Primary Postpartum Haemorrhage With a Contraindicated Uterotonic on the Chart
Ms A, 28, G2P1, delivered a 3.4 kg boy 40 minutes ago after a 6-hour spontaneous labour. She had gestational hypertension (booking and antenatal BP around 150/95) with no proteinuria. Active management: oxytocin 10 units IM after delivery; placenta complete; perineum intact. Now: HR 118, BP 148/94, RR 22, SpO2 97% on room air, estimated blood loss 750 mL and still trickling; fundus boggy, 2 cm above the umbilicus and deviated to the right; bladder not emptied since delivery. She says she feels "wet and dizzy". One 18 G cannula with Ringer's lactate at 125 mL/hr. Orders: oxytocin 20 units in 1000 mL over 4 hours; methylergonovine 0.2 mg IM every 4 hours PRN; carboprost 250 mcg IM every 15 minutes PRN (max 2 mg); misoprostol 800 mcg sublingual PRN. No asthma, no cardiac disease.
1. What is happening, and what are your first four actions in order?
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Diagnosis: primary postpartum haemorrhage from uterine atony, with bladder distension preventing contraction. Blood loss >500 mL after vaginal delivery with a boggy, elevated, dextroverted uterus is atony until proven otherwise; the rightward deviation is the classic sign of a full bladder.
- Call for help - obstetrician, midwife-in-charge, anaesthetist, and the blood bank/porter. PPH is a team event and the clock starts at recognition.
- Fundal massage - rub up a contraction with one hand while supporting the lower segment, and express clots. This is the fastest, most effective first intervention for atony.
- Empty the bladder - in-and-out catheterisation. A full bladder mechanically prevents contraction; massage will fail until it is emptied.
- Uterotonics and access - start/continue the oxytocin infusion, give an appropriate second-line agent (see next task), insert a second large-bore (14–16 G) cannula, take bloods (FBC, coagulation, crossmatch 2 units, U&E), and begin warmed crystalloid.
Simultaneously: quantify loss (weigh pads and drapes - 1 g ≈ 1 mL), apply gentle uterine massage and bimanual compression if bleeding continues, monitor HR/BP every 5–15 minutes, watch for shock index >1 (HR 118 ÷ SBP 148 is still <1, which is falsely reassuring - hypovolaemia in young women is masked until 30–40% loss), keep her warm, and never leave her alone.
Escalate to obstetric emergency call if loss reaches 1000 mL, she becomes tachycardic with falling BP, or the uterus stays boggy despite two uterotonics - that is the trigger for theatre and transfusion.
2. Of the PRN uterotonics ordered, which would you give and which is contraindicated? Justify your choice.
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Contraindicated: methylergonovine 0.2 mg IM. It is an ergot alkaloid and a potent vasoconstrictor; it is contraindicated in hypertension and in pregnancy-induced hypertension/pre-eclampsia. Her BP is 148/94 with a background of gestational hypertension, so giving it risks severe hypertension, headache, seizure and, rarely, coronary or cerebral vasospasm. If the chart is ambiguous, query it with the prescriber - do not give it "because it was ordered".
Safe and appropriate options in this patient:
- Oxytocin infusion - first-line, already ordered, continue it.
- Carboprost (PGF2α) 250 mcg IM, repeatable every 15 minutes to a maximum of 2 mg - reasonable second-line here because she has no asthma (it causes bronchospasm and is contraindicated in asthma). Note it can cause diarrhoea, vomiting, fever and hypertension.
- Misoprostol 800 mcg sublingual - also appropriate; expect shivering and pyrexia.
Order of action: massage and bladder emptying first (they are immediate and free), then oxytocin, then add carboprost or misoprostol if the fundus remains boggy after 5–10 minutes.
Reasoning principle being tested: a written PRN order never abolishes the nurse's duty to check the indication against the individual patient. Two patients with the same chart can have different correct answers.
3. Ms A's bleeding continues and total loss is now estimated at 1100 mL. What changes in your management and monitoring, and what do you tell her?
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This is now a major PPH and requires escalation beyond the delivery room.
Actions:
- Declare a PPH emergency and call the obstetric consultant and anaesthetist; alert theatre and blood bank; activate the massive haemorrhage protocol per local policy.
- Transfuse - crossmatched blood as available, with a 1:1:1–type approach or locally agreed ratios; do not wait for lab results if she is unstable.
- Two large-bore cannulae, warmed fluids, tranexamic acid 1 g IV over 10 minutes if within 3 hours of delivery and not already given.
- Mechanical measures: bimanual uterine compression, then intrauterine balloon tamponade or examination under anaesthesia as directed; consider surgical options if atony is refractory.
- Monitor for the classic trap: a young, fit woman maintains BP until she suddenly decompensates. Track HR, BP, capillary refill, urine output, conscious level, and repeat lactate/haemoglobin; a shock index (HR ÷ SBP) approaching or above 1 is an early warning even when BP looks acceptable.
- Keep her warm (coagulopathy), monitor for oozing from cannula sites, and record cumulative loss by weighing.
What to tell her: use short, honest, calm sentences: "The bleeding is heavier than we expected and we need to move you to a bigger room with more people and give you blood. You are in the right place and we are treating it now." Explain each intervention as it happens, keep her partner informed if she wishes, and - once she is stable - offer the baby for skin-to-skin or support expression of colostrum. Do not leave her alone, and debrief her afterwards, including the risk of postnatal PTSD and the plan for future pregnancies.