Primary postpartum haemorrhage ninety minutes from blood
A 24-year-old woman, para 3, delivered a live 3.4 kg baby 45 minutes ago at a health centre. The placenta was complete. She is now bleeding heavily: about 600 mL in the kidney dish plus two soaked maternity pads, and the uterus feels soft and boggy above the umbilicus. Pulse 114, BP 100/62, respirations 24, she is restless and says she feels "cold and thirsty". There is no blood bank, no theatre, and one unit of oxytocin in the fridge. The district hospital is 90 minutes away by road; the ambulance is there but the driver must be called from home. The midwife on duty is supported by one health assistant. The woman's mother is asking that she be given "a strong injection and left to rest".
1. Give your immediate clinical reasoning: what is happening, how severe is it, and what is the single biggest risk in how this case is handled in the next ten minutes?
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Diagnosis: primary postpartum haemorrhage from uterine atony, with compensated shock already present.
Reasoning:
- Blood loss of roughly 600 mL in the dish plus two soaked pads exceeds 500 mL after vaginal birth - PPH by definition - and visual estimation underestimates true loss by a wide margin, so assume more.
- Pulse 114 with a soft uterus and a rising fundus is the picture of atony. Restlessness, thirst and feeling cold are early warning signs of hypovolaemia; BP 100/62 is not reassuring, because a fit young woman maintains her systolic pressure until she has lost a great deal. Treat the pulse and the restlessness, not the blood pressure.
- She has three risk amplifiers: grand multiparity (para 3 but young), a large baby, and a distended bladder is possible.
The biggest risk is delayed referral while 'observing'. A health centre cannot replace what she is losing. The decision to transfer must be made within minutes, in parallel with treatment - not after the bleeding 'settles' or after the family is persuaded. The second biggest risk is that the mother's request is allowed to delay active management.
2. Write the treatment bundle you would deliver while the ambulance is being called, in order, stating doses and what is available versus not available.
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Simultaneous, not sequential:
- Call for help: send the health assistant to phone the ambulance and the district hospital to warn them; assign one person to keep calling until the driver confirms.
- Rub up the fundus and perform bimanual uterine massage/compression - this is immediate, free, and does not wait for anyone.
- Empty the bladder (catheterise).
- Oxytocin 10 IU IM (or 5 IU slow IV if a line is running) - use the unit you have; do not save it 'in case'.
- Tranexamic acid 1 g IV over 10 minutes if available and within 3 hours of birth - this is the intervention most often forgotten and it reduces death from bleeding.
- Intramuscular or sublingual misoprostol 800 micrograms if oxytocin is exhausted and referral is delayed; anticipate shivering and fever and do not mistake them for sepsis.
- Two large-bore IV lines (14–16 G), warm crystalloid, keep her flat and warm, cover with a blanket, monitor pulse, BP, respirations and lochia every 15 minutes.
- Do not give ergometrine if she is hypertensive or pre-eclamptic - check her record first.
- Non-pneumatic anti-shock garment if the facility has one - it buys time during transport.
- Escort her and hand over in writing: time of birth, estimated loss, drugs and doses given, vital signs trend, blood group if known.
3. The mother insists the woman should not be moved and says the family will 'take her home to rest'. How do you handle this, and what if she deteriorates and becomes unconscious before the ambulance arrives?
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Handle the objection as a communication problem with a clinical deadline attached.
- Speak to the mother directly and concretely: "She is bleeding inside. If she stays here she may die, and there is nothing here that can replace her blood. The hospital can. We are not sending her away - I am going with her."
- Do not debate tradition or religion; do not be drawn into an argument. Use the person the family trusts (often the oldest woman, sometimes a respected staff member) and keep treating while talking.
- Consent cannot be manufactured from a relative when the patient is an adult and has capacity - but a bleeding, restless woman who is drifting will soon lose capacity, and at that point the duty to preserve life governs. Involve the medical officer or district director by phone if there is any question, and document the discussion including the family's refusal if they maintain it.
- Never hand over a haemorrhaging woman to relatives to 'rest at home'. If the family physically obstructs transfer, that is an emergency in itself - call the police and the district health directorate.
If she becomes unconscious before transport:
- Airway first: recovery position or lateral tilt (she is postpartum), suction if available, oxygen, monitor breathing.
- Keep bimanual compression going, keep the lines running, keep her warm - hypothermia worsens coagulopathy.
- Assume she is in profound shock: treat the ambulance as a resuscitation vehicle and continue the bundle en route rather than waiting for improvement at the health centre.
- Record the time of every intervention; the receiving team needs the timeline to decide on hysterectomy or transfusion.