Postpartum haemorrhage at a district hospital without a blood bank

Resuscitate and stop the uterus bleeding at the same time - not one after the other.

1. Call for help, allocate roles, note the time, start a documented PPH bundle. Second 14–16G cannula; send full blood count, coagulation, fibrinogen, crossmatch, biochemistry. Catheterise to empty the bladder. Keep her warm - hypothermia worsens coagulopathy.
2. Mechanical control first: bimanual uterine compression, not just fundal massage. It holds the bleeding while drugs act and is the single most useful bedside manoeuvre.
3. Oxytocin 5 IU slowly IV, then 40 IU in 500 mL over 4 hours. A bolus alone has a short half-life and receptors desensitise, so an infusion sustains tone.
4. Ergometrine 0.25 mg IM - safe here because she is not hypertensive; expect nausea and vomiting.
5. Carboprost 250 micrograms IM every 15 minutes, maximum 8 doses (avoid in asthma), and/or misoprostol 800 micrograms sublingual.
6. Tranexamic acid 1 g IV over 10 minutes, repeated once after 30 minutes; benefit is greatest within 3 hours and it does not substitute for uterotonics.
7. Transfuse the two O-negative units now, not at the point of collapse, and run crystalloid cautiously to avoid dilutional coagulopathy. Her starting haemoglobin of 10.2 g/dL leaves very little reserve.

Examiners reward parallel action: compression plus tranexamic acid plus drugs, not a sequential checklist.

This is refractory atonic haemorrhage with incipient shock: operate here, do not transfer.

A 90-minute ambulance journey with no blood bank, no anaesthetist and no balloon means uncontrolled bleeding for an hour and a half; she will likely arrest en route. Theatre, a general surgeon and a functioning autotransfusion-free but staffed operating list are on site, and the anaesthetist can be called in parallel. Call the tertiary centre for advice and to arrange retrieval after bleeding is controlled.

In theatre:

• Do not delay for the anaesthetist if the airway is at risk - the general surgeon can intubate and you can start.
• Open, pack, deliver the uterus, inspect for trauma and evacuate retained products.
• Atonic uterus with bleeding from the placental site: B-Lynch brace suture or vertical compression sutures.
• If bleeding persists, stepwise devascularisation: bilateral uterine artery ligation (O'Leary) watching the ureter, then utero-ovarian ligation.
• Subtotal hysterectomy if the lower segment and cervix are not bleeding, otherwise total hysterectomy. Decide early; do not wait until she is coagulopathic.
• Improvised tamponade while you operate: a condom tied over a Foley catheter, inflated with 300–500 mL saline, is a legitimate balloon substitute.
• Record the sequence and times; give prophylactic antibiotics.

Treat this as the coagulopathy of massive haemorrhage, not as a laboratory puzzle.

• Tranexamic acid 1 g IV if not already given.
• Activate the massive haemorrhage protocol, request emergency release from the regional blood service, and ask the tertiary unit to send products by the fastest route.
• Give fresh frozen plasma alongside red cells (aim for a ratio close to 1:1 rather than crystalloid), platelets if the count is under 50, and - most important for obstetric bleeding - cryoprecipitate 2 pools or fibrinogen concentrate 3–4 g to keep fibrinogen above 2 g/L.
• 10% calcium gluconate 10 mL for every 4 units of blood to counter citrate-induced hypocalcaemia, which worsens clotting and myocardial contractility.
• Keep her warm, avoid fluid overload, accept permissive hypotension until the source is controlled.
• Control the source: if the uterus is still atonic, a condom balloon plus compression buys time, but continuing conservative measures in a coagulopathic bleeding woman is how deaths occur - proceed to laparotomy/hysterectomy.
• Give broad-spectrum antibiotics; once packed or with a balloon in place and products running, transfer to the tertiary ICU.

Document consent, times and product ratios; the case will be reviewed against the local PPH protocol.