Postpartum Haemorrhage with Retained Placenta at a Rural Health Centre

First 15 minutes: call for help and activate the emergency transfer pathway while assessing airway, breathing and circulation. The uterus is soft and boggy, so uterine atony is the most likely cause of continuing bleeding; perform fundal massage and empty the bladder (catheterise if possible). Establish a second large-bore IV line if only one is present, take blood for cross-match if available, and give a crystalloid bolus of 500–1000 mL while monitoring BP and pulse. Start an oxytocin infusion per protocol (the 10 IU IM has already been given), and give misoprostol if ordered and available for ongoing atony. Check whether the placenta has separated; do not apply strong cord traction unless trained and there are signs of separation. Keep her warm, monitor vital signs every 15 minutes, and observe for shock. Keep the baby warm and supported; skin-to-skin or breastfeeding can continue if the mother is stable and willing. The priorities are stopping the bleeding, restoring circulating volume, and getting her to definitive care without delay.

The decision depends on whether the placenta is retained and whether the nurse is trained and authorised to perform manual removal. In a health centre without a doctor, the safest approach for a retained placenta with active bleeding is usually to stabilise, give uterotonics, perform bimanual uterine compression if atony is life-threatening, and transfer urgently to a facility where manual removal and blood products are available. Manual removal on site should only be attempted if the nurse has current competency, the procedure is within scope and facility protocol, and transfer would be delayed enough to risk death. Because the ambulance is 45 minutes away and the hospital is 90 minutes by road, the nurse should call early rather than wait for signs of severe shock. The decision should be made with the medical officer by phone if possible, documented, and explained to the woman and her husband. If the placenta delivers during transfer, continue oxytocin and monitor for further bleeding.

Document: time of delivery, time placenta not delivered, estimated blood loss and how it was measured, fundal tone, vital signs and trend, IV access, fluids and drugs with doses and times, catheterisation and urine output, baby’s condition, time the ambulance was called, persons notified, consent for transfer, and the woman’s condition at handover. The referral letter should state G4P3, 39 weeks, live birth, retained placenta, PPH with atony, estimated 700 mL plus ongoing loss, BP 90/60, pulse 118, oxytocin and misoprostol given, no blood products available, and the specific request: manual removal and blood products. Handover should use a structured format such as SBAR and include allergies, weight, and any known comorbidities. The receiving facility should be phoned before departure to confirm acceptance and blood availability. Document the husband’s involvement and any cultural concerns. Clear documentation protects continuity of care and provides the evidence base for review if the outcome is poor.