Midwife Licensure Exam Independent Delivery & Emergency Obstetric Care — Emergency Obstetric First-Response for the MidwifeExam Answer Templates

Marks

1

Topic

Postpartum Hemorrhage

Difficulty

easy

Template Id

T1

Examiner Tip

The examiner wants the number. '≥500 mL after vaginal birth' in the first line secures the full mark immediately.

Model Answer

PPH is defined as blood loss of 500 mL or more after a vaginal birth, or any amount of blood loss that causes signs of hemodynamic instability (pallor, tachycardia, hypotension) in the mother.

Question Type

very_short_answer

Answer Structure

• State the specific blood-loss threshold (≥500 mL) for vaginal birth [1 mark]

Scoring Breakdown

Common Mark Deductions

• Writing '1000 mL' only without specifying it is for cesarean births
• Omitting the threshold entirely and only describing symptoms
• Writing '>500 mL' (greater than) instead of '≥500 mL' (greater than or equal to)

Key Phrases To Include

• ≥500 mL
• vaginal birth
• hemodynamic instability

Marks

2

Topic

Postpartum Hemorrhage

Difficulty

easy

Template Id

T2

Examiner Tip

Examiners want to see that you know the meaning behind each T, not just the letter. Add 'uterine atony' after 'Tone' and '~70%' to secure the second mark.

Model Answer

The 4 T's of PPH are: (1) Tone — uterine atony (most common, ~70% of PPH); (2) Trauma — lacerations, hematoma, uterine inversion/rupture; (3) Tissue — retained placenta or membranes; (4) Thrombin — coagulation disorders.

Question Type

very_short_answer

Answer Structure

• List all four T's with their correct full-word meanings [1 mark]
• Identify Tone/uterine atony as the most common cause or give a detail for at least two T's [1 mark]

Scoring Breakdown

Common Mark Deductions

• Listing only the T-words without their meanings (e.g., writing 'Tone' but not 'uterine atony')
• Confusing 'Tissue' with 'Trauma'
• Forgetting 'Thrombin' (coagulation) as the fourth T

Key Phrases To Include

• Tone
• uterine atony
• Trauma
• Tissue
• Thrombin
• most common
• 70%

Marks

3

Topic

Postpartum Hemorrhage

Difficulty

medium

Template Id

T3

Examiner Tip

The examiner marks sequentially — write in a numbered list so each step is obvious. Include 'first-line' when describing oxytocin to show clinical reasoning.

Model Answer

The first three immediate actions for PPH are: (1) Massage the uterine fundus firmly through the abdomen to stimulate uterine contraction — this addresses the most common cause, uterine atony. (2) Administer Oxytocin 10 IU intramuscularly (or 20 IU in 1 liter of IV fluid if IV access is available) — oxytocin is the first-line uterotonic. (3) Start a large-bore IV line and run IV fluids (Normal Saline or Ringer's Lactate) rapidly to treat or prevent hypovolemic shock while monitoring vital signs. Simultaneously, call for help and prepare for urgent referral to a CEmONC facility.

Question Type

short_answer

Answer Structure

• Step 1: Fundal massage with rationale [1 mark]
• Step 2: Oxytocin 10 IU IM with correct route [1 mark]
• Step 3: IV line with correct fluid type and rationale [1 mark]

Scoring Breakdown

Common Mark Deductions

• Giving methylergometrine as the first-line uterotonic instead of oxytocin
• Omitting the dose or route of oxytocin
• Writing 'give IV fluids' without specifying the type (Normal Saline or Ringer's Lactate)
• Not mentioning referral to CEmONC facility

Key Phrases To Include

• fundal massage
• Oxytocin 10 IU IM
• first-line uterotonic
• large-bore IV
• Normal Saline
• Ringer's Lactate
• CEmONC referral

Marks

3

Topic

Postpartum Hemorrhage

Difficulty

medium

Template Id

T4

Examiner Tip

The contraindication mark is a patient-safety marker. Examiners specifically look for 'hypertension' or 'pre-eclampsia' as the contraindication — do not omit it.

Model Answer

The second-line uterotonic for PPH when oxytocin is insufficient is Methylergometrine (ergometrine) 0.2 mg given intramuscularly (IM). Important contraindication: It must NOT be given to mothers with hypertension or pre-eclampsia/eclampsia, as it causes vasoconstriction and can dangerously worsen high blood pressure. (Alternative second-line options include misoprostol 800 mcg sublingually or tranexamic acid 1 g IV administered early.)

Question Type

short_answer

Answer Structure

• Name the drug correctly: Methylergometrine/ergometrine [1 mark]
• State correct dose and route: 0.2 mg IM [1 mark]
• State the contraindication: hypertension/pre-eclampsia [1 mark]

Scoring Breakdown

Common Mark Deductions

• Confusing methylergometrine dose with misoprostol dose
• Stating it is given IV (not the standard IM route in this context)
• Forgetting the hypertension contraindication — this is a patient safety mark

Key Phrases To Include

• methylergometrine
• ergometrine
• 0.2 mg
• IM
• contraindicated
• hypertension
• pre-eclampsia

Marks

2

Topic

Shoulder Dystocia

Difficulty

medium

Template Id

T5

Examiner Tip

Knowing what NOT to do is as important as what to do. If your answer mentions avoiding fundal pressure, it signals excellent clinical judgment to the examiner.

Model Answer

The turtle sign — where the baby's head delivers but then retracts tightly back against the perineum and restitution does not occur — indicates shoulder dystocia, meaning the anterior shoulder is impacted behind the symphysis pubis and cannot be delivered with normal traction. The FIRST maneuver is McRoberts maneuver: sharply hyperflex both of the mother's thighs onto her abdomen (knees brought to chest). This rotates the symphysis pubis upward and flattens the sacrum, freeing the impacted shoulder, and resolves most cases of shoulder dystocia.

Question Type

short_answer

Answer Structure

• Correctly identify the turtle sign as indicating shoulder dystocia [1 mark]
• State McRoberts maneuver as the first action with a brief description [1 mark]

Scoring Breakdown

Common Mark Deductions

• Stating fundal pressure as the first maneuver — this is WRONG and dangerous
• Applying forceful downward traction on the head — also wrong
• Confusing McRoberts with suprapubic pressure

Key Phrases To Include

• turtle sign
• shoulder dystocia
• anterior shoulder
• symphysis pubis
• McRoberts maneuver
• hyperflex thighs

Marks

2

Topic

Shoulder Dystocia

Difficulty

medium

Template Id

T6

Examiner Tip

The location distinction — 'above symphysis pubis' for suprapubic vs. the fundus for fundal — is the crux of this question. Be anatomically precise.

Model Answer

Suprapubic pressure (Mazzanti technique) involves an assistant applying firm downward and lateral pressure just above the symphysis pubis — this pushes the anterior shoulder from behind toward the baby's face, helping it slide under the pubic arch. It is used alongside McRoberts maneuver when the anterior shoulder remains impacted in shoulder dystocia. Fundal pressure is contraindicated because it pushes the shoulder further down and more tightly into the symphysis pubis, worsening the impaction and increasing the risk of brachial plexus injury to the baby and uterine rupture in the mother.

Question Type

short_answer

Answer Structure

• Define suprapubic pressure with correct location and direction [1 mark]
• Explain why fundal pressure is contraindicated [1 mark]

Scoring Breakdown

Common Mark Deductions

• Describing pressure on the fundus (top of uterus) instead of above the pubic bone
• Not providing a reason why fundal pressure is dangerous

Key Phrases To Include

• suprapubic pressure
• above symphysis pubis
• downward and lateral
• anterior shoulder
• fundal pressure contraindicated
• worsens impaction

Marks

3

Topic

Umbilical Cord Prolapse

Difficulty

hard

Template Id

T7

Examiner Tip

The examiner looks for the hand-in-vagina detail — 'push the presenting part upward off the cord' is the most critical first-response action. Write it explicitly.

Model Answer

This is cord prolapse — an obstetric emergency requiring immediate action: (1) Call for help immediately, note the time, and arrange EMERGENCY TRANSFER to a CEmONC facility for cesarean section — this is the definitive treatment. (2) With a gloved hand inserted into the vagina, push the presenting part (baby's head) UPWARD and off the cord to relieve compression — maintain this elevation continuously until arrival at the operating room. (3) Position the mother in the knee-chest (genupectoral) position or Trendelenburg/exaggerated Sims position to further reduce cord compression by gravity. (4) If the cord is outside the vagina: keep it warm and moist using a warm, saline-soaked pad — do NOT attempt to push it back inside the vagina as this causes vasospasm. (5) Stop any oxytocin infusion, provide oxygen to the mother, monitor fetal heart rate, and continue presenting-part elevation throughout transport.

Question Type

case_study

Answer Structure

• Identify cord prolapse and immediately call for help/arrange CEmONC referral [1 mark]
• Push presenting part upward off the cord AND correct maternal positioning [1 mark]
• Management of external cord (warm/moist pad) AND supportive measures (stop oxytocin, oxygen) [1 mark]

Scoring Breakdown

Common Mark Deductions

• Saying 'push the cord back inside' — this is WRONG and causes vasospasm
• Not maintaining upward pressure on the presenting part continuously
• Failing to mention CEmONC referral for cesarean as the definitive treatment
• Applying fundal pressure to try to deliver the baby — contraindicated

Key Phrases To Include

• cord prolapse
• push presenting part upward
• knee-chest position
• Trendelenburg
• warm saline-soaked pad
• do NOT push cord back
• CEmONC transfer
• stop oxytocin

Marks

2

Topic

Eclampsia and Severe Pre-eclampsia

Difficulty

easy

Template Id

T8

Examiner Tip

Both thresholds (≥140/90 for PET and ≥160/110 for severe) must be in your answer. Write them as numbers — do not paraphrase 'very high blood pressure'.

Model Answer

Pre-eclampsia is the development of new-onset hypertension (BP ≥140/90 mmHg) with proteinuria after 20 weeks of gestation, in a previously normotensive woman. Eclampsia is pre-eclampsia that has progressed to convulsions (seizures) — it is the same disease with the addition of fitting. Severe pre-eclampsia is defined by a BP of ≥160/110 mmHg accompanied by severe symptoms such as severe headache, visual disturbances, epigastric or right-upper-quadrant pain, and hyperreflexia.

Question Type

short_answer

Answer Structure

• Define pre-eclampsia (BP ≥140/90 + proteinuria after 20 weeks) and eclampsia (pre-eclampsia + convulsions) [1 mark]
• State the BP threshold for severe pre-eclampsia: ≥160/110 mmHg [1 mark]

Scoring Breakdown

Common Mark Deductions

• Omitting 'after 20 weeks' — onset timing is part of the definition
• Confusing the thresholds (e.g., writing ≥160/90 instead of ≥160/110 for severe)
• Describing eclampsia without mentioning that it includes convulsions

Key Phrases To Include

• BP ≥140/90 mmHg
• proteinuria
• after 20 weeks
• eclampsia
• convulsions
• severe
• ≥160/110 mmHg

Marks

2

Topic

Eclampsia and Severe Pre-eclampsia

Difficulty

medium

Template Id

T9

Examiner Tip

This is a classic MLE question. Memorize: '4 g IV (20%) + 10 g IM split 5 g each buttock (50%)' as a single phrase — the details are worth marks.

Model Answer

The drug of choice for preventing and treating eclamptic seizures is Magnesium Sulfate (MgSO4) — NOT diazepam or other anticonvulsants. Using the Pritchard regimen (standard in Philippine BEmONC): Loading dose is 4 g of 20% MgSO4 given intravenously (IV) slowly over 5–20 minutes, PLUS simultaneously 10 g of 50% MgSO4 given deep intramuscularly (IM) — 5 g into each buttock (with 1 mL of 2% lignocaine added to each injection to reduce pain).

Question Type

short_answer

Answer Structure

• Name Magnesium Sulfate (MgSO4) as drug of choice and exclude diazepam [1 mark]
• State the Pritchard loading dose: 4 g IV (20%) + 10 g IM (5 g each buttock, 50%) [1 mark]

Scoring Breakdown

Common Mark Deductions

• Writing diazepam as the drug of choice — this is a critical error
• Stating 4 g IM instead of IV for the IV component
• Omitting the concentration (20% for IV, 50% for IM) of MgSO4
• Forgetting that the IM dose is split: 5 g per buttock, not 10 g in one site

Key Phrases To Include

• Magnesium Sulfate
• MgSO4
• NOT diazepam
• Pritchard regimen
• 4 g IV
• 20%
• 10 g IM
• 5 g each buttock
• 50%
• lignocaine

Marks

3

Topic

Eclampsia and Severe Pre-eclampsia

Difficulty

hard

Template Id

T10

Examiner Tip

Three signs = three marks. Write them as a numbered list with the exact thresholds. 'Absent patellar reflex' is the most frequently tested — never omit it.

Model Answer

Before each maintenance dose of MgSO4, the midwife must assess for signs of magnesium toxicity by checking: (1) Respiratory rate — withhold the dose if RR is LESS THAN 16 breaths per minute; (2) Patellar (knee-jerk) reflex — withhold if patellar reflex is ABSENT; (3) Urine output — withhold if urine output is LESS THAN 30 mL/hour (or less than 100 mL in 4 hours). If magnesium toxicity occurs (respiratory depression), the antidote is Calcium Gluconate 1 g IV given slowly over 3 minutes — administered as 10 mL of a 10% calcium gluconate solution.

Question Type

short_answer

Answer Structure

• State two of the three toxicity signs with correct thresholds [1 mark]
• State the third toxicity sign with correct threshold [1 mark]
• State the antidote: Calcium Gluconate 1 g IV with correct preparation [1 mark]

Scoring Breakdown

Common Mark Deductions

• Writing the wrong threshold for RR (e.g., <12 instead of <16)
• Confusing calcium gluconate with calcium chloride
• Omitting the urine output criterion
• Not specifying the concentration/volume of calcium gluconate

Key Phrases To Include

• respiratory rate
• <16 breaths/minute
• absent patellar reflex
• urine output <30 mL/hour
• calcium gluconate
• 1 g IV
• 10 mL of 10%

Marks

2

Topic

Neonatal Resuscitation

Difficulty

easy

Template Id

T11

Examiner Tip

In HBB protocol, drying IS the stimulation — state this connection clearly. Saying 'drying is a form of stimulation' earns extra credit from alert examiners.

Model Answer

The 'Golden Minute' is the first 60 seconds after birth — within this time, a newborn who is not breathing adequately must be assessed, stimulated, and if still not breathing, should be receiving positive-pressure ventilation with a bag and mask. It is the core principle of the Helping Babies Breathe (HBB) program used in Philippine BEmONC. The first action when a newborn is not breathing is thorough DRYING — drying the baby vigorously with a clean, warm towel serves both to warm and stimulate the baby. After drying, the midwife assesses: if the baby is still not crying or breathing, ventilation with a bag and mask is started immediately within the Golden Minute.

Question Type

short_answer

Answer Structure

• Define the Golden Minute: first 60 seconds; if not breathing, begin ventilation within this time [1 mark]
• State drying/stimulation as the FIRST action [1 mark]

Scoring Breakdown

Common Mark Deductions

• Saying 'suction the airway first' — drying/stimulation precedes suctioning
• Confusing the Golden Minute duration (not 30 seconds, not 2 minutes)

Key Phrases To Include

• Golden Minute
• 60 seconds
• Helping Babies Breathe
• HBB
• drying
• stimulation
• bag and mask
• ventilation

Marks

3

Topic

Neonatal Resuscitation

Difficulty

medium

Template Id

T12

Examiner Tip

The examiner will mark 'rising chest' as the effectiveness criterion — write it explicitly. 'Chest rise' earns the mark; 'good air entry' alone may not.

Model Answer

Technique for bag-and-mask ventilation of a newborn: (1) Positioning: Place the baby on a warm, firm surface. Position the head in a neutral 'sniffing' position (slight neck extension) to open the airway. (2) Mask application: Select the correct size mask — it should cover the newborn's mouth and chin but NOT the eyes. Apply firmly to create an airtight seal over the nose and mouth. (3) Ventilation rate: Squeeze the bag at 40–60 breaths per minute using room air (21% oxygen) for term newborns. (4) Seal and technique check: The PRIMARY sign of effective ventilation is a RISING CHEST with each breath. If the chest does not rise, correct in sequence: reapply the mask seal, reposition the head to neutral, clear secretions from the airway, and open the mouth slightly. (5) Continue ventilation and reassess the heart rate — if heart rate is below 60 despite good ventilation, refer urgently for advanced support.

Question Type

short_answer

Answer Structure

• Correct head positioning (neutral/sniffing) and mask placement [1 mark]
• Correct ventilation rate: 40–60 breaths per minute [1 mark]
• Primary sign of effectiveness: rising chest [1 mark]

Scoring Breakdown

Common Mark Deductions

• Stating the wrong ventilation rate (e.g., 60–80 or 20–30 breaths/min)
• Saying 'listen for breath sounds' as the primary sign — it is RISING CHEST
• Using pure oxygen for term newborns — room air is correct for initial resuscitation

Key Phrases To Include

• neutral position
• sniffing position
• mask seal
• 40–60 breaths per minute
• room air
• rising chest
• airtight seal

Marks

5

Topic

Eclampsia and Severe Pre-eclampsia

Difficulty

hard

Template Id

T13

Examiner Tip

This is a 5-mark question — write in clear sections with headings (I, II, III, IV). Each section represents one mark. Examiners reward organized, systematic answers over dense paragraphs. Include 'definitive treatment is delivery' to show you understand why referral is essential.

Model Answer

MANAGEMENT OF AN ECLAMPTIC SEIZURE — MIDWIFE FIRST-RESPONSE I. IMMEDIATE GENERAL MEASURES (Airway and Safety) - Turn the woman onto her LEFT LATERAL position to protect the airway and prevent aspiration and to reduce aortocaval compression. - Clear the airway; do NOT insert anything forcefully into the mouth and do NOT restrain the patient. - Administer oxygen via face mask if available. - Call for help immediately; stay with the woman at all times. II. ANTI-CONVULSANT DRUG THERAPY — Magnesium Sulfate (MgSO4) MgSO4 is the drug of choice for eclamptic seizures — NOT diazepam. Loading Dose (Pritchard Regimen): - 4 g of 20% MgSO4 IV given slowly over 5–20 minutes SIMULTANEOUSLY with - 10 g of 50% MgSO4 deep IM — 5 g into each buttock, with 1 mL of 2% lignocaine added to each injection to reduce pain. Maintenance Dose: - 5 g of 50% MgSO4 deep IM every 4 hours, alternating buttocks, continued for 24 hours after the last fit OR after delivery (whichever is later). III. MONITORING FOR MgSO4 TOXICITY (before each maintenance dose) WITHHOLD the dose if ANY of the following are present: 1. Respiratory rate < 16 breaths per minute 2. Absent patellar (knee) reflex 3. Urine output < 30 mL/hour (or < 100 mL in 4 hours) Antidote for MgSO4 Toxicity: Calcium Gluconate 1 g IV (10 mL of 10% solution) given slowly over 3 minutes. IV. REFERRAL - After starting the MgSO4 loading dose and stabilizing the airway, arrange URGENT TRANSFER to a CEmONC facility. - The definitive treatment of eclampsia is delivery — this requires a CEmONC facility. - Continue MgSO4 and monitor vital signs throughout transport; transfer with an accompanying health professional. - The midwife's role ends with recognition, first-line MgSO4 loading, stabilization, and timely referral.

Question Type

long_answer

Answer Structure

• Airway/general immediate care: left lateral, airway clearance, oxygen, call for help [1 mark]
• Name MgSO4 as drug of choice (NOT diazepam) with correct Pritchard IV loading dose (4 g IV, 20%, slow) [1 mark]
• Correct Pritchard IM loading dose (10 g IM, 5 g each buttock, 50%, with lignocaine) [1 mark]
• MgSO4 toxicity monitoring criteria (all three: RR, patellar reflex, urine output) and antidote (calcium gluconate) [1 mark]
• Urgent CEmONC referral with rationale (delivery is definitive treatment) and continuation of MgSO4 during transport [1 mark]

Scoring Breakdown

Common Mark Deductions

• Using diazepam instead of magnesium sulfate — critical error, loses the drug-therapy mark
• Omitting any one of the three toxicity monitoring signs
• Not stating 'delivery is definitive treatment' when explaining why CEmONC referral is needed
• Writing the loading dose as 4 g IM — the IV dose must be stated separately from the IM dose
• Omitting lignocaine in the IM injection detail
• Not including the antidote (calcium gluconate) — always expected in MgSO4 questions

Key Phrases To Include

• left lateral
• MgSO4
• NOT diazepam
• 4 g IV
• 20%
• 10 g IM
• 5 g each buttock
• 50%
• lignocaine
• RR <16
• absent patellar reflex
• urine output <30 mL/hr
• calcium gluconate 1 g IV
• CEmONC
• delivery is definitive treatment

Marks

2

Topic

Postpartum Hemorrhage

Difficulty

medium

Template Id

T14

Examiner Tip

The word 'bimanual' means TWO hands — one inside, one outside. This anatomical detail is what the examiner looks for. Distinguish it clearly from uterine fundal massage.

Model Answer

Bimanual uterine compression is a manual compression technique used when the uterus remains atonic (soft and boggy) despite fundal massage and oxytocin. Technique: One fist is placed in the anterior vaginal fornix, pushing the uterus upward and forward; the other hand is placed on the abdomen behind the fundus, compressing the uterus firmly between the two hands. This mechanically stops bleeding from the atonic uterine sinuses. It is indicated when fundal massage and first-line uterotonics (oxytocin) have not achieved adequate uterine contraction and bleeding continues. Aortic compression may also be applied as a temporizing measure during preparation for referral.

Question Type

short_answer

Answer Structure

• Describe the technique: one hand in vaginal fornix, one hand on abdomen, compress between them [1 mark]
• State the indication: continued PPH/atony despite massage and oxytocin [1 mark]

Scoring Breakdown

Common Mark Deductions

• Describing external massage only (not bimanual = internal + external)
• Not specifying the indication (when it is done)

Key Phrases To Include

• bimanual uterine compression
• anterior vaginal fornix
• compress between two hands
• uterine atony
• despite oxytocin

Marks

5

Topic

Postpartum Hemorrhage

Difficulty

hard

Template Id

T15

Examiner Tip

Organize with Roman numeral headings: Recognition, Immediate Management, Continued Bleeding, Referral. Examiners can quickly see all five marks. A well-organized 5-mark answer impresses and earns full marks more reliably than a narrative paragraph.

Model Answer

COMPLETE FIRST-RESPONSE TO POSTPARTUM HEMORRHAGE (PPH) I. RECOGNITION - Diagnose PPH: blood loss ≥500 mL after vaginal birth, OR any blood loss causing maternal symptoms (pallor, dizziness, rapid weak pulse, falling BP). - Identify the likely cause using the 4 T's: Tone (atony — most common, 70%), Trauma (lacerations/hematoma), Tissue (retained placenta), Thrombin (coagulopathy). II. IMMEDIATE FIRST-LINE MANAGEMENT (perform simultaneously while calling for help) 1. CALL FOR HELP; stay with the mother; note the time. 2. MASSAGE the uterine fundus firmly through the abdomen — a sustained, firm circular massage until the uterus contracts and remains firm. 3. Give OXYTOCIN 10 IU IM (first-line uterotonic) — or 20 IU added to 1 L IV fluid running rapidly if IV is in place. 4. START a large-bore IV line; infuse Normal Saline or Ringer's Lactate rapidly to treat/prevent hypovolemic shock; monitor vital signs every 5–15 minutes. 5. EMPTY the bladder by catheterization — a full bladder prevents uterine contraction. 6. INSPECT for trauma — check for perineal, vaginal, and cervical lacerations; apply direct pressure to any bleeding tear. 7. CHECK the placenta — if incomplete, retained placenta requires CEmONC-level removal. III. IF BLEEDING CONTINUES 8. BIMANUAL UTERINE COMPRESSION: one fist in the anterior vaginal fornix, other hand on the abdomen behind the fundus — compress firmly between both hands. 9. Second-line uterotonics: - Methylergometrine 0.2 mg IM (CONTRAINDICATED in hypertension/pre-eclampsia) - Misoprostol 800 mcg sublingual (or 600–800 mcg rectally) - Tranexamic acid 1 g IV (given early reduces mortality) 10. Aortic compression may be applied as a temporizing measure. IV. TREAT FOR SHOCK AND REFER - Position woman flat with legs elevated; keep her warm; administer oxygen if available. - REFER URGENTLY to a CEmONC facility — the midwife cannot surgically address the cause (e.g., uterine rupture, retained placenta requiring manual removal, or intractable atony requiring surgical intervention). - CONTINUE fundal massage, bimanual compression, and IV fluids DURING TRANSPORT; transfer with an accompanying health worker. - Document all interventions and vital signs for the receiving facility.

Question Type

long_answer

Answer Structure

• Recognition: ≥500 mL threshold and 4 T's framework [1 mark]
• Steps 1–4: call for help, fundal massage, Oxytocin 10 IU IM, large-bore IV/fluids [1 mark]
• Steps 5–7: empty bladder, inspect trauma, check placenta completeness [1 mark]
• Continued bleeding management: bimanual compression, second-line uterotonics (methylergometrine, misoprostol, tranexamic acid) with contraindication noted [1 mark]
• Shock management and CEmONC referral with rationale, continuing management during transport [1 mark]

Scoring Breakdown

Common Mark Deductions

• Omitting the bladder emptying step — this is a classic missed mark
• Giving methylergometrine without stating its contraindication in hypertension
• Not mentioning all three second-line options (ergometrine, misoprostol, tranexamic acid)
• Not explaining why CEmONC referral is needed (surgical intervention beyond midwife scope)
• Forgetting to continue management during transport

Key Phrases To Include

• ≥500 mL
• 4 T's
• Tone uterine atony 70%
• fundal massage
• Oxytocin 10 IU IM
• Normal Saline Ringer's Lactate
• empty bladder
• bimanual compression
• methylergometrine contraindicated hypertension
• misoprostol 800 mcg SL
• tranexamic acid 1 g IV
• CEmONC referral
• legs elevated