Case Study: Primary Postpartum Hemorrhage Due to Uterine Atony

Patient profile

• Name: Mrs A, 28 years old
• Gravida/Para: G2P2
• Gestation: 39 weeks + 2 days
• Mode of delivery: Normal vaginal delivery
• Baby: Male, 3.4 kg, cried immediately after birth
• Past history: No hypertension, asthma, cardiac disease, bleeding disorder, or prior postpartum haemorrhage
• Labour history: Induced labour with oxytocin; prolonged second stage of labour

Presenting problem

Assessment findings

Clinical diagnosis

Risk factors in this case

1. Induction/augmentation with oxytocin
2. Prolonged labour
3. Possible uterine fatigue after a prolonged second stage

Immediate management

1. Call for help and begin resuscitation

• Obstetrician, anaesthetist, senior midwife, theatre team, and blood bank notified.
• Two wide-bore IV cannulas inserted.
• High-flow oxygen administered.
• Patient kept warm and positioned flat with legs elevated.
• Rapid assessment of airway, breathing, and circulation performed.
• Blood samples sent for:
  • Complete blood count
  • Blood group and cross-match
  • Coagulation profile
  • Fibrinogen level
  • Renal function tests
• Strict fluid balance and urine output monitoring started with a Foley catheter.
• Warmed crystalloid infusion initiated while blood products were arranged.

2. Identify and treat the cause

• Immediate bimanual uterine massage was performed.
• The bladder was emptied.
• Placenta and membranes were rechecked for completeness.
• The birth canal was examined for cervical, vaginal, and perineal trauma.

3. Uterotonic treatment

• Oxytocin infusion commenced after delivery.
• As bleeding continued, second-line uterotonics were administered:
  • Methylergometrine 0.2 mg IM was used because the patient had no hypertension.
  • Carboprost 0.25 mg IM was available if needed, but should be avoided in asthma.
  • Misoprostol 600 to 800 micrograms may be used by oral, sublingual, or rectal route according to protocol.

4. Tranexamic acid

• Tranexamic acid 1 g IV was given promptly, within 3 hours of birth.
• A second dose may be considered if bleeding continues after 30 minutes or restarts within 24 hours, under the treating team's protocol.

Progress of the case

1. Perform bimanual uterine compression.
2. Transfuse packed red blood cells because of ongoing haemorrhage and haemodynamic instability.
3. Insert an intrauterine balloon tamponade.
4. Continue close monitoring in the operating theatre/high-dependency setting.

If bleeding had continued

1. Examination under anaesthesia and repair of genital tract tears
2. Removal of retained placental tissue, where present
3. Uterine balloon tamponade
4. Compression sutures, such as B-Lynch suture
5. Uterine artery ligation or internal iliac artery ligation
6. Uterine artery embolisation, if the patient is stable and expertise is immediately available
7. Emergency peripartum hysterectomy as a life-saving procedure when bleeding is uncontrolled

Outcome

• Bleeding remained controlled.
• The intrauterine balloon was removed the next day without recurrent bleeding.
• Haemoglobin after resuscitation was 8.9 g/dL.
• Oral iron therapy and dietary counselling were prescribed.
• She was discharged on postnatal day 3 in stable condition, with follow-up for anaemia and counselling regarding recurrence risk in a future pregnancy.

Nursing responsibilities in PPH

1. Quantify and document blood loss accurately.
2. Monitor pulse, blood pressure, respiratory rate, oxygen saturation, temperature, consciousness, and urine output frequently.
3. Maintain IV access and prepare blood products as ordered.
4. Assist with uterine massage, bimanual compression, uterotonic administration, and balloon tamponade.
5. Check for signs of shock: tachycardia, hypotension, pallor, cold extremities, restlessness, reduced urine output, and altered mental state.
6. Provide clear communication and emotional support to the woman and her family.
7. Document every intervention, drug dose, timing, blood loss, response, and escalation step.
8. Ensure post-PPH follow-up, including haemoglobin assessment, iron therapy, and debriefing.

Key learning points

• PPH is an obstetric emergency requiring simultaneous resuscitation, identification of cause, and definitive treatment.
• Think systematically using the 4 Ts: Tone, Trauma, Tissue, Thrombin.
• A soft, boggy uterus with heavy bleeding strongly suggests uterine atony.
• Do not delay escalation while waiting for a single intervention to work.
• Early uterine massage, uterotonics, tranexamic acid, blood-product support, and timely use of balloon tamponade can prevent severe maternal morbidity and death.
• Protocol-based teamwork and regular emergency drills improve response to PPH. A recent systematic review also highlights the importance of recognising risk factors for PPH early (2025 systematic review).