Five Hundred Millilitres and Forty Minutes to the Ambulance
A 26-year-old woman, para 2, delivered a 3.1 kg boy at home in a village 12 km from the nearest community health centre at 9:40 p.m. after a four-hour labour conducted by a trained birth attendant. The placenta was delivered complete ten minutes later. At 10:05 p.m. the attendant calls the ASHA because the woman is bleeding: the pads, the floor mat and a cloth are soaked, and the estimated loss is already about 500 mL. The uterus feels soft and boggy above the umbilicus. The woman is pale and restless, pulse 118/min, blood pressure 96/60 mmHg, and she says she feels dizzy. The ASHA has a misoprostol kit, gloves, IV fluid and a phone, but the ambulance will take 40 minutes to reach the village.
1. It is 10:10 p.m. What should the ASHA do in the next 30 minutes, in order, and with what doses?
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Recognise and act. An estimated loss of about 500 mL with a boggy uterus, pulse 118 and systolic 96 means atonic postpartum haemorrhage with compensated shock, which can worsen quickly in a dark village room.
- Call for help: a second ASHA, the ANM, and confirm the ambulance is coming. Do not stay alone with her.
- Uterine massage: place a hand on the fundus through the abdomen and massage firmly and continuously until it contracts, and expel clots. This is the single most effective first action.
- Put the baby to the breast if the baby is with her, because suckling releases endogenous oxytocin.
- Empty the bladder: encourage her to pass urine, or catheterise if trained and equipped. A full bladder prevents contraction.
- Misoprostol 800 micrograms sublingually as the treatment dose; 600 micrograms orally is the prevention dose, not this one. Check expiry, place the tablets under the tongue and record the time. Do not repeat the dose routinely.
- Start IV normal saline through a wide-bore cannula if trained and authorised, raise the legs, cover her with a blanket, and monitor pulse, blood pressure, urine output and bleeding every 15 minutes.
- Estimate blood loss and keep the soaked pads for handover; roughly 1 g of soaked pad is 1 mL.
- Bimanual compression only if trained, and prepare for transfer as soon as the ambulance arrives.
2. Fifteen minutes later the bleeding has slowed and the uterus feels firm. Should the ambulance be cancelled? Justify your answer and state what else must be done.
Read the worked answer
No. Do not cancel. It is tempting because the room looks calmer and she says she feels better, but the decision must rest on the whole picture, not on the last pad.
- She has already lost around 500 mL or more and remains tachycardic at 118 with a systolic of 96. Those numbers do not normalise because the bleeding slowed, and compensated shock can look like recovery and then collapse when she is moved.
- The uterus can relax again. Atony is not cured by one massage, and the misoprostol effect cannot be topped up indefinitely.
- The cause has not been established. Retained placental fragments, a tear in the birth canal and an inverted uterus all need a facility, and the attendants impression that the placenta was complete is not a finding.
- She needs ongoing IV access, blood grouping and cross-match, haemoglobin, and observation for at least 24 hours. Tranexamic acid, if indicated, belongs to the facility protocol and must be given early.
Continue massage as required, keep the IV running, monitor every 15 minutes, keep her warm and travel with her. Record times, drugs, estimated loss and vital signs, and hand over the pads. If the ambulance is delayed, escalate again to the ANM and the emergency service.