Postpartum haemorrhage at a soum health centre in winter
A 29-year-old woman, G3P2, gave birth at home 40 minutes ago at 39 weeks after an uncomplicated labour. The placenta delivered 20 minutes ago but bleeding has continued. The family carried her to the soum health centre, where you are the feldsher on duty. Estimated blood loss is 800 mL. She is pale, anxious and sweaty. BP 88/58 mmHg, pulse 120/min and weak, respirations 26/min, temperature 36.3°C. The uterus is soft and boggy, the fundus is at the level of the umbilicus and rises when you massage it. The perineum has no tear. You have two 18-gauge cannulas, 3 litres of Ringer's lactate, oxytocin 10 IU ampoules, misoprostol 200 microgram tablets, tranexamic acid 1 g/10 mL, and a working ambulance. The aimag hospital is 180 km away on a winter road; the drive takes about 3 hours in daylight. There is no blood bank at the soum and no obstetrician on site.
1. List your first-line actions in the first 20 minutes, in order, and explain the reason for each.
Read the worked answer
1. Call for help and organize the team. One person manages the airway and monitors vital signs while you manage the bleeding. In a soum centre this may mean the nurse and the driver.
2. Airway, breathing, circulation. Give oxygen if available. Keep her flat and warm; hypothermia worsens coagulopathy, and the room may be cold.
3. Two large-bore IV cannulas (18G). Start Ringer's lactate rapidly - a 1 L bolus, then reassess. Do not wait for laboratory results; none are available.
4. Uterine massage and bimanual compression. A boggy uterus that rises on massage is the classic sign of uterine atony. Massage the fundus firmly and, if bleeding continues, perform bimanual uterine compression.
5. Empty the bladder. A full bladder prevents uterine contraction; insert a urinary catheter.
6. Check the placenta for completeness. If cotyledons are missing or membranes are ragged, retained products are likely and referral for manual removal or vacuum aspiration is needed.
7. Give oxytocin 10 IU IM immediately. This is the first-line uterotonic and should not be delayed.
8. Give tranexamic acid 1 g IV over 10 minutes. It reduces mortality if given within 3 hours of birth.
9. Monitor BP, pulse, respirations and blood loss every 15 minutes. Record the time of each drug and the total fluids given.
2. Write the uterotonic plan with exact doses and routes, including what you will do if bleeding continues after the first measures.
Read the worked answer
Initial dose: oxytocin 10 IU IM (or slow IV) as soon as the diagnosis of atony is made. This is the most effective first-line drug.
Maintenance infusion: oxytocin 20 IU in 500 mL of Ringer's lactate over 4 hours (about 5 IU/hour). Titrate to uterine tone and bleeding; do not give a rapid bolus, which can cause hypotension.
If bleeding continues after oxytocin and massage: give misoprostol 800 micrograms sublingually (four 200-microgram tablets). Sublingual absorption is reliable even when the patient is cold or peripherally shut down. Expect fever and shivering; treat symptomatically.
Tranexamic acid: 1 g IV over 10 minutes within 3 hours of birth. If bleeding persists after 30 minutes, repeat 1 g IV.
Mechanical measures: continue bimanual compression; if not effective, perform aortic compression or apply a uterine balloon if available. These are temporizing measures before transfer.
Do not give ergometrine if there is hypertension or pre-eclampsia; it is not listed in your supplies. Avoid giving oxytocin as an undiluted rapid IV push.
If the uterus remains atonic despite these measures, the patient needs surgical management at the aimag hospital. Continuing to give uterotonics without arranging transfer wastes time.
3. Decide whether and when to transfer, and what must be done before and during transport.
Read the worked answer
Decision: transfer urgently, but do not delay for full stabilization. The soum cannot provide blood, surgery or obstetric care. The target is a systolic BP above 90 mmHg and a pulse below 120/min if achievable quickly, but ongoing bleeding is an indication to move.
Before departure:
- Secure the airway and two IV lines; keep the oxytocin infusion running.
- Give tranexamic acid if not already given and record the time.
- Catheterize and record urine output.
- Check the placenta; if incomplete, state this in the referral note.
- Warm the patient, wrap her in blankets and use a hot water bottle safely.
- Send a blood sample if the soum can take one, and label it.
During transport:
- A feldsher or nurse must accompany her. Monitor pulse, BP, respirations and vaginal bleeding every 15 minutes.
- Continue uterine massage and oxytocin infusion.
- Keep the ambulance warm; cold is a major risk in winter.
Handover: give the receiving doctor the time of birth, estimated blood loss, drugs and doses given, time of tranexamic acid, placental findings, vital signs trend and total IV fluids. Document the transfer in the referral form and obtain a signature from the receiving facility if possible.