Postpartum Hemorrhage in a District Hospital

The most likely cause is uterine atony - a large baby, prolonged labor, and a soft boggy uterus all point to failure of the uterus to contract. Retained placenta is also possible since it has not delivered, but atony is the dominant reversible cause.

Immediate sequence (simultaneous, not sequential):

1. Call for help - activate the obstetric emergency team and the blood bank.
2. Uterine massage and bimanual compression while giving uterotonics: oxytocin (IV infusion and/or IM), then misoprostol (sublingual/rectal) if oxytocin insufficient.
3. Tranexamic acid 1 g IV within 3 hours of onset - this is time-critical.
4. Two large-bore IV lines, crystalloid resuscitation, cross-match, and activate massive transfusion protocol with the blood bank's available products.
5. Empty the bladder (catheter) - a full bladder impairs contraction.
6. Attempt controlled cord traction for placental delivery once the uterus is contracted; if placenta is retained and bleeding continues, manual removal is needed.
7. Monitor vital signs, urine output, and blood loss continuously; reassess for shock.

The key exam point is that these steps overlap - you do not wait for one to fail before starting the next.

With ongoing hemorrhage, atony refractory to first-line uterotonics, and no theatre, options include:

• Bimanual uterine compression maintained while awaiting transfer or theatre.
• Uterine tamponade - a balloon (e.g., Bakri) if available, or a condom catheter tamponade as a resource-adapted alternative.
• Additional uterotonics - carboprost (if available and no contraindication) or ongoing high-dose oxytocin infusion.
• Aortic compression as a temporizing maneuver in severe hemorrhage while arranging transfer.
• Resuscitation with blood products - packed cells are available; without platelets/FFP, watch for dilutional coagulopathy and consider transfer to a facility with full blood component therapy.
• Arranging urgent transfer to a facility with theatre and blood products is itself a treatment decision, not a failure.

Counseling: explain in plain language that she is bleeding heavily, that the team is doing everything possible here, that she may need surgery or transfer, and that her life is the priority. Discuss the possibility of hysterectomy if bleeding cannot be controlled, and involve her husband/decision-maker as culturally appropriate. Document the conversation. Honesty about the limits of the facility is part of ethical care - do not promise what the facility cannot deliver.

Two issues:

1. Acute kidney injury - prolonged hypotension, hemorrhage, and possible transfusion put her at risk of prerenal AKI or acute tubular necrosis. An 8-hour absence of urine needs: bladder scan/catheter check (is it obstruction or true oliguria?), fluid status assessment, creatinine and electrolytes, and careful fluid management. Do not simply give more fluid without assessing volume status - she may be fluid-overloaded after resuscitation.
2. Severe anemia (6.5 g/dL) - symptomatic? Tachycardic? This likely needs transfusion of packed cells given ongoing recovery and the risk of decompensation; transfuse and recheck.

Also watch for: Sheehan syndrome (pituitary necrosis after severe postpartum hemorrhage - failure to lactate, later amenorrhea), infection/endometritis, and secondary postpartum hemorrhage. Document and plan follow-up for pituitary and renal function.