Postpartum haemorrhage in a woman with asthma

1. Call for help and quantify the loss - pull the emergency bell, call the obstetrician and the anaesthetist, and start weighing or collecting blood in a calibrated drape. Visual estimation underestimates loss by up to 50%, and the plan depends on the true volume.
2. Empty the bladder and massage the uterus - a full bladder prevents contraction. Catheterise, then perform firm bimanual or fundal massage. Uterine atony causes about 70–80% of primary postpartum haemorrhage, and massage is immediate, free and effective.
3. Escalate oxytocin and secure access - give a slow intravenous bolus of 5 IU oxytocin (over 1–2 minutes; rapid bolus causes hypotension), continue the infusion, and insert a second 16G cannula. Take blood for full blood count, coagulation, urea and electrolytes, fibrinogen and crossmatch 4 units.
4. Give tranexamic acid 1 g intravenously over 10 minutes - it reduces death from postpartum haemorrhage when given within 3 hours of birth, and the window is closing.
5. Contact the blood bank and keep her warm - request紧急 blood and activate the major haemorrhage protocol; warm fluids and blankets, monitor urine output and observe for shock. Coagulopathy, hypothermia and acidosis form the lethal triad and must be prevented early.

Choose misoprostol 800 micrograms sublingually (or 600 micrograms, per local protocol). It is a prostaglandin E1 analogue with good uterotonic effect, does not cause bronchoconstriction, and is absorbed rapidly from the sublingual route. Warn her that it commonly causes shivering and pyrexia, treat the fever if needed, and document the dose so it is not repeated too soon.

Avoid carboprost (15-methyl prostaglandin F2α) unless there is no alternative and the obstetrician accepts the risk. It is a potent uterotonic but it is a bronchoconstrictor; it is contraindicated or used with extreme caution in asthma because it can precipitate severe bronchospasm and hypoxia. In a woman already tachycardic and hypovolaemic, an acute asthma attack would be catastrophic.

Other options to consider

• Ergometrine is not the answer either if she is hypertensive or has cardiac disease - it causes vasoconstriction and nausea. Her blood pressure is currently normal, so it is a possible adjunct, but misoprostol is the safer first choice here.
• If bleeding continues despite drugs, the next steps are intrauterine balloon tamponade, bimanual compression, uterine artery embolisation or laparotomy. Do not persist with drugs alone while she deteriorates.

Non-drug measures

• Bimanual uterine compression while waiting for the obstetrician, and ensure the uterus is contracted before removing the hand.
• Inspect the genital tract for tears and check the placenta for completeness; retained tissue or a cervical tear will not respond to uterotonics.
• Empty the bladder fully and keep it on hourly measurement.
• Insert a second large-bore line, warm the patient, and start blood products early if loss exceeds 1,000 mL or she remains tachycardic after drugs.
• Prepare for intrauterine balloon tamponade; if that fails, escalation is to theatre for examination under anaesthesia, uterine artery ligation, B-Lynch suture, or hysterectomy.

Monitoring

• Pulse, blood pressure, respiratory rate and SpO2 every 15 minutes; watch for a rising pulse and narrowing pulse pressure before the blood pressure falls.
• Hourly urine output - an indwelling catheter is essential.
• Fundal height and tone, and the volume of ongoing loss.
• Serial haemoglobin, lactate, coagulation and fibrinogen; fibrinogen below 2 g/L predicts severe haemorrhage.
• Watch for signs of transfusion reaction and fluid overload, and document clearly. Keep the woman and her partner informed and obtain consent for procedures.