Postpartum Complications: Hemorrhage, Uterine Inversion, Embolism, Postpartum Preeclampsia, and Cardiomyopathy Practice Questions

25 multiple-choice questions on Postpartum complications: hemorrhage, uterine inversion, embolism, postpartum preeclampsia, and cardiomyopathy for paramedic and EMT students, from Chapter 42 (Obstetrics). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. Under the current ACOG (reVITALize) definition, postpartum hemorrhage in the first 24 hours after birth is a cumulative blood loss of:

   1. A. 500 mL vaginal or 1,000 mL cesarean birth
   2. B. 1,000 mL or more, or loss with hypovolemia
   3. C. 1,500 mL or more, whatever the vital signs
   4. D. A loss large enough to need transfusion
   Show answer

   Answer: B. 1,000 mL or more, or loss with hypovolemia

   Since 2017, ACOG defines postpartum hemorrhage as a cumulative loss of 1,000 mL or more, or any loss accompanied by signs or symptoms of hypovolemia, within 24 hours of birth regardless of route; signs of shock count even when the measured loss seems small. The 500 mL vaginal and 1,000 mL cesarean figures are the older definition, although a loss above 500 mL after a vaginal birth is still abnormal and should prompt treatment. A threshold of 1,500 mL that ignores vital signs would miss hemorrhage until it is massive. The need for transfusion is not part of the definition. Visual estimates usually underestimate the true loss. (ACOG Practice Bulletin 183.)

2. The most common cause of postpartum hemorrhage is:

   1. A. Retained placenta
   2. B. Cervical laceration
   3. C. A clotting disorder
   4. D. Uterine atony
   Show answer

   Answer: D. Uterine atony

   A uterus that fails to contract after delivery leaves the placental site bleeding freely, and atony causes most postpartum hemorrhage. Tears of the birth canal are the next most common cause.

3. The causes of postpartum hemorrhage are often remembered as the four Ts: tone, trauma, tissue, and:

   1. A. Tachycardia
   2. B. Thrombin
   3. C. Temperature
   4. D. Twins
   Show answer

   Answer: B. Thrombin

   Thrombin stands for clotting problems such as DIC or anticoagulant use; tone, trauma, and tissue cover atony, lacerations, and retained placenta. Twins raise the risk of atony but are not one of the four categories.

4. A woman delivered 15 minutes ago and is bleeding heavily. Her fundus feels soft and boggy above the umbilicus. Your first action should be to:

   1. A. Massage the fundus firmly
   2. B. Pack the vagina with gauze
   3. C. Pull the cord to remove clots
   4. D. Place her in a seated position
   Show answer

   Answer: A. Massage the fundus firmly

   A boggy uterus is atony, and fundal massage stimulates contraction to compress the bleeding vessels. Packing the vagina does not stop bleeding from inside the uterus and hides the true loss.

5. When performing fundal massage, you should place one hand just above the symphysis pubis in order to:

   1. A. Feel for a second fetus
   2. B. Check the bladder volume
   3. C. Push the placenta out
   4. D. Support the lower uterus
   Show answer

   Answer: D. Support the lower uterus

   Supporting the lower uterus with one hand while the other massages the fundus keeps the uterus from being pushed down, which could contribute to inversion. Feeling for a second fetus is done before oxytocin, not during massage.

6. Your protocol allows IV oxytocin for postpartum hemorrhage. It should be given:

   1. A. As a rapid, undiluted IV push
   2. B. Sublingually, as a crushed oral tablet
   3. C. Diluted in IV fluid as an infusion
   4. D. Intranasally with an atomizer
   Show answer

   Answer: C. Diluted in IV fluid as an infusion

   Oxytocin given as a rapid undiluted IV bolus can cause sudden hypotension, tachycardia, and arrhythmias, so IV doses are diluted in a bag of fluid and infused (or given IM). Oxytocin is not given by mouth, under the tongue, or by nasal spray for hemorrhage; the tablet given sublingually or rectally is misoprostol. A rapid push is the dangerous error this item tests.

7. Before giving oxytocin to a woman who has just delivered, you must first confirm that:

   1. A. The newborn has latched on to breastfeed
   2. B. The newborn has an Apgar score of 7 or above
   3. C. The mother has emptied her bladder fully
   4. D. No second fetus remains in the uterus
   Show answer

   Answer: D. No second fetus remains in the uterus

   Oxytocin causes strong, sustained contractions that can trap an undelivered twin, so palpate the abdomen and confirm a single pregnancy first; many EMS protocols also wait until the placenta delivers. Breastfeeding releases oxytocin naturally, but it is not a prerequisite for giving the drug. The newborn's Apgar score reflects the infant's condition and has no bearing on the mother's treatment. An empty bladder helps the uterus contract but is not required before oxytocin, and bleeding should not wait for it. (WHO PPH recommendations; Caroline.)

8. Which delivery most raises the risk that the mother's uterus will fail to contract after the birth?

   1. A. A single 3-kg infant after 6 hours
   2. B. Twins after a 20-hour labor
   3. C. A preterm infant born at 35 weeks
   4. D. A first baby delivered in 45 minutes
   Show answer

   Answer: B. Twins after a 20-hour labor

   An overstretched uterus (twins, a large infant, or excess amniotic fluid) and a long, exhausting labor both raise the risk of uterine atony, the most common cause of postpartum hemorrhage. A fast first delivery raises the risk of tears, not atony.

9. Where protocol allows, tranexamic acid for postpartum hemorrhage is given as:

   1. A. 1 g IV push any time in the first week
   2. B. 10 g IV over 1 hour after 24 hours
   3. C. 1 g IV over 10 minutes within 3 hours
   4. D. 100 mg IM once the placenta delivers
   Show answer

   Answer: C. 1 g IV over 10 minutes within 3 hours

   The usual dose is 1 g IV over 10 minutes, ideally as soon as possible and within 3 hours of birth, with a second dose if bleeding continues. Given more than 3 hours after birth, it has not shown benefit.

10. A woman is still bleeding heavily after fundal massage. Her uterus is firm. The most likely source now is:

    1. A. A tear in the birth canal
    2. B. Ongoing atony of the uterus
    3. C. An undelivered placenta
    4. D. Normal postpartum lochia
    Show answer

    Answer: A. A tear in the birth canal

    Heavy bleeding with a firm, contracted uterus points to trauma, such as a vaginal or cervical tear. Atony is unlikely when the uterus is already firm.

11. Ten days after delivery, a woman calls for heavy vaginal bleeding with clots. She is pale and tachycardic. The most likely cause is:

    1. A. A new ectopic pregnancy
    2. B. Normal lochia after birth
    3. C. Recurrence of placenta previa
    4. D. Retained placental fragments
    Show answer

    Answer: D. Retained placental fragments

    Delayed postpartum hemorrhage, from 24 hours to about 12 weeks after birth, is most often from retained tissue or infection. Normal lochia decreases over time and does not cause shock.

12. Just after the placenta delivers, a mass appears at the vaginal opening and the woman goes into shock. Bleeding is heavy. You should suspect:

    1. A. An undelivered second twin
    2. B. Uterine inversion
    3. C. Prolapsed cord
    4. D. Bladder prolapse
    Show answer

    Answer: B. Uterine inversion

    In uterine inversion the uterus turns inside out, often after traction on the cord, causing severe pain, hemorrhage, and shock. The cord has already been delivered with the placenta, so cord prolapse cannot explain it.

13. For uterine inversion with the placenta still attached, you should:

    1. A. Leave the placenta attached
    2. B. Peel the placenta off first
    3. C. Pull on the cord gently
    4. D. Give oxytocin right away
    Show answer

    Answer: A. Leave the placenta attached

    Removing an attached placenta from an inverted uterus can cause torrential bleeding. Oxytocin contracts the uterus and makes repositioning harder, so it is held until the uterus is replaced.

14. An inverted uterus is visible at the vaginal opening of a woman who delivered 5 minutes ago. Field care includes treating for shock and:

    1. A. Packing the vagina to hold it in place
    2. B. Applying ice packs directly to the uterus
    3. C. Covering it with moist sterile towels
    4. D. Placing her upright with legs together
    Show answer

    Answer: C. Covering it with moist sterile towels

    Cover the exposed uterus with moist sterile towels, treat shock, and transport; many protocols allow one gentle attempt to replace it. Applying ice could injure the tissue and does not help repositioning.

15. The most common preventable cause of uterine inversion is:

    1. A. Breastfeeding in the first hour
    2. B. Massaging the fundus after delivery
    3. C. Cord traction before separation
    4. D. Placing the mother on her left side
    Show answer

    Answer: C. Cord traction before separation

    Pulling on the cord before the placenta has separated can drag the uterine wall inside out. Fundal massage done properly, with the lower uterus supported, does not cause inversion.

16. A woman in the late stage of labor suddenly develops severe dyspnea, cyanosis, hypotension, and then a seizure. The most likely cause is:

    1. A. Supine hypotensive syndrome
    2. B. Amniotic fluid embolism
    3. C. Hyperventilation
    4. D. Uterine atony
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    Answer: B. Amniotic fluid embolism

    Amniotic fluid embolism causes sudden respiratory distress, hypoxia, cardiovascular collapse, and often DIC during labor or just after delivery. Supine hypotension improves when she is turned and does not cause cyanosis or seizure.

17. The care of a patient with suspected amniotic fluid embolism is mainly:

    1. A. Oxygen, ventilation, and CPR as needed
    2. B. Fundal massage alone for 15 minutes or more
    3. C. Magnesium sulfate as the primary drug
    4. D. Rapid IV oxytocin to stop the bleeding
    Show answer

    Answer: A. Oxygen, ventilation, and CPR as needed

    There is no field treatment that removes the embolism, so care focuses on airway, oxygen, circulatory support, and rapid transport. Magnesium is for eclamptic seizures, not embolic collapse.

18. A woman at 36 weeks has had mild breathlessness on stairs for a month. Today she has sudden severe dyspnea at rest, a pulse of 124, and SpO2 of 90%. The best interpretation is:

    1. A. Normal breathlessness from the large uterus
    2. B. Anxiety about the coming delivery
    3. C. Supine hypotension from lying flat
    4. D. A new cause, such as pulmonary embolism
    Show answer

    Answer: D. A new cause, such as pulmonary embolism

    Mild exertional dyspnea is common late in pregnancy, but sudden dyspnea at rest with tachycardia and hypoxia is not, and the hypercoagulable state makes pulmonary embolism a leading concern. Attributing it to the growing uterus misses a life threat.

19. Two hours after a field delivery, the mother has severe, worsening perineal pain and a tense, bluish swelling beside the vaginal opening. Her pulse is 118. The most likely problem is:

    1. A. Normal perineal swelling after a birth
    2. B. Retained fragments of the placenta
    3. C. Uterine inversion through the cervix
    4. D. A vulvar hematoma with hidden bleeding
    Show answer

    Answer: D. A vulvar hematoma with hidden bleeding

    Injury to vessels during delivery can bleed into the soft tissue of the vulva and vagina, forming an expanding, very painful, discolored mass. The external bleeding may be small while the hidden blood loss is large, as her rising pulse suggests. Apply cold packs and pressure, treat for shock, and transport. An inverted uterus appears as a red mass from the vagina right after placental delivery with shock, not a bluish swelling beside the opening.

20. A 30-year-old at 37 weeks with no heart history has new orthopnea, crackles in both lungs, and SpO2 of 89%. BP is 138/86 mmHg, and peripartum cardiomyopathy is suspected. The best initial care is to:

    1. A. Lay her flat and give a 1-liter fluid bolus
    2. B. Sit her up, tilted left, and give oxygen
    3. C. Give oxytocin to start labor right away
    4. D. Raise her legs to improve venous return
    Show answer

    Answer: B. Sit her up, tilted left, and give oxygen

    Peripartum heart failure is treated like other pulmonary edema: sit her up to reduce preload and work of breathing, keep a left tilt to avoid caval compression, give oxygen to keep SpO2 at about 95%, and use CPAP or nitroglycerin per protocol. Lying flat and giving a large fluid bolus worsens pulmonary edema. Oxytocin is not used to induce labor in the field and can cause fluid retention and hypotension. Raising the legs increases venous return to a failing heart. (ESC HFA position statement on PPCM, 2019; ACOG PB 212.)

21. Three months after delivery, a 32-year-old has worsening dyspnea when lying flat, leg swelling, and crackles in both lungs. She had no prior heart disease. You should suspect:

    1. A. Normal postpartum fatigue
    2. B. Postpartum hemorrhage
    3. C. Peripartum cardiomyopathy
    4. D. Hyperemesis gravidarum
    Show answer

    Answer: C. Peripartum cardiomyopathy

    New heart failure signs in the months after delivery suggest peripartum cardiomyopathy, which needs prompt evaluation. Calling it normal postpartum tiredness misses the orthopnea and crackles that point to the heart.

22. Three days after delivery, a woman has a fever of 39°C (102.2°F), foul-smelling lochia, and a tender uterus. The most likely diagnosis is:

    1. A. Endometritis
    2. B. Mastitis
    3. C. Uterine atony
    4. D. Cystitis
    Show answer

    Answer: A. Endometritis

    Infection of the uterine lining after birth, more common after cesarean or prolonged labor, causes fever, uterine tenderness, and foul discharge. Mastitis causes breast pain and redness rather than uterine tenderness.

23. A woman 2 weeks postpartum is withdrawn, tearful, and says the baby would be better off without her. Your priority is to:

    1. A. Reassure her it is the baby blues
    2. B. Leave her at home with family
    3. C. Suggest she get more rest first
    4. D. Assess her for suicidal intent
    Show answer

    Answer: D. Assess her for suicidal intent

    Thoughts of self-harm or harm to the infant suggest serious postpartum depression, so ask directly about intent and arrange transport. Dismissing it as baby blues, which are mild and resolve within 2 weeks, could be fatal.

24. A woman 1 week postpartum has hallucinations, confusion, and says voices tell her to harm her infant. This suggests:

    1. A. Postpartum psychosis
    2. B. The baby blues
    3. C. Mild postpartum anxiety
    4. D. Sleep deprivation only
    Show answer

    Answer: A. Postpartum psychosis

    Postpartum psychosis is a psychiatric emergency with a risk of suicide and infanticide, so ensure the infant's safety and transport. The baby blues cause tearfulness and mood swings, not hallucinations.

25. After a field delivery with a normal blood loss, you should monitor the mother during transport for:

    1. A. Fever from endometritis
    2. B. Leg swelling from a clot
    3. C. Uterine tone and bleeding
    4. D. Fetal heart tones of a twin
    Show answer

    Answer: C. Uterine tone and bleeding

    Recheck the fundus and pad frequently, because atony and hemorrhage can develop at any time in the first hours after birth. Endometritis and deep vein thrombosis develop over days rather than during the transport, and after a normal delivery with the placenta out and a firm, contracting uterus, a hidden twin is not the concern.