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Nursing QUESTION #9127
Question 1
A multigravida (G4P3) delivers and immediately develops heavy vaginal bleeding. Uterus is soft, boggy, and non-contracting. Estimated blood loss is 600 mL within 30 minutes. The FIRST-LINE uterotonic drug of choice is:
  • Ergometrine 0.5 mg IV
  • Misoprostol 800 mcg sublingual
  • Oxytocin 10 IU IM or slow IV✔
  • Carboprost (PGF₂α) 0.25 mg IM
Correct Answer Explanation

This is Primary Postpartum Hemorrhage (PPH) due to Uterine Atony — the most common cause of PPH (accounts for ~70–80% of cases).

According to WHO guidelines and Pakistan national protocols:

  • Oxytocin 10 IU IM (or slow IV) = First-line uterotonic for PPH prevention and treatment.
  • It has rapid onset, minimal side effects, and is heat-stable when refrigerated.
  • If oxytocin fails: add Ergometrine (avoid in hypertension/cardiac disease), or Carboprost (avoid in asthma).
  • Misoprostol is used where oxytocin is unavailable (resource-limited settings).

Remember the 4 T's of PPH: Tone (atony), Trauma, Tissue (retained placenta), Thrombin (coagulopathy). Atony is always ruled out first.

Blood loss threshold for PPH: \(\geq 500\,\text{mL}\) after vaginal delivery, \(\geq 1000\,\text{mL}\) after CS.