Objective: To compare the effect of different uterotonic agents on prevention of postpartum hemorrhage following cesarean section in high risk pregnant women.Study design: randomized controlled prospective study on 120 women were going to do Cesarean section who are at high risk to develop postpartum hemorrhage. They were randomized to receive 100 microgram of carbetocin, 5 units of oxytocin followed by 20-40 units of IV oxytocin infusion and 5 units of oxytocin concomitant with 800 microgram of misoprostol. The primary outcomes were to compare the occurance of major obstetric hemorrhage and need for uterine massage and additional uterotonic agents. Secondary outcomes included estimated mean operative loss, objective changes in hemoglobin and hematocrite, preoperative and postoperative blood pressure and pulse, severe anemia, need for blood transfusion, side effects and postnatal hospital stay.Results: patients received carbetocin developed less postpartum hemorrhage, required less intervention with less mean operative blood loss than oxytocin and misoprostol, with nearly similar safety profileConclusion: Carbetocin seems to be more effective in maintaining adequate uterine tone and preventing excessive blood loss in patients undergoing cesarean section with high risk to develop postpartum hemorrhage. Carbetocin was well tolerated with nearly similar safety profile to other uterotonic agents