus oxytocin IV infusion (20–40 IU in 500 mL at 60 drops/min) for sustained uterotonic effect, concurrent with resuscitation.

PPH escalation: first-line IM oxytocin → second-line IV oxytocin infusion + misoprostol → third-line carboprost or ergometrine (check contraindications) → surgical/interventional.

After first-line IM oxytocin fails, escalate to second-line uterotonics: IV oxytocin infusion plus misoprostol. Ergometrine should be checked for contraindications first (hypertension). Balloon tamponade is third-line when uterotonics fail.

Correct. Carboprost (15-methyl PGF2α) is absolutely contraindicated in asthma because it causes bronchoconstriction via PGF2α receptors in bronchial smooth muscle, potentially precipitating a life-threatening bronchospasm. Ergometrine is a valid choice here as there is no hypertension documented.

Carboprost (PGF2α): contraindicated in asthma and active cardiac/pulmonary disease. Ergometrine: contraindicated in hypertension, cardiac disease. Know both; examination often tests asthma-carboprost and HTN-ergometrine pairs.

Carboprost is the drug to avoid in asthma — its prostaglandin F2α mechanism causes bronchoconstriction. Ergometrine is safe in normotensive patients. Tranexamic acid and balloon tamponade have no bronchoconstrictor effect.

Correct. This is disseminated intravascular coagulopathy (DIC) complicating obstetric haemorrhage: thrombocytopenia, prolonged PT/APTT, and low fibrinogen. Massive transfusion protocol (1:1:1 — packed RBC:FFP:platelets) addresses all three deficits simultaneously. Cryoprecipitate would specifically replenish fibrinogen but cannot address all components alone.

Obstetric DIC requires component therapy: RBC (oxygen-carrying) + FFP (coagulation factors) + platelets. Target: Hb ≥8, platelets ≥50,000, PT/APTT <1.5×normal, fibrinogen ≥2 g/L in active PPH.

The coagulation profile shows DIC: low platelets, prolonged clotting times, low fibrinogen. All three components are depleted, requiring a massive transfusion protocol (1:1:1 ratio). Transfusing RBCs alone risks dilutional coagulopathy.

Correct. Shock index = HR/systolic BP. SI ≥1.0 is abnormal; SI ≥1.5 indicates severe compromise. SI of 1.33 (HR 120, sBP 90) corresponds to Class III shock (>30% blood volume loss, hypotension, significant tachycardia). Immediate resuscitation and surgical escalation are warranted.

Shock Index = HR ÷ systolic BP. SI ≥1.0 = significant haemodynamic compromise. Class III shock: 30-40% blood volume loss, BP falling, tachycardia. Use shock index alongside clinical signs; it is a more sensitive early warning tool than BP alone.

Shock index (HR/systolic BP): normal <0.9; 0.9–1.0 borderline; ≥1.0 significant; ≥1.5 severe. SI of 1.33 with hypotension maps to Class III haemorrhagic shock — this is haemodynamic emergency requiring immediate intervention.

Correct. Bleeding decreasing to a trickle after balloon inflation is a positive tamponade test, indicating hydrostatic pressure is controlling haemorrhage. Management: leave balloon in situ for up to 24 hours with antibiotics, monitor closely, then slowly deflate (not sudden removal) to assess for re-bleeding.

Tamponade test: positive = bleeding controlled by balloon → leave 24h with monitoring + antibiotics → gradual deflation. Negative = bleeding continues despite balloon → surgical escalation (B-Lynch, devascularisation, hysterectomy).

A positive tamponade test (bleeding controlled by balloon) allows conservative management — the balloon can be left 24 hours. Gradual deflation at 24 hours (not sudden removal) tests for durable haemostasis. Only proceed to surgery if the test is negative (bleeding persists with balloon inflated).

Correct. The NASG is a non-pneumatic (no pump required) neoprene garment applied to lower limbs and abdomen. It auto-transfuses ~500–1000 mL of blood centrally, raises BP, and supports cardiac output. Key advantage: can be applied by auxiliary nurse-midwives or paramedics during transfer, before reaching a blood bank.

NASG: non-pneumatic, neoprene lower-body compression garment. Increases central perfusion by ~500-1000 mL autotransfusion. Applied foot-to-navel; no specialist skill required. Key in resource-limited, pre-referral settings for haemorrhagic shock.

NASG is non-pneumatic (no pump), applied from feet upward to the lower abdomen with velcro panels. It does not require blood to be infused first — it works by redistribution of existing blood volume. Its simplicity makes it ideal for first-responder use in resource-limited settings.

Correct. This is classic acute complete (Grade 3) uterine inversion: a firm red mass beyond the introitus (the inverted fundus), absent uterine fundus on abdominal palpation, and vasovagal bradycardia (triggered by traction on uterine ligaments). The immediate cardiovascular collapse without initial massive haemorrhage is characteristic.

Uterine inversion clinical triad: smooth red mass at/beyond introitus + absent fundus abdominally + vasovagal shock (bradycardia). Shock is partly neurogenic (vagal), partly haemorrhagic. Grade 3 = fundus beyond introitus.

Uterine inversion triad: (1) mass at or beyond introitus, (2) absent uterine fundus on abdominal exam, (3) vasovagal shock (bradycardia, hypotension disproportionate to visible bleeding). Grade 3 = fundus beyond introitus. Vagal shock occurs because the inversion stretches the broad ligament nerve supply.

Correct. When manual reduction is difficult, uterine relaxation with a tocolytic is required to relax the retracted cervical ring. Options include: IV nitroglycerine (GTN) 200–500 mcg bolus, IV terbutaline, or IV magnesium sulphate. Do NOT give uterotonics (oxytocin, ergometrine) before reduction — they tighten the cervical ring.

Johnson manoeuvre: cup the fundus in the palm, apply steady upward pressure through the cervix. If the cervical ring is tight, give tocolysis (GTN/terbutaline/MgSO4) BEFORE attempting further reduction. NEVER give oxytocin/ergometrine until reduction is complete.

Tocolysis is required before difficult reduction: GTN (nitroglycerine), terbutaline, or MgSO4 relax the cervical ring. Oxytocin and ergometrine are uterotonics that worsen cervical contraction and make reduction impossible. Uterotonics are given AFTER successful reduction.

Correct. After successful reduction, the uterotonic (oxytocin IV infusion) is immediately given to promote contraction and prevent re-inversion. This is the critical reversal: tocolytic before/during reduction → uterotonic immediately after. Continued tocolysis post-reduction prevents the uterus from forming the protective contraction that holds it in place.

Post-reduction sequence: (1) oxytocin IV infusion immediately (prevents re-inversion), (2) then remove placenta once uterus is contracted, (3) then IV antibiotics, (4) haemodynamic monitoring. Reverse from tocolytic → uterotonic as soon as fundus is repositioned.

Sequence after reduction: IMMEDIATELY give oxytocin IV infusion to promote sustained uterine contraction and prevent re-inversion. Do NOT continue tocolysis after reduction. Remove the placenta only after the uterus is well-contracted. Exploratory laparotomy is only needed for Huntington or Haultain procedures if manual reduction failed.

Correct. A missing cotyledon with a firm uterus and continued bleeding is Tissue PPH (retained placenta). The uterus cannot fully contract with a retained fragment occupying the cavity. Definitive management is manual/surgical removal under adequate analgesia or anaesthesia, followed by IV oxytocin infusion.

Retained placenta/fragment (Tissue PPH): uterus may feel firm but bleeding persists because the retained tissue prevents full cavity closure. Must be manually/surgically removed. Do not confuse with atony (soft boggy uterus = Tone PPH).

Retained placental fragment = Tissue (T) PPH. The missing cotyledon prevents complete uterine contraction. The uterus may feel firm over the placental tissue but cannot achieve haemostatic closure. Definitive treatment is removal (manual exploration or curettage under anaesthesia).

Correct. The condom catheter balloon: a male condom is tied securely around the tip of a rubber catheter (or Foley). It is inserted into the uterine cavity and inflated with 250–500 mL of normal saline via a large syringe through the catheter lumen. The inflated condom exerts hydrostatic pressure on the placental bed.

Improvised condom catheter balloon: male condom tied to catheter tip, inserted into uterine cavity, inflated with 250-500 mL normal saline. Evidence-based alternative to commercial balloons in resource-limited settings. Competency in assembly and insertion is an NMC OG16.2 skill requirement.

Condom catheter balloon: male condom + rubber/Foley catheter → insert into uterine cavity → inflate with 250-500 mL normal saline. Cost <₹10 vs commercial Bakri (₹15,000+). Equally effective for atonic PPH in studies from sub-Saharan Africa and South Asia.

Correct. This is subacute uterine inversion (>24 hours but <4 weeks) with a thickened fibrous cervical ring. The Huntington procedure (laparotomy: Allis forceps on the round ligaments with upward traction while the vaginal operator pushes the fundus up) is the first-choice surgical approach. Haultain procedure (posterior cervical ring incision) is used when the Huntington procedure fails.

Surgical reduction options: (1) Huntington procedure (abdominal — Allis clamps on round ligaments, upward traction with vaginal push) → first choice. (2) Haultain procedure (abdominal + posterior cervical incision) → when Huntington fails. Hysterectomy only as last resort — uterine conservation is strongly preferred.

Subacute inversion with rigid cervical ring: surgical reduction is indicated. Huntington procedure (laparotomy, upward traction on round ligaments) is first-choice. Haultain (posterior colpotomy) is used if Huntington fails. Hysterectomy is a last resort. Tocolysis alone is insufficient for a fibrosed ring.