Postpartum haemorrhage after caesarean section with asthma
Fatima is a 36-year-old G3P2 who has just had an emergency caesarean section at 39 weeks for pathological fetal heart rate decelerations. After delivery, the uterus is boggy and blood loss is estimated at 1,500 mL. She is tachycardic at 122 bpm, blood pressure 92/58 mmHg, and pale. She has a history of asthma and is on regular salbutamol; she has no hypertension. Her haemoglobin is 76 g/L, platelets 138 × 10^9/L, fibrinogen 1.3 g/L, and INR 1.3. The anaesthetist is present, two units of packed red cells are available, and the theatre team is scrubbed. The uterus remains atonic despite an oxytocin infusion and 500 µg of intramuscular carboprost given by a colleague. Bleeding continues.
1. What is your immediate management, and which uterotonics are safe in her asthma?
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This is major postpartum haemorrhage after caesarean section, likely uterine atony, with shock and coagulopathy. Call for help and activate the massive haemorrhage protocol. Resuscitate with two large-bore cannulae, warmed crystalloid and blood products; give tranexamic acid 1 g IV within 3 hours of birth. Perform bimanual uterine massage and empty the bladder. Oxytocin infusion is safe. Misoprostol is a reasonable uterotonic in asthma. Carboprost should be avoided in asthma because it can cause bronchospasm; she has already received it, so assess for wheeze, hypoxia and bronchospasm and treat with oxygen and salbutamol, and inform the anaesthetist. Ergometrine is relatively contraindicated in asthma in many formularies and should be avoided if there is bronchospasm or hypertension. If uterotonics fail, move promptly to mechanical measures: intrauterine balloon tamponade, B-Lynch or uterine artery ligation, and hysterectomy if bleeding is uncontrolled. Inspect the uterus and broad ligaments at caesarean section for trauma or retained products.
2. How would you manage the coagulopathy and decide on surgical intervention?
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Her fibrinogen is 1.3 g/L, which is low for pregnancy and predicts worsening haemorrhage. Send full blood count, coagulation screen, fibrinogen and cross-match, and use point-of-care coagulation testing if available. Give fibrinogen concentrate or cryoprecipitate to keep fibrinogen above 2 g/L, fresh frozen plasma if INR is prolonged, and platelets if count falls below 50 × 10^9/L or there is ongoing bleeding. Transfuse red cells to maintain perfusion, not just a target haemoglobin. Correct hypothermia, acidosis and calcium. Surgical intervention should not be delayed while waiting for blood: if the uterus remains atonic despite oxytocin, misoprostol and tranexamic acid, proceed to balloon tamponade or laparotomy. Hysterectomy is life-saving if bleeding persists. Involve a second senior obstetrician and anaesthetist, and consider interventional radiology only if the patient is stable and it is available.
3. What system factors would you address after the event?
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After stabilisation, conduct a structured debrief with the team and document the timeline, estimated blood loss, drugs given and responses. Report the case through the incident reporting system because carboprost was given despite asthma, and review whether the contraindication was checked. Audit PPH management, including tranexamic acid timing, uterotonic availability, blood product activation and documentation. Provide simulation training for postpartum haemorrhage and asthma contraindications. Ensure the patient receives thromboprophylaxis when bleeding is controlled, iron supplementation and follow-up for anaemia, and counselling about future pregnancy. If a hysterectomy was performed, arrange psychological support and gynaecological follow-up. Review the neonatal outcome and communicate with the family. These steps improve individual care and system safety.