Postpartum Haemorrhage in a PHC Without Blood Bank

I would call for help and the doctor, note the time, and stay with her. First, I would rub up the uterus and express clots: a boggy uterus indicates atony, and massage stimulates contraction to compress the placental site. Second, I would catheterise the bladder, because a full bladder prevents the uterus from contracting. Third, I would give oxytocin 10 IU intramuscularly, or 5 IU slowly intravenously, as the first-line uterotonic; I would not give an undiluted rapid IV bolus because of hypotension. Fourth, I would secure a second large-bore IV line and infuse crystalloid, and take blood for grouping and crossmatch. Fifth, I would give tranexamic acid 1 g IV over 10 minutes within three hours of birth, because it reduces fibrinolysis and bleeding. I would monitor blood pressure, pulse, respiration, and oxygen saturation every 15 minutes, weigh pads to estimate loss, keep her warm, and prepare for transfer. Methylergometrine would not be my first drug; it is contraindicated in hypertension, and oxytocin is first-line.

I would resuscitate and arrange transfer immediately rather than wait 30 minutes for full stabilisation. Estimated loss of 700 mL, pulse 116/min, blood pressure 92/60 mmHg, and antenatal haemoglobin 9.2 g/dL mean she is already at risk of decompensation, and the ambulance response alone is about 20 minutes. The PHC has no blood bank, so definitive management may require blood. Before transfer I would secure two IV lines, give tranexamic acid and oxytocin, catheterise, monitor vital signs, keep her warm, apply a non-pneumatic anti-shock garment if available and staff are trained, and write a referral note with time of delivery, drugs given, estimated blood loss, and blood group. During transfer a nurse or midwife should accompany her with oxygen, pads, and resuscitation equipment, checking vital signs every 15 minutes. I would telephone the First Referral Unit to announce the referral. Delay would increase the risk of shock and coagulopathy.

I would acknowledge his fear without agreeing: 'I understand you are worried because there is no blood here. She is bleeding because her uterus is not contracting. Without treatment she can go into shock. We have medicines to stop the bleeding and we are arranging an ambulance to the First Referral Unit, where blood is available.' I would not criticise the PHC. Because Mrs. R. is conscious, I would also ask her own wishes; a competent adult's decision should be respected, but her husband is not automatically the sole decision-maker. If he continues to refuse, I would escalate to the doctor and medical officer, involve a respected family member or ASHA, and continue care while discussing. I would not physically detain her. I would document the time, people present, advice given in plain words, risks explained, her own statement if any, his response, and any signature. This protects the patient and shows that information was given without coercion.