Primary postpartum haemorrhage after a 4.1 kg birth at a freestanding birth centre

Classification This is a primary postpartum haemorrhage: blood loss is over 500 mL after a vaginal birth, it is continuing, and the uterus is soft. The estimated loss of 700 mL with tachycardia, dizziness, and a falling blood pressure means I would treat it as a significant haemorrhage, not a minor one. Visual estimation underestimates loss, so I would weigh swabs and pads if possible.

Immediate actions

1. Call for help: second midwife, ambulance, and the obstetric unit. State ‘postpartum haemorrhage, ongoing, symptomatic’.
2. Assess airway, breathing, and circulation. Lay Jo flat with legs elevated, keep her warm, and give oxygen only if she is hypoxic.
3. Rub up a contraction: fundal massage and empty the bladder if it is full. A full bladder prevents the uterus from contracting.
4. Gain IV access with a large-bore cannula and take bloods for full blood count, coagulation, and crossmatch.
5. Give tranexamic acid 1 g IV slowly, ideally within three hours of birth.
6. Give oxytocin 5 IU slowly IV or start an infusion, according to local protocol.
7. Perform bimanual compression if the uterus remains soft while waiting for transfer.
8. Keep the baby with Jo if possible and safe, with a second midwife supporting breastfeeding, because separation increases distress and does not help the haemorrhage.

I would not delay transfer to complete every drug; the priority is to stop the bleeding and get to definitive care.

Sequence

• Oxytocin: 5 IU slowly IV, or an infusion of 40 IU in 500 mL over 4 hours, depending on local protocol. Rapid IV bolus can cause hypotension.
• Ergometrine: 0.5 mg intramuscularly. It is contraindicated in hypertension and pre-eclampsia because it causes vasoconstriction. Jo’s blood pressure is 98/58 mmHg, so it is not contraindicated on these readings, but I would check her history.
• Carboprost: 0.25 mg intramuscularly every 15 minutes up to a maximum of 8 doses. It is contraindicated in asthma and should be used with caution in cardiac disease. It can cause diarrhoea, vomiting, and fever.
• Misoprostol: 800 micrograms sublingually as a single dose if other drugs are unavailable or insufficient. It can cause shivering and fever.

Reasoning I would give drugs in a logical sequence while continuing fundal massage and preparing for transfer. I would not give ergometrine and carboprost at the same time without checking the history and local guideline. I would record the time, dose, route, and response to each drug. If the uterus remains soft despite these measures, the cause may be retained placental fragments, genital tract trauma, or coagulopathy, and transfer is urgent.

Transfer decision I would transfer as soon as the ambulance arrives. The bleeding is ongoing, Jo is symptomatic, and the birth centre has no blood products. I would not wait for the uterus to become firm if she remains tachycardic and dizzy.

During transfer

• Continue fundal massage and bimanual compression if needed.
• Maintain IV access and continue oxytocin infusion according to protocol.
• Monitor blood pressure, pulse, respiratory rate, and conscious level every 5–10 minutes.
• Keep Jo warm and give oxygen only if hypoxic.
• Bring the baby if a second midwife can safely care for the baby, or arrange for the partner to follow with the baby; do not separate mother and baby unnecessarily.
• Give a structured handover to the receiving team: time of birth, estimated loss, drugs given, uterine tone, observations, and IV access.

Afterwards I would document the haemorrhage, the timeline, the drugs and doses, the observations, the transfer, and the handover. I would debrief Jo and her partner, explain what happened, and arrange follow-up for iron levels, feeding support, and emotional wellbeing. I would also complete an incident review according to local policy.