Postpartum Haemorrhage at a Soum Health Centre
A 30-year-old woman, G3P2, gave birth at a soum health centre 25 minutes ago. The placenta was delivered complete 10 minutes ago. She is now bleeding heavily: an estimated 800 mL has been collected, and the uterus is soft and boggy on palpation. BP 86/54, HR 124, RR 24, SpO2 96% on room air, temp 36.9°C. She is pale, anxious, and thirsty. One 18-gauge IV line is in place; 500 mL of normal saline is running. Oxytocin 10 IU was given intramuscularly after delivery. The centre has tranexamic acid, misoprostol, ergometrine, oxygen, and a small stock of packed red cells, but no blood bank on site. The referral hospital is 2.5 hours away by ambulance. A midwife and one nurse are on duty.
1. What are the first five actions in the next 10 minutes, in order, and why?
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- Call for help and activate the referral/ambulance pathway while staying with the woman. 2. Perform bimanual uterine massage to stimulate contraction and assess tone; this is the fastest mechanical treatment for atony. 3. Empty the bladder with a catheter, because a full bladder inhibits uterine contraction. 4. Insert a second large-bore IV line and give warmed crystalloid for hypotension while arranging blood. 5. Give tranexamic acid 1 g IV over 10 minutes and start/continue a uterotonic infusion per protocol.
The order reflects ABCs and cause: she is conscious and breathing, so circulation and bleeding control come first. The boggy uterus and 800 mL loss make uterine atony the most likely cause. Massage and bladder emptying are immediate and do not depend on medicines. IV access and fluids address hypovolaemia, and tranexamic acid reduces mortality when given within 3 hours of birth. Monitor BP, HR, lochia, uterine tone, and consciousness continuously; do not leave her alone.
2. Which uterotonic and adjunct medicines would you choose with the supplies available, and what precautions apply?
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She has already received oxytocin 10 IU IM. Start an oxytocin infusion per local protocol, and give misoprostol 800 micrograms sublingually as a second uterotonic because it does not require injection or refrigeration. Give tranexamic acid 1 g IV over 10 minutes; repeat once after 30 minutes if bleeding continues. Ergometrine 0.2 mg IM can be used if there is no hypertension, cardiac disease, or pre-eclampsia, but it may cause vomiting and should not be given IV. She is hypotensive, so check whether the low BP is from blood loss rather than a reason to avoid ergometrine.
Precautions: do not give multiple uterotonics without monitoring tone and vital signs; misoprostol can cause fever and shivering; ergometrine can raise BP and cause nausea. Type and cross-match blood, and use the small packed red cell stock only as clinically indicated while arranging transfer. Keep her warm, monitor urine output, and reassess bleeding every 15 minutes.
3. How would you decide whether to transfer now or stabilize longer, and what must be monitored en route?
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Transfer should not be delayed until she is fully stable if bleeding continues, because the centre has no blood bank and only limited resources. The decision is to stabilize briefly: control uterine tone, secure IV access, give tranexamic acid and uterotonics, and start fluids, then transfer with an escort as soon as the ambulance is ready. If BP remains below 90 systolic or she becomes confused, transfer is still urgent, with fluids and blood products arranged en route.
Monitor BP, HR, respiratory rate, SpO2, consciousness, uterine tone, amount of lochia, IV site, urine output, and temperature every 15 minutes. Continue oxytocin infusion, keep her warm, give oxygen if SpO2 falls, and have misoprostol available. Notify the referral hospital before departure with estimated blood loss, vital signs, drugs and times, and blood group. Document everything; ongoing bleeding, falling BP, or reduced consciousness requires reassessment and possibly additional uterotonics.