Retained placenta and haemorrhage with no blood bank and a 90-minute road
A 26-year-old woman, gravida 3 para 2, delivered a 3.4 kg baby at home 50 minutes ago and is brought by motorcycle to a health centre. The placenta has not delivered. Estimated blood loss is about 800 mL on the wrappers. She is pale, sweaty and anxious; pulse 124/min, BP 88/56 mmHg, respiratory rate 26/min. The uterus is soft at the level of the umbilicus, and there is a gush of blood when the fundus is pressed. There is no blood bank, no theatre, and no ambulance; the referral hospital is 90 minutes away on a rough road. The facility has oxytocin, misoprostol, tranexamic acid, ergometrine, intravenous fluids, and one other nurse on duty.
1. Write your actions in order for the first 30 minutes, stating doses and routes.
Read the worked answer
Call and prepare (0–5 minutes)
- Shout for the second nurse, send for the maternity pack and a second IV line; telephone the referral hospital to warn them.
- Two large-bore cannulae (16–18 G). Take blood for haemoglobin and cross-match, and send a sample with the family if the hospital can accept it.
- 0.9% sodium chloride 1 L as fast as it will run, then a second litre; warm her and cover her.
- Catheterise to measure urine output.
Mechanical measures (concurrent)
- Empty the bladder.
- Uterine massage and bimanual compression while drugs are drawn up.
- Controlled cord traction only if the placenta has separated; do not pull on a fundal uterus.
Drugs
- Oxytocin 10 IU intramuscularly immediately, then 40 IU in 500 mL over 4 hours.
- Tranexamic acid 1 g intravenously over 10 minutes - within 3 hours of birth, which is still the case; repeat 1 g after 30 minutes if bleeding continues.
- If bleeding persists and oxytocin is unavailable or inadequate, misoprostol 800 micrograms sublingually as a single dose.
- Ergometrine 0.2 mg intramuscularly is an alternative only if she is not hypertensive; her BP is low now, but check again before giving it.
Reassess at 30 minutes: pulse, BP, urine output, fundal height and tone, and whether the placenta is out. If she remains shocked with a soft uterus, add aortic compression while arranging movement.
2. At 30 minutes bleeding continues, the placenta is still inside and the uterus remains soft. Do you remove the placenta here or transfer? Justify your answer.
Read the worked answer
Remove it here, while the transfer is being arranged - not one instead of the other. The reasoning:
- A retained placenta with an atonic uterus will not stop bleeding. No amount of oxytocin empties the uterus, and she is losing blood she cannot be transfused for at this facility.
- A 90-minute rough-road journey with an actively bleeding, shocked woman and no escort capacity is itself life-threatening; she could arrive dead.
- Manual removal of the placenta is a competency expected of a clinical officer and is far safer than waiting. Proceed with antibiotic cover (ampicillin 2 g IV plus metronidazole 500 mg IV), analgesia (pethidine 50–100 mg IV with an antiemetic, or ketamine if trained and monitoring is available), a single attempt at a time, and a plan to stop and transfer if she deteriorates.
- If manual removal fails, or the placenta is morbidly adherent, or she remains shocked after 500 mL of further bleeding, transfer immediately with the placenta left in situ and a note explaining why.
Throughout: keep the oxytocin infusion and tranexamic acid running, continue uterine massage, monitor pulse and BP every 10 minutes, and write the times down. This is a classic "do both, in parallel" judgement - the trap is believing there is a choice between definitive treatment and referral.
3. What would you do differently if her BP were 170/110 mmHg with 3+ proteinuria on dipstick, and why?
Read the worked answer
Drug choice changes; urgency of delivery does not.
- Do not give ergometrine. It is contraindicated in hypertension and can precipitate a stroke or eclampsia. Misoprostol is also used cautiously, as it can raise blood pressure and temperature.
- Use oxytocin 10 IU intramuscularly and an infusion, plus tranexamic acid 1 g intravenously, and rely more on mechanical measures - bimanual compression, aortic compression.
- Give magnesium sulphate now for seizure prophylaxis because this is severe pre-eclampsia: Pritchard regimen - 4 g intravenously over 10–15 minutes plus 10 g intramuscularly (5 g into each buttock), then 5 g intramuscularly every 4 hours. Watch respiratory rate, urine output and reflexes; keep calcium gluconate at hand.
- Lower the blood pressure: hydralazine 5 mg intravenously over 5 minutes, repeated every 20 minutes to a maximum of 20 mg, or nifedipine 10 mg orally; target a diastolic of about 90–100 mmHg, not normal.
- Reframe the differential: with severe hypertension and proteinuria, think of abruption and genital tract trauma as well as atony. Inspect the cervix and vagina with good light and analgesia before attributing all bleeding to the uterus.
- Transfer becomes more, not less, urgent: she needs a facility that can deliver her and manage a possible eclampsia. The receiving hospital must be told about the magnesium, the blood pressure and the retained placenta.