Postpartum haemorrhage at a midwife-led unit with four units of blood and no interventional radiology
A 31-year-old woman, G2P1, delivers a 3.9 kg baby spontaneously at a midwife-led unit 40 minutes from the nearest obstetric theatre. The third stage is prolonged and the placenta is delivered by controlled cord traction. She then bleeds heavily. Estimated blood loss is now 1,500 mL, heart rate 132, blood pressure 84/50 mmHg, respiratory rate 26, temperature 36.4 °C, and she is agitated. The uterus is soft and boggy on palpation; the perineum and vagina appear intact; the placenta appears complete. There is no interventional radiology on site, the on-call obstetrician is 30 minutes away, and the blood bank holds two units of O-negative and two units of cross-matched packed cells for her, with no formal massive transfusion protocol.
1. Set out your first 20 minutes in a prioritised sequence, naming drugs with doses and the mechanical steps, and state the point at which you would call for theatre.
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Simultaneously: call for help and resuscitate.
- Activate the obstetric emergency call: obstetrician, anaesthetist, second midwife, haematologist, porters, theatre team, blood bank. Declare a major haemorrhage.
- Two 14–16 Gauge cannulae; bloods for full blood count, coagulation, fibrinogen, crossmatch, calcium and arterial gas; warmed crystalloid in modest volume (aim under 2 L); start O-negative blood early rather than waiting for crossmatch.
- Warm her, catheterise to empty the bladder, and give oxygen.
Mechanical control first.
- Bimanual uterine compression and continuous fundal massage; empty the bladder; check the placenta and membranes for completeness and inspect for genital tract trauma.
Drugs, in sequence, while compression continues.
- Oxytocin 5 IU slow IV (or 10 IU IM), then an infusion of 40 IU in 500 mL over four hours.
- Ergometrine 0.25–0.5 mg IM or slow IV - effective for atony, but avoid in hypertension or cardiac disease.
- Carboprost 250 micrograms IM every 15 minutes, to a maximum of 8 doses (2 mg) - avoid in asthma.
- Misoprostol 800 micrograms sublingual (or 600 micrograms rectally).
- Tranexamic acid 1 g IV over 10 minutes, given within three hours of birth, repeated once after 30 minutes if bleeding continues.
Mechanical escalation. If drugs plus compression fail, insert an intrauterine balloon (250–500 mL) while preparing theatre.
When I call for theatre: ongoing bleeding after two or three uterotonics plus bimanual compression, an estimated loss above 1,500 mL with persistent shock, a balloon that will not hold or continues to drain blood, or any suspicion of retained tissue or trauma. With theatre 40 minutes away, that call is made early - she is moved while resuscitation continues, not after it is complete.
2. How would you allocate the four available units, and what resuscitation targets would you use? Justify with the physiology of pregnancy and of obstetric coagulopathy.
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Allocation. Give the two units of O-negative immediately, without waiting for crossmatch, because she is shocked and tachycardic now. Send a crossmatch sample at the same time; the two cross-matched units follow as soon as they are released. Simultaneously, ask the blood bank to activate a major haemorrhage protocol, request further red cells, fresh frozen plasma, cryoprecipitate or fibrinogen concentrate and platelets from the regional centre, and ask the haematologist to advise by phone.
Targets, treating clinically rather than waiting for results.
- Haemoglobin above 80 g/L, but not as a trigger to withhold blood in an actively bleeding woman.
- Fibrinogen above 2 g/L - a higher threshold than in trauma, because obstetric haemorrhage is fibrinogen-driven.
- Platelets above 50 × 10⁹/L, and above 75 if surgery is planned.
- PT and APTT under 1.5 times normal; ionised calcium normal - replace calcium with every few units of blood.
- A balanced red cell to plasma ratio, roughly 1:1, with cryoprecipitate or fibrinogen concentrate as the fibrinogen source.
- Warm everything; avoid colloid; limit crystalloid to prevent dilutional coagulopathy and clot disruption.
The physiology behind this. Pregnancy expands plasma volume by 40–50%, so a woman can lose 1,000–1,500 mL before her blood pressure falls - a systolic of 84 with a heart rate of 132 means she has already lost far more than the estimate suggests. Pregnancy is also a hypercoagulable, fibrinolytic state with high fibrinogen, so the coagulopathy that develops is dilutional and consumptive and shows first as a falling fibrinogen and a prolonged clotting time, before the platelet count changes. That is why fibrinogen replacement is prioritised and why a normal-looking coagulation screen does not reassure me here.
3. Bleeding continues despite balloon tamponade. The obstetrician recommends hysterectomy on site; the family asks for transfer to the tertiary unit 90 minutes away. How do you decide, and what do you tell them?
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The decision. An unstable, coagulopathic woman 90 minutes from definitive care is more likely to die in the ambulance than to be saved by the journey. Prolonged haemorrhage compounds the lethal triad - hypothermia, acidosis and coagulopathy - and every minute of continued bleeding makes surgery harder and survival less likely. So the decision is to operate here, now, with the obstetrician, the general surgeon if needed and the anaesthetist, while blood products are pushed and tranexamic acid and fibrinogen are given. Transfer is reconsidered only once bleeding is controlled and she is stable.
Surgical sequence. Laparotomy, bimanual compression, uterine artery ligation, a B-Lynch compression suture, ovarian and internal iliac ligation if the operator is skilled. If atony remains uncontrolled, hysterectomy is the life-saving procedure - it should be framed as definitive treatment, not as a failure. Ask the haematologist to attend or advise, keep the massive transfusion running, and consider aortic compression or a aortic clamp as a temporising measure in extremis.
What I tell the family. Plainly and without hedging: the womb is not contracting, we have given all the drugs and are giving blood, and the bleeding is not stopping; her life is at risk now; the operation to remove the womb is the most reliable way to stop the bleeding; transferring her in this condition risks her dying on the way. I would explain that this is an emergency decision taken in her best interests if she cannot consent, that we will discuss fertility and everything else once she is safe, and that a senior clinician will stay with them.
Also. Ask the obstetrician to confirm the plan with a second senior clinician, document the discussion and the times, and pre-alert the tertiary unit for later transfer once stable.