12. A woman has delivered 4000g baby within 3 hours since labor starts . At the initial postpartun assessment, fundus is firm and at the level of the umbilicus. But there is heavy brighter red bleeding with occasional small clots. Vital signs are unchanged from prenatal value. What is the best next step of your intervention? (Hidar 2012/December 2019 ) A. Tell the mother it is normal having vaginal discharge after delivery B. Tell the mother it is okay as long as the bleeding is less than 500ml C. Begin aggressive intravenous fluid and oxytocic administration D. Insert speculum and explore cervix , vagina and perineum for tear 13. A 25-year-olc woman delivered her baby at a health center. You attempt to deliver the placenta actively with intramuscular oxytocin but it was not successful. She starts to bleed heavily. It has been 40 minute since the delivery of the baby . Despite your attempt, the placenta neither expels out nor it shows sign of separation. What is your best intervention at this level? ( Hidar 2012/December 2019 ) A. Put her on IV fluid, give ampicilline 2 g IV , refer her B. Change oxytocin with ergometrine and attempt CCT once again C. Wait the placenta for additional 20 minutes, attempt manual removal D. Give sedative agent and prophylactic antibiotics, attempt manual removal

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12. A woman has delivered 4000g baby within 3 hours since labor starts . At the initial postpartun assessment, fundus is firm and at the level of the umbilicus. But there is heavy brighter red bleeding with occasional small clots. Vital signs are unchanged from prenatal value. What is the best next step of your intervention? (Hidar 2012/December 2019 ) A. Tell the mother it is normal having vaginal discharge after delivery B. Tell the mother it is okay as long as the bleeding is less than 500ml C. Begin aggressive intravenous fluid and oxytocic administration D. Insert speculum and explore cervix , vagina and perineum for tear 13. A 25-year-olc woman delivered her baby at a health center. You attempt to deliver the placenta actively with intramuscular oxytocin but it was not successful. She starts to bleed heavily. It has been 40 minute since the delivery of the baby . Despite your attempt, the placenta neither expels out nor it shows sign of separation. What is your best intervention at this level? ( Hidar 2012/December 2019 ) A. Put her on IV fluid, give ampicilline 2 g IV , refer her B. Change oxytocin with ergometrine and attempt CCT once again C. Wait the placenta for additional 20 minutes, attempt manual removal D. Give sedative agent and prophylactic antibiotics, attempt manual removal

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12. The correct answer is D. Insert speculum and explore cervix, vagina, and perineum for tear.In this scenario, the woman has delivered a large baby (4000g) and is experiencing heavy bleeding with occasional small clots. The firm fundus and unchanged vital signs from prenatal values indicate that there is no uterine atony or other immediate postpartum complications. However, the heavy bleeding suggests the possibility of a postpartum hemorrhage (PPH) due to a retained placental fragment or a tear in the birth canal.The best next step is to insert a speculum and explore the cervix, vagina, and perineum for any tears or retained placental fragments. This will help identify the cause of the bleeding and guide appropriate management. If a tear is found, it should be repaired, and if a retained fragment is found, it should be removed. If no abnormalities are found, other causes of the bleeding should be considered, such as coagulation disorders or uterine atony.13. The correct answer is C. Wait the placenta for an additional 20 minutes, attempt manual removal.In this scenario, the woman has delivered her baby and is experiencing heavy bleeding despite attempts to deliver the placenta actively with intramuscular oxytocin. It has been 40 minutes since the delivery, and the placenta shows no signs of separation or expulsion.The best next step is to wait for an additional 20 minutes and attempt manual removal of the placenta. This is known as "active management of the third stage of labor" and is recommended when the placenta does not deliver spontaneously within 30 minutes of delivery. Manual removal should only be attempted if the placenta does not deliver after this period, as it can be associated with complications such as uterine inversion or retained fragments.If manual removal is unsuccessful or if the bleeding continues, other interventions such as administering additional oxytocic agents, ergotamine, or blood transfusion may be considered. However, these interventions should only be done under the guidance of a healthcare professional and in a hospital setting.

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