Postpartum haemorrhage from uterine atony in a district hospital without a blood bank
District hospital, 120 km from the regional perinatal centre, 02:15. A 26-year-old woman (gravida 2, para 2) delivered a 3,600 g boy 40 minutes ago by spontaneous vaginal delivery. She received 10 IU oxytocin intramuscularly after delivery; the placenta was complete on inspection. Blood loss is estimated at 800 mL, and the pad under her is soaked again. The uterus feels soft and boggy, and is above the umbilicus and deviated to the right. Pulse 118, blood pressure 96/58, respirations 22, SpO2 97%; she is pale, anxious and thirsty. The bladder is not palpable. The unit has no blood bank; ambulance transfer takes about 90 minutes. One unit of oxytocin and one ampoule of tranexamic acid 1 g/10 mL are on the shelf; the pharmacy is closed until 08:00. The newborn is on the mother's chest, crying and rooting.
1. What do you do in the first 10 minutes, and in what order?
Read the worked answer
Recognise the picture: a boggy uterus above the umbilicus, deviated to the right, with ongoing bleeding after a complete placenta, is uterine atony with a full bladder - the commonest cause of primary postpartum haemorrhage. The pulse and blood pressure already show compensated hypovolaemia; thirst and anxiety are early signs, not reassurance.
In order:
- Call for help - second midwife, doctor, anaesthetist - and start the clock; record times from here on.
- Massage the fundus continuously until it contracts, and express clots.
- Empty the bladder: catheterise. A full bladder prevents the uterus from contracting, and this alone sometimes stops the bleeding.
- Two large-bore IV cannulas; send blood for group and cross-match, full blood count and coagulation.
- Start the oxytocin infusion and give tranexamic acid 1 g IV over 10 minutes.
- Oxygen by mask, keep her flat and warm; monitor pulse, blood pressure, SpO2, fundus and lochia every 5–15 minutes; weigh every pad.
- Inspect the birth canal for tears and re-check the placenta for completeness.
- Hand the baby to the second midwife. The mother's resuscitation comes first; the baby must be kept warm and fed.
Loss of 800 mL plus a soaked pad means she is already near or above 1,000 mL. Do not wait for a haemoglobin result to act.
2. State the drugs, doses and routes you would give, and what you would not do.
Read the worked answer
Oxytocin. 10 IU IM has already been given - that is the standard third-stage dose. Continue with an infusion: 20 IU in 500 mL sodium chloride, run at the unit protocol rate and titrated to uterine tone. Never give undiluted oxytocin as an IV bolus push: it causes hypotension and arrhythmia in a patient who is already hypotensive.
Tranexamic acid. 1 g (the whole 10 mL ampoule) diluted in 100–200 mL sodium chloride, IV over 10 minutes, given as soon as PPH is diagnosed and within 3 hours of birth - after 3 hours the survival benefit is lost. It is added to uterotonics, never a substitute for them, and it does not replace mechanical measures.
If bleeding continues. The next-line agent is misoprostol 800 µg sublingually, which is not on this shelf and cannot be improvised. So the realistic escalation is bimanual compression, aortic or uterine pressure as the doctor directs, and transfer - not hunting for drugs in a closed pharmacy.
What I would not do: give a second 10 IU IM oxytocin as a 'top-up' and consider the uterus managed; give tranexamic acid late and call it prophylaxis; or delay arranging transfer in order to complete the drug sequence first. Tranexamic acid is fully effective only when given early, and so is transfer.
3. When and how do you transfer, and what happens to the newborn?
Read the worked answer
Decision. Atony not controlled within about 30 minutes, estimated loss over 1,000 mL, tachycardia with a systolic of 96, and no blood bank in the building: activate transfer to the regional perinatal centre now, not after the next pad.
Before and during transfer:
- Speak directly to the perinatal centre and give the numbers: time of birth, estimated loss, drugs with doses and times, vital-sign trend, IV access, urine output.
- Two IV lines running, oxytocin infusion continuing, catheter in place with hourly urine measurement, oxygen, warm blankets.
- Escort: doctor plus midwife. The ambulance must carry oxygen and suction; take the partogram, notes and drug chart.
- Monitor every 10 minutes in the ambulance and record on paper - the transfer is where documentation usually collapses.
The baby. If the mother is conscious and stable, keep him skin-to-skin and put him to the breast: suckling releases endogenous oxytocin and helps the uterus contract. If she is unstable, the second midwife keeps him warm, checks his glucose and feeds him; he travels in the same ambulance with a relative. Do not separate mother and newborn without a documented reason, and never leave the newborn behind in the district hospital.