Primary postpartum haemorrhage with a mildly depressed newborn
Rania is 31, G3P2. She gave birth vaginally 40 minutes ago to a 3.9 kg boy after a 6-hour labour. Active management was used: 10 IU oxytocin intramuscularly within one minute of birth and controlled cord traction, with a complete placenta delivered at 12 minutes. Blood loss at birth was estimated at 250 mL. She is now bleeding continuously; the pad beneath her is soaked, the running estimate is 550 mL and rising. The uterus is soft, 2 cm above the umbilicus and displaced to the right. She has not passed urine since before the birth. Pulse is 114, blood pressure 98/60 mmHg, respirations 22, skin cool with capillary refill of 3 seconds; she is anxious but talking, and holding her baby. The newborn scored at one minute: heart rate 130, slow irregular respirations, some flexion of the limbs, grimace on suctioning, and a pink trunk with blue hands and feet. At five minutes: heart rate 140, crying vigorously, active movement, pink all over.
1. Classify the haemorrhage and set out your first-line actions in priority order, with doses and the reasoning behind each.
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Classification: primary postpartum haemorrhage, currently about 550 mL and ongoing after a vaginal birth, so it has crossed the 500 mL threshold. The cause is almost certainly uterine atony, and the uterus being displaced to the right with no voiding since before birth points to bladder distension as a contributing and easily reversible factor. Pulse 114 with a blood pressure of 98/60 and delayed capillary refill indicates compensated class 2 shock - she is still talking, which is falsely reassuring.
Actions in order:
- Call for help, note the time, and activate the unit's PPH protocol; assign one person to the mother and one to the baby.
- Rub up a contraction and perform bimanual compression if massage alone fails; empty the bladder with a catheter.
- Give a uterotonic: oxytocin 10 IU IM or 5 IU slowly IV, followed by an infusion (commonly 40 IU in 500 mL over 4 hours), plus tranexamic acid 1 g IV over 10 minutes within 3 hours of birth.
- Two large-bore IV cannulae, warm crystalloid, blood for full blood count, coagulation, renal function, group and crossmatch.
- Inspect the perineum, vagina and cervix for tears, and confirm the placenta and membranes are complete.
- Monitor pulse, blood pressure, urine output and fundal tone every 15 minutes; keep the baby skin-to-skin and encourage breastfeeding if the mother is stable, because suckling releases endogenous oxytocin.
- Escalate if bleeding continues: balloon tamponade, uterine artery procedures or laparotomy, plus blood products. Avoid ergometrine in hypertensive women and avoid NSAIDs where bleeding is ongoing.
2. The unit protocol orders 30 IU of oxytocin in 500 mL of 0.9% sodium chloride over 4 hours through a 20 drops/mL giving set. Calculate the rate in mL/hour and in drops per minute, and explain what you would do if the infusion had to be reduced because uterine tone became excessive.
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Step 1 - concentration: 30 IU in 500 mL means 30 ÷ 500 = 0.06 IU per mL.
Step 2 - hourly volume: the whole 500 mL is to run over 4 hours, so 500 ÷ 4 = 125 mL/hour. That delivers 125 × 0.06 = 7.5 IU/hour.
Step 3 - drops per minute: 125 mL/hour ÷ 60 = 2.08 mL/minute. With a 20 drops/mL set, 2.08 × 20 = 41.7, so approximately 42 drops/minute - but on a pump the rate is set as 125 mL/hour, and the drop count is only a cross-check.
If uterine tone becomes excessive: do not adjust the rate by guesswork or by counting drops on a free-flowing line. Reduce the rate on the pump according to the prescription or protocol, assess the contraction pattern and fetal heart if antenatal, check the woman's blood pressure and urine output, and document the change, the reason and who authorised it. If hyperstimulation occurs, stop the infusion entirely, turn her to the left lateral position, give oxygen and fluids, and inform the obstetrician. Oxytocin is a high-alert medication: it should be prescribed with a clear concentration and rate, prepared with an independent double-check, labelled with the drug, dose and time, and never left running unobserved.
3. Score the newborn at one and five minutes, and explain your actions in the first minutes, including what should happen about feeding, vitamin K and handling of the cord.
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One-minute APGAR: heart rate 130 = 2; slow irregular respirations = 1; some flexion = 1; grimace = 1; pink trunk with blue extremities = 1. Total 6. This is moderate depression, largely from respiratory effort and tone.
Five-minute APGAR: heart rate 140 = 2; crying vigorously = 2; active movement = 2; (reflex response assumed active) = 2; completely pink = 2. Total 10. The improvement shows the baby responded to simple support rather than needing prolonged resuscitation.
Actions in the first minutes: dry the baby thoroughly, place under a radiant warmer or skin-to-skin with a cover, and stimulate the soles of the feet. Position the head neutrally and clear secretions only if needed. Because the heart rate is above 100 and there is spontaneous respiratory effort, positive pressure ventilation is not indicated at one minute; reassess at five minutes. Continue to watch breathing, colour and temperature. Document the scores with the time, and remember that APGAR guides assessment but never delays resuscitation - you resuscitate on the examination, not the score.
Feeding and procedures: once stable, skin-to-skin contact and initiation of breastfeeding within the first hour support thermoregulation and oxytocin release in the mother, but only once her bleeding is controlled. Give vitamin K 1 mg IM to the term newborn (0.5 mg if under 1.5 kg) into the vastus lateralis, and eye prophylaxis according to unit policy. Do not cut a pulseless cord early for convenience; in a baby needing resuscitation, leave the cord intact while stabilising if the equipment allows.