Ongoing Bleeding After a Macrosomic Birth in a Woman With Asthma

Quantification. 900 mL in the calibrated drape at 15 minutes is already a major obstetric haemorrhage by any modern definition (≥1,000 mL, or any loss with haemodynamic compromise), and the drape is still filling. Visual estimation systematically underestimates by 30–50%, so treat the measured figure as a floor, not a ceiling. Weigh swabs and add them. Expect the true cumulative loss to exceed 1,200 mL.

Vital signs. The shock index (HR ÷ systolic BP) is 122 ÷ 104 = 1.17. A value above 0.9–1.0 in a postpartum woman signals significant hypovolaemia even when the blood pressure looks reassuring, because healthy young women compensate by vasoconstriction and tachycardia until 1,500 mL is lost. A normal BP here is a warning, not reassurance. Note also the pale, woozy presentation and falling pulse pressure (42 mmHg).

Working diagnosis. Uterine atony, with the bladder contributing: the fundus is boggy, high, and deviated to the right - a classic sign of a distended bladder preventing contraction.

Differential, worked through systematically (the four T's):

• Tone - atony, the leading cause; macrosomia and oxytocin-augmented labour are risk factors.
• Trauma - re-examine the vulva, vagina, and perineum for haematoma or an unrecognised high laceration; the repaired second-degree tear may be concealing a bleeding vessel.
• Tissue - the placenta looked complete, but a succenturiate lobe or retained fragments remain possible; inspect the membranes and consider ultrasound or manual exploration.
• Thrombin - send fibrinogen, PT/INR, APTT, and full blood count from a fresh sample if bleeding continues.

Uterotonics, in sequence:

1. Oxytocin infusion - continue and, if bleeding persists, increase the rate under protocol; do not give a further rapid IV bolus (hypotension, dilutional hyponatraemia).
2. Ergometrine/methylergonovine 0.2 mg IM - safe here: her BP is 104/62, with no hypertension or pre-eclampsia. Contraindications are hypertension and pre-eclampsia, not asthma.
3. Misoprostol 800 micrograms sublingual or buccal - watch for pyrexia and shivering, and treat symptomatically.
4. Carboprost is contraindicated - she has asthma; the bronchospasm risk is real. State this explicitly on the drug chart so no one gives it in an emergency.

Also simultaneous mechanical measures: empty the bladder with an indwelling catheter, perform bimanual uterine massage/compression, and inspect for bleeding trauma.

Tranexamic acid 1 g IV over 10 minutes, given as soon as haemorrhage is recognised - the survival benefit is greatest within 3 hours of birth, and earlier is better. A second 1 g dose can be given if bleeding continues after 30 minutes or restarts within 24 hours.

Fluids and blood. Insert two 14–16 G cannulae and take a full blood count, coagulation profile, fibrinogen, and crossmatch. Give warm crystalloid cautiously rather than pouring in litres - large volumes dilute clotting factors and worsen coagulopathy. Transfuse with ongoing bleeding and haemodynamic instability; request packed cells, fresh frozen plasma, and platelets via the major haemorrhage protocol if bleeding exceeds 1,500 mL. Cell salvage is available - use it.

Supportive. Keep her warm, monitor urine output hourly, and position her flat with legs raised if she feels faint.

Escalation to operative care. Uterotonics plus massage plus tranexamic acid have failed, so move to mechanical and then surgical control without further delay.

Mechanical first. Bimanual compression maintained continuously while transferring to theatre; insert an intrauterine balloon tamponade device and inflate; re-examine under anaesthesia for a missed tear or haematoma and perform manual exploration or curettage if a retained fragment is suspected.

Surgical. Laparotomy with stepwise devascularisation: uterine artery ligation, then B-Lynch or compression sutures, then internal iliac ligation or hysterectomy if bleeding persists. She has had two previous births and wishes should be checked, but life-saving hysterectomy must not be delayed for a family-planning discussion.

Transfer. There is no on-site interventional radiology. If she is stabilised with a balloon and blood products, consider transfer to a facility with uterine artery embolisation - but only after haemorrhage is controlled or she is stable enough to travel. Transfer with uncontrolled bleeding is far more dangerous than definitive surgery in-house; make that comparison explicit in your decision.

Documentation. A running, time-stamped record of measured loss, vital signs, the shock index, every drug with dose and route (including the explicit carboprost contraindication), catheters and balloon volumes, blood products, personnel present, and the escalation times. Record the woman's and family's understanding at each stage. Then hand over with a written summary, request placental histology, and organise a structured debrief with the team - haemorrhage protocols get better only when the near-misses are reviewed.