Primary postpartum haemorrhage after home birth
A 36-year-old para 2 planned a home birth 25 minutes by road from the base hospital. She has just birthed a 4.1 kg baby after an uncomplicated labour. The placenta was delivered 10 minutes ago after active management with 10 IU oxytocin IM. She is now bleeding heavily; the uterus is boggy and felt above the umbilicus. Estimated blood loss is 800 mL and continuing. Her observations are BP 95/55 mmHg, pulse 118 bpm, respiratory rate 22, temperature 36.8°C, and she is pale, clammy and dizzy. The midwife is the LMC; the backup midwife is 15 minutes away and the ambulance is 10 minutes away. The woman is breastfeeding the baby and does not want to be separated. She has no known hypertension and no allergies. There is no IV fluid on site apart from 1 L of normal saline.
1. Outline your immediate management of this postpartum haemorrhage in the home setting.
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This is a primary postpartum haemorrhage with maternal instability: estimated loss 800 mL and continuing, boggy uterus, tachycardia and hypotension. I would call for help immediately: ambulance and backup midwife, and pre-alert the hospital. I would stay with the woman, call out for the partner to help, and keep the baby skin-to-skin if safe.
I would perform uterine massage and empty the bladder, secure IV access and start the 1 L of normal saline, take bloods if possible, and give additional uterotonics according to local protocol. She has already had 10 IU oxytocin IM; I would give tranexamic acid 1 g IV over 10 minutes within 3 hours of birth if not contraindicated, and consider ergometrine or carboprost depending on availability and protocol. I would perform bimanual compression if bleeding continues and the uterus remains boggy. I would monitor pulse, blood pressure, respirations, oxygen saturation, colour, consciousness and blood loss continuously, keep her warm, and lie her flat.
I would prepare for transfer and possible resuscitation, and document drug doses, times, observations and the response. If the baby needs attention, the backup midwife or partner can care for the baby nearby. The priority is controlling bleeding and restoring circulation.
2. How do you decide on and coordinate transfer while supporting breastfeeding and the woman’s wishes?
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Transfer is indicated because she is haemodynamically unstable, bleeding is ongoing, and home birth cannot provide definitive management. I would explain clearly but calmly that she needs hospital care now, and that the baby can travel with her and remain skin-to-skin if her condition and the ambulance crew allow. I would ask her partner to accompany the baby if she cannot hold the baby safely.
I would coordinate with the ambulance crew on arrival, give a structured handover including estimated blood loss, uterotonics given, IV fluids, observations and response, and pre-alert the hospital to prepare for possible blood products and theatre. I would continue uterine massage, IV fluids and monitoring en route, with the midwife escorting. If the baby cannot safely stay skin-to-skin, I would support expression or hand expression and keep the baby warm and fed according to the family’s wishes. I would document her wishes, the information given, the transfer decision, times and the handover. After transfer, I would ensure a debrief and follow-up, including feeding support and screening for postnatal mental health.