Postpartum Haemorrhage and a Cold, Grunting Newborn: Two Patients, Two Nurses
Ms Wanjiku, 29, G3P2, delivered a 3.6 kg boy 25 minutes ago at a sub-county hospital with no blood bank. Active management of the third stage was given: oxytocin 10 IU intramuscularly after birth, controlled cord traction, and the placenta was complete 10 minutes ago. She is now restless and pale. There is a steady trickle of dark blood; the under-buttock pad and linen are soaked. Estimated loss since delivery is 700 mL and still ongoing. The uterus feels soft, is displaced above and to the right of the umbilicus, and the bladder is palpable and distended. Pulse 118, blood pressure 96/58 mmHg, respiratory rate 24, temperature 36.8 °C. The newborn, lying on the resuscitaire, has grunting respiration, rate 72, SpO2 88% in room air, and feels cool. Two nurses are on duty; the doctor has left for the day and the referral hospital is 90 minutes away by road.
1. Explain what is driving the bleeding and set out, in priority order, what you and your colleague must do for the mother in the first 15 minutes. Justify the order.
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Cause. Uterine atony, worsened by bladder distension. The soft, high, right-deviated uterus is the classic picture: a full bladder splints the lower segment and prevents contraction, so bleeding continues even though oxytocin was given correctly. The blood loss plus tachycardia and narrowing pulse pressure says she is already compensating poorly.
Order of action.
- Call for help and start the referral process now - ambulance, on-call clinician, blood arrangements. Referral takes 90 minutes; it must not be the last thing you think of.
- Empty the bladder with an indwelling catheter. This is mechanical, immediate, free, and it removes an ongoing cause of atony. It is correctly done before more drugs.
- Uterine massage and bimanual compression - immediate, no prescription needed, and it buys time while drugs take effect.
- Oxytocin infusion 40 IU in 500 mL over 4 hours (she has already had 10 IU IM), titrated to tone and bleeding.
- Tranexamic acid 1 g IV over 10 minutes, given within 3 hours of birth. Its benefit is time-dependent; do not hold it back as a reserve.
- Second IV line, warmed crystalloid, keep her warm, monitor every 15 minutes, quantify loss by weighing pads.
- If atony persists: misoprostol 800 micrograms sublingually, continue compression, and prepare for transfer.
Drugs are useless against a distended bladder and an uncontracted uterus, which is why steps 2 and 3 precede the infusion.
2. There are two nurses and two deteriorating patients. How do you allocate roles, and what is the minimum safe package of care for the newborn before transfer?
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Allocation. The senior midwife stays with the mother: the mother is the one actively exsanguinating and her interventions are time-critical and require clinical judgement. The second nurse takes the newborn and does not leave him. Neither patient is left alone. Both nurses must first shout for help - an on-call clinical officer, a theatre attendant, hospital security, anyone who can phone the ambulance and carry equipment. Two staff for two critical patients is an unacceptable staffing position, and naming that early is part of the clinical decision, not a complaint.
Newborn package. Grunting, respiratory rate 72, SpO2 88% and coolness are respiratory distress plus hypothermia, with sepsis in the differential.
- Dry, stimulate, position the airway, suction only if secretions are obstructing.
- Warm actively: radiant warmer or skin-to-skin with the mother if she is stable, hat, blanket; recheck temperature every 30 minutes.
- Oxygen by nasal prongs or, if available, bubble CPAP; continuous oximetry targeting 90–95% for a newborn.
- Check capillary glucose and treat if low; hypoglycaemia worsens distress.
- Do not feed; secure IV access if trained and prescribe antibiotics as part of the referral.
- Document observations with times.
Transfer. Mother and baby travel together if at all possible - separating them creates breastfeeding and bonding problems and splits the handover. One nurse escorts; the oxytocin infusion continues during transfer.
3. Bleeding continues 10 minutes after the oxytocin infusion is running and misoprostol is the only additional uterotonic in stock. What do you do, and what is the essential handover for the receiving hospital?
Read the worked answer
Immediate. Give misoprostol 800 micrograms sublingually (600 micrograms orally is an alternative). Continue uterine massage and maintain bimanual compression; if bleeding is torrential, aortic compression or a firm lower-segment pressure is a legitimate temporising measure while waiting for transfer. Anticipate misoprostol's effects - shivering and pyrexia are common and are not a reason to withhold the drug in a woman who is bleeding.
Simultaneously continue the oxytocin infusion, keep two lines running with warmed crystalloid, monitor pulse, BP, respiration and lochia every 15 minutes, catheterise for hourly urine output, and keep her flat and warm. Recognise that crystalloid does not carry oxygen: if she is pale, tachycardic and restless despite fluid, she needs blood, and the only route to blood is the referral hospital.
SBAR handover, written and verbal:
- Situation: G3P2, spontaneous vertex delivery 35 minutes ago, ongoing postpartum haemorrhage, estimated loss 700 mL and rising.
- Background: active third stage with oxytocin 10 IU IM; placenta complete; no blood bank on site.
- Assessment: atonic uterus, distended bladder relieved by catheter, pulse 118, BP 96/58, ongoing bleeding despite oxytocin and misoprostol.
- Recommendation: time tranexamic acid was given, total estimated loss, drugs already given, request for blood products and gynaecology review on arrival.
Include the newborn's observations and treatment in the same handover. Speak to the family together, in plain language, explaining why transfer is needed - not that the facility has failed, but that she needs blood and theatre, which are only available there.