Primary postpartum haemorrhage with pregnancy-induced hypertension: a protocol order that must not be followed

The order matters because uterine atony kills by ongoing loss while you are still setting up the next step, and because each minute of delay worsens coagulopathy.

1. Call for help and note the time. Announce estimated blood loss; ask one person to record it. Never manage PPH alone.
2. Assess and stimulate the uterus. Rub up a contraction and perform bimanual uterine compression; this is the fastest mechanical stop while drugs are drawn up. Empty the bladder with a catheter, since a full bladder prevents contraction.
3. Look for other sources - even with an intact perineum, inspect the vagina and cervix for tears and check whether the placenta is complete; retained tissue keeps the uterus atonic.
4. Oxytocin infusion (for example 40 IU in 500 mL over 4 hours) while the bolus of Ringer's lactate runs; large-bore access is already present.
5. Tranexamic acid 1 g IV over 10 minutes, given within 3 hours of birth.
6. Resuscitate: oxygen, keep her warm, second line wide open, blood samples for haemoglobin, coagulation and crossmatch of at least 2 units, vital signs every 15 minutes, and quantified loss using weighed swabs and graduated drapes rather than eyeballing.

I would not give it, and I would say so out loud. Methylergometrine is an ergot alkaloid with alpha-adrenergic vasoconstrictor action; it raises blood pressure and can precipitate a hypertensive crisis, seizure or stroke. It is contraindicated in pregnancy-induced hypertension and in any hypertensive disorder of pregnancy. This woman's record documents PIH with a peak of 158/100 mmHg, so the printed protocol - which is written for the default patient - is overridden by the patient in front of you. Protocols do not replace assessment.

Actions: withhold the drug, inform the obstetrician immediately and ask for an alternative in writing, and record the omission with the reason and the time.

Alternatives and their own contraindications:

• Continue the oxytocin infusion, which is already running.
• Carboprost (15-methyl prostaglandin F2alpha) 250 micrograms intramuscularly, repeatable every 15 minutes to a maximum of 8 doses - contraindicated in asthma, which she does not have, so it is available here.
• Misoprostol 800 micrograms sublingually if prostaglandin F2alpha is unavailable.
• Mechanical measures: bimanual compression, intrauterine balloon tamponade, and theatre if bleeding persists.

Monitoring: pulse, blood pressure, respiratory rate and oxygen saturation every 15 minutes for the first hour, then every 30 minutes; uterine tone and fundal height at each check; character and amount of lochia; urine output with a target of at least 30 mL/hour; temperature; and cumulative blood loss by weighing swabs and pads, not by memory. Blood pressure deserves special attention because she is hypertensive and has just been resuscitated.

Call back immediately for: renewed or continued heavy bleeding, a fundus that stays soft despite massage and oxytocin, systolic BP below 90 mmHg or a rising pulse, urine output below 30 mL/hour, oozing from puncture sites or a non-clotting sample (suggesting coagulopathy), restlessness or confusion, or any fall in oxygen saturation suggesting fluid overload.

Documentation: time of every drug and every measurement, the reason methylergometrine was withheld, who was informed and what was advised, estimated and quantified loss, and the balloon if inserted (time, volume, traction). Hand over using SBAR at shift change, and ensure a named nurse stays with her for the first hour - the commonest failure in PPH is a patient left alone because she 'looked stable'.