Self-Assessment Questions (SAQs) for Study Session 11

Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering the following questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.

SAQ 11.1 (tests Learning Outcome 11.1)

You are drafting the information that you want to send with the referral notice for a mother with PPH and you write it out as below. A young trainee colleague asks you to explain what you have written. How would you explain your referral note, including all the terms in bold, so that your colleague can understand?

‘I am referring Mebrihit. She is a high parity mother with excessive bleeding and is considered to be experiencing primary postpartum haemorrhage. I was careful to avoid trauma when assisting her delivery. Palpation indicates atonic postpartum haemorrhage which I suspect is due to failure of the myometrium.’


Here is how you could have explained to your trainee colleague what you had written in your referral note:

‘I am referring Mebrihit. She has had more than 5 pregnancies (high parity) and developed bleeding in excess of 500 ml of blood (excessive bleeding) within 24 hours of delivery (primary postpartum haemorrhage). I was very careful to avoid any injury (trauma) during the delivery. Feeling her abdomen (palpation) indicates that her uterus is soft and has not contracted properly after delivery (atonic postpartum haemorrhage). I suspect this is because the muscular wall of her uterus (myometrium) is failing to contract and close the blood vessels where the placenta pulled away from the uterus’.

SAQ 11.2 (tests Learning Outcomes 11.2 and 11.3)

You are assessing a pregnant woman in your care for potential risk of PPH.

  • a.What questions would you ask her and what would you remember to check as part of your antenatal care visit?
  • b.What checks and interventions would you make during her labour and delivery?


Here are some of the questions to ask and things to do. We expect you may have thought of even more.

  • a.Antenatal care - questions to ask and things to check:
    • Is she a first-time mother (primiparous) or has she had one or more deliveries already (multiparous), i.e. putting her more at risk of atonic PPH?
    • If multiparous, was her earlier baby very large (over 4 kg) or did she have twins? (either of which may have overstretched her uterus).
    • Does she remember if she had an excessive amount of amniotic fluid in a previous pregnancy (polyhydramnios)? More than 3 litres can also overstretch the uterus.
    • Have you screened for anaemia (which you should continue in your postnatal checks)? If she has anaemia have you advised her about good nutrition?
    • Is the community transport plan ready in case of emergency referral?
  • b.During and after delivery – interventions to make and things to check:
    • Make sure she regularly empties her bladder to avoid interfering with normal uterine contractions, including immediately after birth.
    • Use the partograph to monitor labour progress so that you quickly notice any signs that might potentially lead to PPH (e.g. obstruction leading to possible uterine rupture).
    • Be careful not to encourage pushing before the cervix is fully dilated and help to ensure controlled delivery of the baby’s head and shoulders in order to prevent tears.
    • Encourage and help the mother to breastfeed immediately (so she starts to make her own oxytocin, which will stimulate the uterus to contract).
    • Check that the placenta has fully separated and is intact, then rub the uterus every 15 minutes for the first 2 hours to help keep the uterus well contracted.

SAQ 11.3 (tests Learning Outcome 11.4)

Gelila delivered a baby 40 minutes ago. You gave her 600 µg of misoprostol orally immediately after the birth, but the placenta has not come out yet. She has emptied her bladder. After 10 minutes the placenta comes out and you check that it is intact, but Gelila starts bleeding heavily. What do you do?


Here is what you should do:

  • Immediately shout for Gelila’s family and neighbours to get transport ready in case the bleeding becomes excessive and she needs to go to the nearest health facility.
  • Check her rate of bleeding and unless it has quickly reduced, assume this is a case of atonic postpartum haemorrhage.
  • If she had 600 μg misoprostol after the birth, give her a second dose of 400 μg misoprostol rectally or under her tongue to help her uterus to contract. If she had oxytocin before, give her another 10 IU by intramuscular injection.
  • Lie Gelila on her back with her feet higher than the head, cover her with blankets and make sure she is warm.
  • If you are trained to do so, begin pre-referral infusion of IV fluids.
  • Try rubbing the uterus to encourage it to contract. If this fails then try two-handed compression on the uterus. If the bleeding stops and the uterus starts to feel firm, slowly release the pressure. If bleeding doesn’t stop, continue the referral process and get her to the health facility as quickly as possible.
  • Accompany Gelila to the facility, checking her vital signs, and continuing to administer intravenous fluids. Make sure her baby comes too and that there are appropriate people to look after it and to act as possible blood donors.
  • Write down everything that you have done on the referral note, together with Gelila’s history and identification details.

Summary of Study Session 11