Postpartum haemorrhage at a peripheral health centre: act or wait?
At 9:40 pm, a 24-year-old woman (G2P1) delivered a 3.1 kg baby at a peripheral health centre 48 km from the district hospital. The placenta was expelled intact 10 minutes later. At 10:20 pm the staff nurse finds the pad soaked, the uterus boggy at the level of the umbilicus and deviated to the right, and the bladder palpable. Pulse 118/min, BP 90/60 mmHg, respiratory rate 24/min, SpO2 97% on room air. Estimated blood loss is 700 mL. The centre has oxytocin, misoprostol, tranexamic acid, IV fluids, a partograph and one ambulance; there is no blood bank and no obstetrician. The road is single-lane and it is raining. The woman is alert but anxious; her mother-in-law asks to wait until morning. The baby is breastfeeding. Two other women are in early labour.
1. State your first four actions in order, and explain why this sequence is better than giving oxytocin first.
Read the worked answer
- Call for help and activate the referral pathway. Ask the medical officer or on-call doctor to attend, tell the ambulance to be ready, and inform the district hospital that a PPH is coming. Referral and resuscitation run in parallel, not after drugs.
- Empty the bladder and massage the uterus. A palpable, deviated bladder prevents the uterus from contracting. Catheterise if needed, express clots, and massage until the uterus firms. This is immediate, needs no drug, and tests whether atony is the cause.
- Give oxytocin 10 IU IM (or 5 IU slow IV if a doctor is present and IV access is secure). This is the first-line uterotonic for atony.
- Secure IV access, start crystalloid, and give tranexamic acid 1 g IV over 10 minutes. TXA reduces death from PPH when given within 3 hours of birth; it is not a substitute for uterine tone or blood.
Giving oxytocin into a woman with a full bladder and unexpressed clots does not fix the mechanical cause of atony. Massage and bladder emptying come first because they are diagnostic and immediately corrective; oxytocin and TXA follow because they take time to act. Monitoring (pulse, BP, urine output, blood loss) and preparing the ambulance continue throughout.
2. The family refuses referral until morning. How do you proceed, and what are the specific risks of an 8-hour delay?
Read the worked answer
Do not accept the refusal silently. Explain in simple terms that the bleeding is continuing and that the centre has no blood bank or obstetrician. Involve the medical officer and the ASHA, and document the conversation with time, names and a witness. Continue resuscitation and uterine massage, monitor vital signs every 15 minutes, and keep the ambulance ready. If the woman is deteriorating, treat it as an emergency transfer under the duty to save life and escalate to the block medical officer. If she remains stable but refuses, record an informed refusal and the advice given.
The risks of waiting 8 hours are concrete: continued bleeding can cause hypovolaemic shock, acute kidney injury, disseminated intravascular coagulation and Sheehan syndrome from pituitary ischaemia; the baby may be separated and breastfeeding interrupted; and death can occur within hours. A woman who is alert now at BP 90/60 can decompensate quickly. The decision is not a matter of convenience but of time-critical access to blood and surgery.
3. What must you record and hand over to the receiving facility?
Read the worked answer
Record the time of delivery, time of placental expulsion, estimated blood loss and how it was measured, uterine tone and position, bladder status, and every drug with dose, route and time (oxytocin, TXA, any misoprostol). Note serial pulse, BP, respiratory rate, SpO2 and urine output; IV fluid type and volume; response to massage and drugs. Document the catheterisation, the referral decision, the family refusal and escalation, the ambulance call time, and the receiving facility contacted. Include the baby's condition and feeding status. Hand over a signed, timed summary and the partograph. A clear handover prevents the receiving team from repeating or missing TXA and tells them whether the uterus responded.