21 question answer with reason
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Finding Sources
Finding Sources
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Finding Sources
Here is the complete answer for both questions visible in the image:
Question 21
A 29-year-old woman develops continuous bleeding per vagina immediately after delivery. Uterus is contracted and fundus is at the level of umbilicus. Placenta and membranes were delivered completely. Pulse 110 bpm, BP 100/70 mmHg. What is the next step?
Answer: b) Examine for genital tract trauma
Reasoning:
This is a classic scenario designed to test your ability to apply the "4 Ts" framework for postpartum hemorrhage (PPH):
| T | Cause |
|---|---|
| Tone | Uterine atony |
| Trauma | Genital tract lacerations |
| Tissue | Retained placenta/membranes |
| Thrombin | Coagulopathy |
The key clinical clues in this question systematically rule out other causes:
- Uterus is contracted and fundus at umbilicus - this rules out uterine atony (in atony the uterus is soft/boggy). So options a (Bimanual Compression) and d (Misoprostol) are not the next step.
- Placenta and membranes delivered completely - this rules out retained products of conception (Tissue). So option c (Uterine exploration) is not indicated yet.
- Bleeding is continuous - since Tone and Tissue are excluded, the next logical step is to examine for Trauma (lacerations of the cervix, vagina, perineum, or vulva).
When uterine atony and retained products are excluded, genital tract trauma becomes the most likely cause and must be examined for immediately. Maternal birth trauma accounts for up to 20% of PPH cases - tears and lacerations of the perineum, vagina, cervix, urethra, and vulva are common after vaginal delivery. (Rosen's Emergency Medicine, p. 3006)
Option e (Balloon tamponade) is a step used when medical and minor surgical measures have failed - it is not the next immediate step before examining the cause.
Correct answer: b) Examine for genital tract trauma
Question 2 (2017 May) - Partially visible
Causes of uterine atony following childbirth - the answer is d) Polyhydramnios
Reasoning:
Uterine atony results from overdistension or anything that prevents the uterus from contracting properly after delivery. The predisposing factors include:
- Overdistension of the uterus: multiple gestations, fetal macrosomia, polyhydramnios (excess amniotic fluid)
- Prolonged labor
- Chorioamnionitis
- Use of tocolytics
- General anesthesia with halogenated agents
Why the other options are NOT primary causes of atony:
- a) Low body mass - not a recognized cause
- b) Maternal anaemia - causes worsening of PPH consequences but is not a cause of atony itself
- c) Placenta accreta - causes PPH by failure of placental separation, not by atony; the uterus may actually contract normally
Polyhydramnios causes overdistension of the uterus, which impairs the ability of myometrial fibers to contract and constrict the spiral arteries at the placental implantation site after delivery - this is the direct mechanism of atony. (Rosen's Emergency Medicine, p. 3002)
Correct answer: d) Polyhydramnios
But still the fundus at the level of umbilicus
Great observation - let me clarify this point directly.
Fundus at the level of umbilicus is actually NORMAL after delivery - this is not a sign of uterine atony.
Here is the distinction:
Normal vs. Atonic Uterus - Fundal Position
| Finding | Meaning |
|---|---|
| Fundus at umbilicus + firm/contracted | Normal postpartum uterus |
| Fundus at umbilicus + soft/boggy | Uterine atony |
Why This Matters for Question 21
The question gives you two separate pieces of information about the uterus:
- "Uterus is contracted" - meaning it is firm, not boggy
- "Fundus is at the level of umbilicus" - this is the expected normal position immediately after delivery (the uterus takes several days to involute back into the pelvis)
So the fundus being at the umbilicus is not pathological here. It is expected. What matters is that the uterus is contracted and firm - which rules out atony.
A common exam trap is assuming that fundus at the umbilicus = problem. It only becomes a concern if:
- The fundus is higher than expected (suggesting a full bladder or retained clots)
- The uterus is soft and boggy alongside that position (= atony)
Since the uterus is contracted, atony is excluded. Placenta is out completely, so retained tissue is excluded. The cause of bleeding must therefore be genital tract trauma - and examining for it is the correct next step.
The answer remains: b) Examine for genital tract trauma
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