Postpartum Hemorrhage With a Boggy, Deviated Fundus
A 29-year-old woman delivered a 3.6 kg infant vaginally 90 minutes ago. The placenta was reported complete. She now has heavy vaginal bleeding; the fundus is boggy, 2 cm above the umbilicus, and deviated to the right. Estimated blood loss is 1,200 mL and ongoing. BP 80/50, HR 140, RR 26, SpO2 97% on room air. She is pale, anxious, and has a 20-gauge IV in the left hand. Hemoglobin is 7.8 g/dL. The unit has 2 units of O-negative red cells, 2 units of plasma, and no massive transfusion protocol pack. The obstetrician is in the operating room and will be available in 10 minutes.
1. List your immediate actions in the first 10 minutes and explain what the fundal findings suggest.
Read the worked answer
Call for help and activate the obstetric hemorrhage protocol. Perform uterine massage and empty the bladder; the boggy, right-deviated fundus suggests uterine atony plus bladder distension. Assess for retained placenta and vaginal or cervical lacerations. Start oxytocin 10 IU IM or IV, then an infusion per protocol; add methylergonovine if there is no hypertension, carboprost if there is no asthma, and misoprostol as ordered. Give tranexamic acid 1 g IV within 3 hours of birth. Place two large-bore IVs, give warm crystalloid, and request blood products early. Monitor vital signs, fundus, lochia, and urine output. Prepare for examination under anesthesia and possible balloon tamponade or surgery. Do not let the hemoglobin of 7.8 g/dL reassure you; acute loss may not be reflected yet.
2. How would you manage transfusion and escalation with only 2 units of O-negative red cells, 2 units of plasma, and no massive transfusion pack?
Read the worked answer
Do not wait for crossmatch in a patient with ongoing hemorrhage and BP 80/50. Give O-negative red cells and plasma in a balanced ratio while calling the blood bank for emergency release and additional products. Activate massive transfusion if bleeding continues. Warm all products, monitor calcium, and assign a recorder and team leader. Escalate to the obstetrician and anesthesia immediately rather than waiting 10 minutes; the patient may need the operating room. If uterine atony persists despite massage, medications, and bladder emptying, proceed to balloon tamponade or surgical intervention. Consider uterine artery embolization if available.
Re-examine the placenta despite the report of completeness; a missing cotyledon suggests retained products. Communicate the risk of deterioration and document the resource limitations and rationale for emergency release.