Which of the following patients is at the highest risk of developing postpartum hemorrhage (PPH)?

AIIMS M.Sc. Nsg Entrance exam-2026

Obstetrics & Gynaecology

Hard

Appeared in: AIIMS M.Sc. Nsg Entrance exam-2026

Explanation

This patient presents with a combination of three major risk factors for postpartum hemorrhage (PPH): grand multiparity (G6P5), multiple gestation (twin pregnancy), and polyhydramnios.
All three of these conditions lead to significant uterine overdistension.
Overdistension of the uterus is the primary cause of uterine atony, where the uterine muscles fail to contract effectively after delivery to compress the blood vessels at the placental site.
Uterine atony is the most common cause of PPH, accounting for 70-80% of cases.
The cumulative effect of these three risk factors places this patient at the highest risk for PPH among the choices.

Option A: A previous cesarean section is a risk factor for PPH, but it is primarily associated with abnormal placentation (like placenta accreta) or uterine rupture, not uterine atony. The risk is considered lower than the combined risk factors of uterine overdistension.
Option B: A labor duration of 6 hours is within the normal range for both primiparous and multiparous women. Prolonged labor (typically defined as greater than 20 hours for a first-time mother or 14 hours for a multiparous woman) is a risk factor for uterine atony due to muscle fatigue, but 6 hours is not prolonged.
Option C: While some studies suggest a weak association between epidural anesthesia and PPH, it is not considered a major or primary risk factor. The association may be related to a longer second stage of labor or the use of oxytocin augmentation, rather than the epidural itself. It poses a much lower risk compared to the severe uterine overdistension in the correct option.

Visual 1: Infographic - The '4 Ts' of Postpartum Hemorrhage. This visual would illustrate Tone, Trauma, Tissue, and Thrombin with icons and brief descriptions, helping students memorize the causes of PPH.
Visual 2: Diagram - Uterine Involution. A diagram showing a well-contracted, firm uterus versus a boggy, atonic uterus, demonstrating how contraction compresses blood vessels to prevent hemorrhage.

Clinical Relevance

Nursing practice connection: This is primarily an exam-oriented knowledge point with limited direct bedside application, so retain Identification of risk factors for postpartum hemorrhage (PPH) as background academic context rather than a clinical decision trigger.
Nurses must be able to rapidly identify patients at high risk for PPH on admission to labor and delivery and monitor them closely postpartum.
The first nursing action for a boggy uterus is immediate and vigorous fundal massage to stimulate contraction, which can be a life-saving intervention.
Recognizing the cumulative effect of multiple risk factors (like in the correct option) is crucial for anticipating complications and ensuring readiness with uterotonics, IV access, and potential for blood transfusion.

How to Approach the Question

First, identify the core concept of the question, which is identifying the patient with the highest risk for postpartum hemorrhage (PPH).
Recall the major causes and risk factors for PPH. The '4 Ts' (Tone, Trauma, Tissue, Thrombin) is a helpful mnemonic, with uterine atony (Tone) being the most common cause.
Evaluate each option to determine the number and severity of risk factors present.
Option A (previous C-section) is a risk factor, but not for atony primarily.
Option B (6-hour labor) is a normal labor duration, not a risk factor.
Option C (epidural) is a minor, debatable risk factor.

Concept Tested & Keywords

Concept Tested: Identification of risk factors for postpartum hemorrhage (PPH).
Stem keywords: postpartum hemorrhage, PPH, highest risk
Lead-in keywords: Which
Clinical cues: Age/sex group narrows the expected diagnosis, intervention, or normal reference range.

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