studying the effect of different uterotonic agents in prevention of postpartum hemorrhage following cesarean section in high risk cases.

pregnant women undergoing cesarean section and at high risk to develop post partum hemorrhage. All the patients will be subjected to the following after taking informed written consent: 1. Full history taking. 2. General examination including patient weight. 3. Abdominal examination including obstetric ultrasound. 4. Routine laboratory tests including hemoglobin and hematocrit. 5. Anesthesia technique will be standardized, spinal anesthesia will be performed. Patients will receive an intravenous bolus of 500 mL crystalloid before spinal anesthesia. A size 25G pencil-point needle will be used at a suitable lumbar inter-space. The patient can be sitting or in the left lateral position for spinal anesthesia. The anesthetic solution consisted of 2 ml 0.5% hypertonic bupivocaine (2.2 ml in the sitting position), 10–20 microgram fentanyl and 0.1 mg preservative free morphine. Anesthesia should be to the level of T5, as assessed by touch. The patient will be tilted 15 degree to the left of supine and standard monitoring used as per the AAGBI guidelines. Anesthetists will replace blood loss at operation with colloid infusion or blood when deemed necessary. Intravenous crystalloids were continued at 1 Litre every 8 hours until the morning after surgery. 6. The patients will be divided randomly in to 3 GROUPS: * GROUP 1:80 patients will receive 100 microgram of PAPAL (carbetocin) IV as a uterotonic agent after delivery of fetal anterior shoulder. * GROUP 2:80 patients will receive 5 IU of IV bolus oxytocin then will be followed by 40 IU of oxytocin infusion on 1000 ml saline with a rate of 150 ml per hour as a uterotonic agent after delivery of fetal anterior shoulder. * GROUP 3:80 patients will receive 800 microgram misoprostol rectally immediately after anesthesia and before Cesarean Section followed by 5 IU of oxytocin IV bolus immediately after delivery of anterior shoulder as a uterotonic agent. 7. Active management of the third stage of labour as the following: * Administration of the uterotonic agent with delivery of the anterior shoulder of the baby. * Clamping and cutting the umbilical cord soon after birth. * Applying controlled cord tension to the umbilical cord while applying simultaneous counter-pressure to the uterus, through the abdomen. 8. The surgical approach to cesarean section is standardized. Surgeons will be asked to operate to a standard procedure that specifies transverse lower segment ceserean section two layer closure of the uterine incision, and to avoid delivering the uterus for suturing unless clinically indicated. 9. Follow up the patients postoperative regarding vital signs and hemoglobin and hematocrit 48 hours after surgery