Postpartum Haemorrhage in a Woman With Chronic Hypertension and Asthma
A 29-year-old woman, G2P1, delivered 40 minutes ago by vacuum-assisted vaginal delivery at 39+2 weeks after induction for prelabour rupture of membranes. The baby weighs 3.7 kg; the second stage lasted 1 hour 50 minutes and a mediolateral episiotomy was cut. She has chronic hypertension treated with nifedipine 30 mg daily, with clinic readings of 140-150/90-95 mmHg, and well-controlled asthma managed with budesonide-formoterol. Estimated blood loss is now 900 mL and the uterus feels soft at the level of the umbilicus with a slow trickle of blood. Pulse 118/min, blood pressure 96/62 mmHg, respiratory rate 24/min, SpO2 98%, capillary refill three seconds; she is anxious and asking for water. Oxytocin 10 IU intramuscularly was given at delivery and an infusion of 10 IU in 500 mL is running. The unit stocks methylergometrine, carboprost, misoprostol and tranexamic acid; the blood bank is 20 minutes away.
1. Rank the available uterotonics for this patient and justify the choice and the exclusions.
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The problem is atony with two drug-specific contraindications sitting in the cupboard.
- Methylergometrine is the classical second-line agent, but it is contraindicated in hypertension and hypertensive disease of pregnancy because it causes generalised vasoconstriction and a measurable rise in blood pressure; she is already hypertensive on treatment. It also provokes bronchospasm and is best avoided in asthma. Do not give it here.
- Carboprost (prostaglandin F2-alpha) is effective in refractory atony but causes bronchospasm and is contraindicated in asthma, and can also raise blood pressure. In a woman with well-controlled but real asthma, it is not the next step; it becomes a last resort only in life-threatening haemorrhage after anaesthetic and obstetric consultant involvement, with bronchodilator cover and a plan for ventilation.
- Misoprostol 800 micrograms sublingually (or per rectum if bleeding is heavy or she is vomiting) has no bronchospastic or hypertensive contraindication; expect fever and shivering, treat the fever symptomatically and do not mistake it for sepsis.
- Oxytocin remains first line and should be continued and, if prescribed, given as a slow diluted intravenous dose rather than a rapid undiluted bolus, which causes hypotension.
- Tranexamic acid 1 g intravenously over 10 minutes should be given now; the benefit falls sharply after three hours from birth.
Simultaneously, not sequentially: bimanual uterine massage, emptying the bladder with a catheter, and securing two large-bore cannulas with bloods for full count, coagulation and crossmatch. Mechanical measures - intrauterine balloon, packing, compression sutures, theatre - are decided by the obstetrician, but the nurse's job is to have them requested early rather than after the next 500 mL is lost.
2. Estimated loss is "only" 900 mL and the blood pressure is 96/62 mmHg. How do you interpret the haemodynamics, and why should you not wait for a further fall?
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Calculate rather than estimate. The shock index is pulse divided by systolic pressure: 118/96 = 1.23. In obstetric practice a value above 0.9-1.0 is abnormal and above 1.1 signals significant concealed or ongoing loss. Capillary refill of three seconds, anxiety, thirst, tachycardia and a rising respiratory rate complete a picture of class II haemorrhage despite a visually reassuring loss.
Why the estimate is wrong. Visual estimation of blood loss underestimates by 30-50%. Add blood on the drapes, in the suction canister, under the buttocks and in the episiotomy field; weigh swabs where possible. A woman with a soft uterus at the umbilicus and continuous trickling is still bleeding as you examine her.
Why the blood pressure misleads. She has chronic hypertension with booking and antenatal readings of 140-150 systolic. For her, 96 mmHg is a fall of 50 mmHg and represents substantial decompensation, not a normal postpartum reading. Young, previously healthy women maintain systolic pressure through intense vasoconstriction until roughly 30% of blood volume is lost, then decompensate abruptly. Waiting for a systolic below 90 mmHg means waiting for collapse.
Therefore: treat this as major obstetric haemorrhage now - activate the protocol, move to a high-dependency bed, crossmatch blood, give tranexamic acid and misoprostol, and expect that the measured loss will exceed 1,500 mL by the time the uterus is contracted. Reassess after each intervention with pulse, blood pressure, capillary refill, urine output and a repeat shock index, and record the trend rather than single values. A falling shock index after treatment is your evidence that the resuscitation is working.
3. Write the prioritized 15-minute action plan, including what you would delegate and what you would record.
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0-2 minutes - call and assess. Pull the emergency bell, state "postpartum haemorrhage, estimated 900 mL and ongoing", note the time. Call the obstetrician and the anaesthetist; ask the ward clerk to call the blood bank. Assess uterine tone, check for retained placenta and genital tract trauma, and start bimanual uterine massage while the obstetrician is coming.
2-5 minutes - access and specimens. Delegate to nurse A: two 16G cannulas, draw full blood count, coagulation, fibrinogen, urea and electrolytes, crossmatch four units and send a clot sample. Delegate to nurse B: catheterise to empty the bladder (a full bladder prevents contraction) and start an hourly urine output chart; apply warm blankets; continuous monitoring.
5-10 minutes - drugs. Give tranexamic acid 1 g intravenously over 10 minutes; give misoprostol 800 micrograms sublingually; continue the oxytocin infusion. Explicitly state that methylergometrine and carboprost are contraindicated in this woman so that no one gives them in the excitement.
10-15 minutes - mechanical and definitive. Obstetrician reviews for intrauterine balloon tamponade, examination under anaesthesia, and theatre; anaesthetist assesses airway with asthma in mind and secures a plan for transfer. Start warmed crystalloid cautiously - 1 to 2 litres, not an open flood - while awaiting blood; if transfusion begins, aim for a balanced ratio rather than crystalloid loading.
Record: time of recognition, estimated and measured loss, uterine tone at each assessment, every drug with dose and route, who was called and when, haemodynamic observations every 5-15 minutes, urine output, and the family's being informed. Assign one nurse to be the scribe; in postpartum haemorrhage the notes are made in real time and the times are the evidence.