Postpartum haemorrhage at a Community Health Centre
A 26-year-old G2P1 delivers a 3.6 kg boy at a Community Health Centre at 02:10 after a six-hour labour. She received 10 IU oxytocin intramuscularly within one minute of birth and controlled cord traction was used. The placenta is complete at 02:18. At 02:50 the staff nurse calls you: pads and the under-sheet are soaked, estimated blood loss 800 mL; the uterus feels soft and is 2 cm above the umbilicus and deviated to the right; the bladder is palpable and she has not passed urine since delivery; pulse 118/min, BP 96/62 mmHg, SpO2 97%, she is anxious and pale. The CHC has no blood bank, no balloon tamponade device and no operating theatre. The district hospital is 45 minutes away by ambulance with a doctor and a nurse available. Oxytocin, methylergometrine and misoprostol are in the cupboard. The woman has no hypertension and no asthma. A second nurse is on duty and one ambulance is on call.
1. Give your actions in correct sequence for the first 10 minutes and justify the order.
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- Call for help and assign roles - second nurse to bring the emergency tray and drugs, someone to record time and vital signs. PPH kills within hours; the sequence only works with a team.
- Empty the bladder with an indwelling catheter. A full bladder splints the uterus and prevents contraction; this is the fastest reversible cause here, along with atony.
- Uterine massage and bimanual compression, plus a second dose of oxytocin (10 IU IM or 5 IU slow IV), then an oxytocin infusion (e.g., 20–40 IU in 500 mL over 4 hours). Rub the fundus until it is firm, not just once.
- Two large-bore IV lines, draw blood for haemoglobin, cross-match, coagulation, and start warmed crystalloid - but do not flood with litres of crystalloid; the aim is to restore perfusion and get blood, not to dilute clotting factors.
- Second-line uterotonics: methylergometrine 0.2 mg IM (safe here - no hypertension, no asthma) or misoprostol 800 micrograms sublingually; tranexamic acid 1 g IV if stocked and within 3 hours of birth.
- Quantify and monitor - weigh or count pads, record vitals every 15 minutes, keep her warm, and reassess the fundus.
Uterine massage and bladder emptying come before drugs because they are immediate and address the commonest reversible cause of atony; drugs take minutes to work.
2. The medical officer advises waiting two hours to see if bleeding settles before referral. Argue your position and list what must be complete before the ambulance leaves.
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Position: do not wait. She has already lost about 800 mL, roughly 15% of a 60 kg woman's blood volume, with tachycardia, pallor and a soft uterus. Her signs are of compensated shock that can decompensate abruptly at the next 300 mL. The CHC cannot provide blood, balloon tamponade or surgery, so time spent observing converts a transferable patient into an unstable one. The transfer decision is made alongside, not instead of, continued resuscitation: transfer while treatment is running, not after it fails.
Before departure
- Two IV lines secured; oxytocin infusion running; second uterotonic given; bladder emptied.
- Blood samples labelled and sent ahead; district hospital alerted by phone to arrange blood.
- Ambulance with oxygen, suction and a trained nurse accompanying; the doctor's pre-referral note with times, drugs, blood loss.
- Pads retained to show the receiving team; vitals recorded every 15 minutes en route; keep her warm; family informed and consent documented.
- Handover directly to the receiving doctor; document that the medical officer advised a delay and the reason you proceeded.
3. Two hours later at the district hospital the uterus is well contracted and bleeding is minimal, but she is oliguric and BP is 88/54 mmHg despite 2 litres of crystalloid. What does this suggest and what would you check?
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Uterine tone being restored does not mean the bleeding has stopped. Persistent hypotension and oliguria despite 2 litres of crystalloid suggest ongoing concealed or slow bleeding, or continuing hypovolaemia - consider a broad-ligament or vaginal haematoma, retained products, a cervical or perineal tear not visualised, or recurrent atony under the drape. Severe anaemia, sepsis and dilutional coagulopathy after crystalloid overload are alternatives.
Check and act
- Inspect the vulva, vagina and perineum and palpate the abdomen for a tender mass; measure fundal height and check the bladder again.
- Haemoglobin, platelet count, PT/INR, fibrinogen, lactate, blood group and cross-match; catheterise for strict hourly output.
- Ultrasound for retained products if available; re-examine under anaesthesia if a tear or haematoma is suspected.
- Transfuse rather than give more crystalloid; monitor for pulmonary oedema if fluids continue.
- Watch for late complications of massive haemorrhage: Sheehan syndrome and anaemia, and arrange iron and follow-up.