Postpartum Haemorrhage at a Road-Isolated Health Post
At a health post in Sindhupalchok, a 24-year-old woman delivered a live boy 90 minutes ago. The placenta is complete. She has soaked two pads and the under-sheet in the past 30 minutes; estimated blood loss is 700 mL. She is pale, sweaty, and restless. BP is 88/56 mmHg, pulse 120/min, respirations 24/min, SpO2 94% on room air, temperature 36.8°C. The uterus feels soft and is above the umbilicus; the bladder is distended. There is one 18-gauge IV cannula, 500 mL Ringer's lactate, oxytocin in a refrigerator with an uncertain cold-chain record, oral misoprostol 200 µg tablets, tranexamic acid, and no blood bank. The ambulance is 50 minutes away on a rough road; the nearest referral hospital has a blood bank. A doctor is not on site. Two other women are in early labour. One ANM and one auxiliary staff are present.
1. List your first five actions in order and justify why each comes before the next.
Read the worked answer
- Call for help and organise the team. Allocate one person to the woman, one to bring the referral vehicle and notes, and one to manage the other labouring women. PPH deteriorates quickly, so parallel action is safer than one nurse doing everything sequentially.
- Assess airway, breathing, circulation, consciousness, and ongoing bleeding while applying fundal massage. Uterine atony is the most likely cause here, and massage is immediate, reversible, and does not depend on drugs or a doctor.
- Empty the bladder. A distended bladder prevents the uterus from contracting; catheterisation is therefore a treatment for atony, not an afterthought.
- Secure a second large-bore IV line if possible and start Ringer's lactate. She is hypotensive and tachycardic; fluid resuscitation must run alongside uterotonics, not after them.
- Give the first-line uterotonic and tranexamic acid without waiting for transfer. Quantify blood loss, keep her warm, monitor every 15 minutes, and prepare referral. Bimanual uterine compression should be started if atony persists and the nurse is trained, while arranging transfer for definitive care.
2. State the uterotonic and tranexamic acid plan with doses and routes, including what you would do if the oxytocin cold chain is unreliable.
Read the worked answer
Give oxytocin 10 IU intramuscularly as the first-line uterotonic, or 5 IU slowly intravenously if IV access is secure and the dilution and rate are controlled. Give tranexamic acid 1 g intravenously over 10 minutes as soon as possible and within 3 hours of birth; if bleeding continues after 30 minutes, a second 1 g dose can be given. Continue fundal massage and monitor vital signs, urine output, uterine tone, and blood loss.
If the oxytocin cold chain is unreliable, do not assume the drug is potent. Check the refrigerator log, expiry date, and whether the vial was frozen or left warm; discard if compromised. In that situation, use tranexamic acid and misoprostol 800 µg sublingually as the available uterotonic, while continuing massage and compression. Misoprostol can cause shivering and fever, so monitor temperature. Do not delay referral while trying multiple drugs; the goal is to stabilise, stop bleeding, and reach surgical care.
3. Plan the referral: what must be done before and during transfer, and what must be documented?
Read the worked answer
Before transfer: confirm the referral hospital can receive her and has blood; obtain informed consent from the woman or her family; secure two IV lines if possible; keep the uterus contracted; catheterise and monitor urine output; keep her warm; give oxygen if saturation falls; and arrange a skilled escort with oxygen and resuscitation equipment. Notify the receiving facility of the estimated blood loss, vital signs, drugs and times given, and the need for blood.
During transfer: monitor pulse, BP, respiration, consciousness, uterine tone, and bleeding every 15 minutes; continue oxytocin as available; keep the IV running; and position her safely. Do not leave her with an untrained driver. If bleeding recurs, perform massage and compression and reassess.
Document the time of birth, estimated blood loss, uterine findings, bladder status, each drug with dose, route and time, IV fluids, vital signs, the referral discussion, the escort's name, and the time of departure. A clear pre-referral note protects continuity of care and gives the receiving team the information needed for transfusion and possible surgery.