Postpartum Hemorrhage at a Hospital Without a Blood Bank

This is primary postpartum haemorrhage with hypovolaemic shock, most likely uterine atony. I would manage it as a resuscitation and haemorrhage-control emergency:

• Call for help: activate the obstetric team, anaesthesia, and blood bank; assign a team leader and a scribe.
• Resuscitation: give oxygen, keep her warm, and run crystalloid through both IV lines while sending blood for crossmatch, full blood count, coagulation, urea, and electrolytes. Give the two units of O-negative blood early rather than waiting for crossmatched blood.
• Uterine massage and emptying: perform bimanual uterine massage and empty the bladder with a catheter.
• Oxytocin: 10 IU IM, then 40 IU in 500 mL over 4 hours.
• Tranexamic acid: 1 g IV over 10 minutes within 3 hours of delivery; repeat 1 g after 30 minutes if bleeding continues.
• Second-line uterotonics: carboprost 250 µg IM every 15 minutes, up to 8 doses, or misoprostol 800 µg sublingual. Methylergometrine 0.2 mg IM can be used if there is no hypertension.
• Mechanical control: bimanual compression, aortic compression, and a condom balloon if bleeding persists.

I would also inspect for genital tract tears and retained placenta. Blood products and definitive surgery require transfer, so local measures must be effective quickly.

I would transfer early, after the first package of resuscitation and uterotonics, rather than waiting for full stabilisation. She is already in shock and the local hospital cannot provide blood products, theatre, or intensive care. Waiting for a normal blood pressure may allow her to arrest before she reaches definitive care.

The plan would be 'load and go' with ongoing resuscitation:

• Continue oxytocin infusion and tranexamic acid during transfer.
• Give the O-negative blood before departure if it is ready; do not delay for crossmatch.
• Insert a condom balloon or maintain bimanual compression if bleeding continues.
• Pre-alert the referral hospital so blood, theatre, and an obstetrician are ready on arrival.
• Send the nurse with the ambulance and a written handover, vital signs, drugs given, and estimated blood loss.
• Ask the obstetrician to meet the ambulance or give telephone advice; do not wait 30 minutes for the obstetrician if the patient is deteriorating.

I would document the capacity limitations and the reason for transfer. The family should be told that she is critically ill and that the referral hospital can provide surgery and blood.

I would start CPR immediately and treat this as a potentially reversible hypovolaemic arrest:

• Airway and breathing: open the airway, ventilate with a bag-mask and 100% oxygen, and place a supraglottic airway if trained.
• Circulation: continue chest compressions, gain access if lost, and give epinephrine 1 mg IV every 3–5 minutes.
• Haemorrhage control: maintain uterine massage and aortic compression, and continue oxytocin and tranexamic acid.
• Volume replacement: give blood or crystalloid rapidly. In this context, hypovolaemia is the most likely cause, so rapid transfusion is both resuscitation and treatment of the cause.
• Reversible causes: consider hypoxia, tension pneumothorax, tamponade, toxins, and thrombosis, but do not lose sight of haemorrhage. Do not perform a perimortem caesarean section because she is already postpartum.
• Destination: continue to the referral hospital while resuscitating; do not divert to a closer facility without blood and theatre unless it can provide haemorrhage control.

The nurse should call ahead for help and prepare for ongoing CPR on arrival. Survival depends on rapid blood products and surgical control of bleeding.