Primary postpartum haemorrhage after a home birth 22 km from the CHC
A 24-year-old woman, P2L1, delivered at home in a village 22 km from the community health centre 40 minutes ago. The placenta has been delivered complete. The ASHA reports that she has soaked four cloths and is still bleeding. On arrival the ANM records: pulse 122/min, blood pressure 86/54 mmHg, respirations 26/min, marked pallor, cold clammy skin, and the uterus is soft and feels at or above the level of the umbilicus. There is no obvious perineal tear on inspection. Ten units of oxytocin were given intramuscularly immediately after delivery of the placenta, and bleeding continues. She has not passed urine since delivery. Her weight is 55 kg. The nearest facility with blood transfusion and an operating theatre is the district hospital, a further 30 km beyond the CHC. The ambulance is not at the sub-centre.
1. Set out your immediate management in the order you would carry it out, explaining the reason for each step.
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This is primary postpartum haemorrhage with shock - the priority is to stop the bleeding while arranging transfer, not after it.
- Call for help and start transport arrangements at once. Phone the CHC medical officer and the 108 ambulance simultaneously; the ASHA or a family member must keep the vehicle moving toward the village while clinical care continues. Delay in transport is the commonest avoidable cause of death here.
- Position flat with legs raised, keep warm, cover with blankets, and give nothing by mouth.
- Two large-bore intravenous lines (16–18 G), draw blood for grouping and cross-match, haemoglobin and coagulation, then run Ringer's lactate or normal saline rapidly - 1 litre in the first 20–30 minutes while reassessing pulse, BP and lung bases.
- Uterine massage through the abdomen until the uterus is firm, and continue intermittently.
- Empty the bladder - a full bladder is pushing the uterus up and preventing contraction; catheterise and measure urine output.
- Uterotonics: repeat oxytocin (10 IU intramuscularly or an infusion of 20 IU in 500 mL over 4 hours) and add methylergometrine 0.2 mg intramuscularly, which is acceptable here because the blood pressure is low; if oxytocin is unavailable, misoprostol 800 micrograms sublingually.
- Tranexamic acid 1 g intravenously over 10 minutes, given within 3 hours of birth.
- Bimanual uterine compression if the uterus stays atonic after these measures.
- Transfer with an escort, with the intravenous line running, records of time of birth, drugs given and estimated blood loss handed over.
2. The uterus is soft and above the umbilicus while bleeding continues. How does this guide you in distinguishing the cause, and what else must you rule out before concluding it is pure atony?
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The soft, elevated fundus is the classic signature of uterine atony, and it has two immediate contributors in this case: a full bladder and under-dosed oxytocin. Atony accounts for about 70–80% of primary postpartum haemorrhage, so it is the correct first working diagnosis - but the nurse should still check the other three causes, because treatment fails if the real cause is missed.
Retained placenta or clots - the placenta is reported complete, but inspect it: the cotyledons should fit together and the membranes should form a complete sac. A uterus that contracts briefly and then relaxes with continued bleeding, or a fundus that is hard but bleeding persists, suggests retained fragments.
Genital tract injury - bleeding that continues despite a well-contracted uterus, or a steady bright red trickle, points to a cervical or vaginal laceration. This needs inspection under good light with a Sims speculum and is common after a precipitate home delivery.
Uterine inversion - the fundus is not palpable abdominally, and the woman is in shock out of proportion to the visible blood loss. Never massage or pull the cord; call for help and keep the uterus in place until the doctor arrives.
Coagulopathy - bleeding that does not clot, or oozing from puncture sites, suggests a clotting failure needing fresh frozen plasma and platelets at a facility with blood banking.
The shock index here is 122 divided by 86, that is about 1.4; a value above 1 signals significant occult loss and supports the decision to transfer without delay.
3. How will you estimate and document the blood loss, and what will you hand over to the receiving facility?
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Estimating loss Visual estimation is unreliable and typically underestimates loss by 30–50%. Use concrete measures:
- Weigh soaked cloths and pads: 1 g of additional weight equals roughly 1 mL of blood; a fully soaked cloth holds about 100–150 mL, so four soaked cloths is at least 400–600 mL before any hidden loss.
- Use a calibrated collection drape if available, and count every pad from the moment of birth.
- Record the running total with the time of each entry, not a single retrospective figure.
- Treat the clinical signs as the more reliable index: pulse 122, systolic 86, cold clammy skin and pallor already indicate at least 30% loss whatever the cloth count suggests.
Handover (situation, background, assessment, recommendation)
- Time of delivery, place, who conducted it, time of placental delivery.
- Estimated loss with the method used, and whether bleeding is continuing.
- Drugs and doses with times: oxytocin 10 IU, repeat oxytocin, methylergometrine, tranexamic acid.
- Vital signs trend, urine output, uterine tone at handover, intravenous fluids given.
- Relevant history: parity, previous caesarean or postpartum haemorrhage, haemoglobin if known, blood group if known.
- Clear request: cross-matched blood, theatre backup and obstetric review.
Postpartum monitoring should continue every 15 minutes until stable: pulse, blood pressure, uterine tone, lochia amount and bladder emptying, plus monitoring for late anaemia and puerperal sepsis.