Postpartum hemorrhage at a soum health center
At a soum health center 3 hours from the aimag hospital, a 26-year-old woman who gave birth 40 minutes ago has ongoing heavy vaginal bleeding. This is her second birth; the first was uncomplicated. The placenta was delivered complete 10 minutes after the baby, and the infant is breastfeeding. She is pale, anxious, and feels dizzy. BP 88/56, pulse 124, respiratory rate 26, SpO2 96%, temperature 36.8. The uterus is soft and boggy, and there is a 2 cm perineal tear that is not actively bleeding. Blood loss is estimated at 800 mL and continues. The center has oxytocin, misoprostol, tranexamic acid, IV fluids, gloves and a transport vehicle, but no blood bank and no operating theatre. The family asks whether she can wait until morning.
1. What is the immediate management of this postpartum hemorrhage, and what sequence would you follow?
Read the worked answer
This is uterine atony with incipient shock. I would call for help, assess airway, breathing and circulation, start two large-bore IV lines, keep her warm, and give oxygen if needed. Immediate uterine massage and bladder emptying are essential. Give oxytocin 10 IU intramuscularly or 5 IU slowly IV, and tranexamic acid 1 g IV over 10 minutes within 3 hours of birth. If bleeding continues, give misoprostol 800 micrograms sublingually and repeat uterine massage. I would inspect the genital tract for retained placental fragments and tears, and start IV crystalloid. Ergotamine can be considered only if there is no hypertension and after checking the blood pressure. I would monitor pulse, blood pressure, urine output and blood loss continuously. The tear is not the main source now, but it must be repaired after stabilization.
2. When would you transfer, and how would you prepare for the 3-hour journey?
Read the worked answer
I would transfer now, not wait until morning, because she is already tachycardic and hypotensive and the center has no blood bank or operating theatre. Stabilization for transfer means continuing oxytocin infusion, giving tranexamic acid and misoprostol, securing IV access, warming her, monitoring vital signs, and arranging a skilled escort and ambulance. The receiving hospital should be notified early so blood and theatre are prepared. If transfer is delayed, I would use bimanual uterine compression and, if necessary, aortic compression while continuing resuscitation. She should not travel alone or in a private car without monitoring. Even if bleeding slows, the risk of recurrent atony and shock remains high, so the threshold for transfer should be low.
3. How would you respond to the family's request to wait until morning, and what would you document?
Read the worked answer
I would explain clearly that she is in shock from ongoing blood loss and that waiting could lead to death, organ failure or the need for hysterectomy. The family can support her, but they cannot consent to a harmful delay if she lacks capacity; her own previously expressed wishes and the urgency of treatment guide care. I would use calm language, involve a senior clinician or administrator by phone, and document the assessment, the advice given, the family's request, the risks explained, and the escalation. If they still resist, I would continue emergency treatment and arrange transfer under medical authority, while respecting cultural concerns and offering an interpreter if needed. Clear documentation protects the patient and the team.