Home Delivery, Major Postpartum Haemorrhage and a Two-Unit Blood Bank
A 28-year-old woman, para 2, delivered at home at 37 weeks after a 3-hour labour and was transferred to your unit 40 minutes later with heavy vaginal bleeding. She is pale and drowsy but rousable. Pulse 128 beats/min, blood pressure 82/48 mmHg, respiratory rate 26/min, oxygen saturation 96% on air, temperature 36.4°C. The uterus is soft and boggy, 2 cm above the umbilicus, and there is active bleeding with clots; estimated blood loss is 1800 mL. Intravenous oxytocin is running. Blood results: haemoglobin 62 g/L, platelets 118 × 10⁹/L, fibrinogen 1.1 g/L, INR 1.4, creatinine 110 µmol/L. The blood bank holds two units of O-negative red cells; the nearest tertiary hospital with intensive care and interventional radiology is 90 minutes away by road.
1. Set out your first 30 minutes of management in order of priority.
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Recognise major postpartum haemorrhage with shock and coagulopathy. She has lost roughly 30% of her blood volume and is drowsy - do not wait for results before acting.
First 30 minutes
- Call for help - senior obstetrician, anaesthetist, haematologist, porters - and activate the massive haemorrhage protocol. Appoint a team leader and a scribe.
- Airway and breathing: high-flow oxygen; tilt her to the left or use a wedge.
- Two large-bore cannulae, warmed crystalloid titrated to a systolic of 80–90 mmHg, and O-negative blood if she is unstable before cross-match.
- Find the cause while resuscitating. Bimanual uterine massage, catheterise to empty the bladder, inspect the perineum and vagina for tears, and perform a manual uterine assessment for retained placenta - nobody has examined her internally since the home delivery.
- Uterotonics: oxytocin 5 IU slow IV plus 40 IU in 500 mL over 4 hours; ergometrine 0.25 mg IM if no hypertension; carboprost 0.25 mg IM every 15 minutes (maximum 8 doses) if no asthma; misoprostol 800 µg sublingually or rectally.
- Tranexamic acid 1 g IV over 10 minutes.
- Bimanual compression or a uterine balloon while drugs are prepared; keep her warm; check calcium and glucose.
Do not chase the blood pressure with large crystalloid volumes - dilution worsens coagulopathy.
2. How do you manage the coagulopathy and the blood product shortfall?
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Treat the coagulopathy early. A fibrinogen of 1.1 g/L in obstetric haemorrhage predicts progression to severe haemorrhage; the target is at least 2 g/L. Give cryoprecipitate (two pools, about 10 units) or fibrinogen concentrate 2–4 g. Give fresh frozen plasma 15 mL/kg if INR is above 1.5 or bleeding continues, and platelets if the count is below 50 × 10⁹/L (keep above 75 × 10⁹/L if surgery is planned). Aim for a balanced red cell : plasma : platelet ratio of about 1:1:1, and give 10 mL of 10% calcium gluconate per 4 units of blood. Use viscoelastic testing if available - a FIBTEM A5 below 12 mm is a practical trigger for fibrinogen replacement.
Blood product shortfall. Two units of O-negative are a bridge, not a treatment. Activate the regional massive transfusion protocol, request group-specific uncrossmatched blood, and use whole blood if the service provides it. Cell salvage is safe in obstetrics with a leucocyte filter. Because she may need 6–10 units and transfer takes 90 minutes, the definitive surgical step must not wait for a full blood bank - surgery and blood must proceed in parallel.
Also correct hypothermia (warmed fluids, forced-air blanket), acidosis (restore perfusion) and hypocalcaemia (target ionised calcium above 1.1 mmol/L), while continuing uterotonics and tamponade.
3. The bleeding continues despite balloons and uterotonics. How do you decide between hysterectomy here and transfer, and how do you handle consent?
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The question is not 'hysterectomy or transfer' but 'can she survive 90 minutes on the road?' A woman with ongoing atony, coagulopathy and shock who is still bleeding after balloon tamponade, bimanual compression and all uterotonics is at high risk of dying during transfer. Transfer is for the stabilised patient; she is not stabilised.
Decision. Proceed to laparotomy in this unit: reassess the uterus, exclude rupture and retained placenta, then apply compression sutures or vessel ligation if the uterus is to be preserved. If bleeding continues, or she is in disseminated intravascular coagulopathy, hysterectomy is definitive and correct, and should be done early rather than after three hours of failed measures. A useful rule: if she has received more than 4–6 units and is still bleeding, the uterus has failed the test.
Consent. Assess capacity formally. If she lacks capacity, treat in her best interests, document that her husband was contacted but unavailable, and have two senior clinicians (obstetrician and anaesthetist) record their agreement. If she can understand, explain simply: 'The womb is not stopping bleeding and you could die; we need to remove it to save your life.' Record her response verbatim.
Afterwards. Debrief the team, inform the family, arrange critical care, and complete incident reporting and a structured review. Debriefing is part of professionalism, not an optional extra.