Primary postpartum haemorrhage: escalating uterotonics

Primary postpartum haemorrhage is blood loss of 500 mL or more within 24 hours of birth, and this woman is already past that with bleeding continuing and a rising pulse. The cause is uterine atony, the most common of the 'four Ts' (tone, trauma, tissue, thrombin). Her risk factors were a large baby, a prolonged augmented labour and an overdistended uterus. The placenta is complete, so retained tissue is unlikely.

Management follows a set sequence, and several things happen at once. Call for help and activate the massive haemorrhage or postpartum haemorrhage protocol: two large-bore cannulas, bloods for full blood count, coagulation, fibrinogen and crossmatch, warmed fluids and early blood products. Give tranexamic acid 1 g intravenously within 3 hours of birth, which reduces death from bleeding (WOMAN trial). Keep the bladder empty with a catheter.

Mechanical measures and drugs run in parallel. Bimanual uterine compression compresses the uterus between a fist in the anterior fornix and a hand on the abdomen. On the drug side, she has already had oxytocin and ergometrine. The next uterotonic is carboprost (a prostaglandin F2-alpha analogue) 250 micrograms intramuscularly, repeated every 15 minutes up to 8 doses, unless the woman has asthma, in which case misoprostol 800 micrograms rectally or sublingually is used instead. Australian state guidelines (for example Queensland Health, 2023) and RANZCOG follow this ladder.

If bleeding continues despite maximal drug therapy, the next steps are examination under anaesthesia in theatre, uterine balloon tamponade, compression sutures, uterine artery ligation and, as a last resort, hysterectomy.

Ergometrine is avoided in hypertension and pre-eclampsia, so always check the blood pressure history before giving it.