Postpartum Haemorrhage Nursing Management
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Direct answer
Postpartum haemorrhage is blood loss of 500 mL or more after a vaginal birth (1000 mL or more after caesarean) within 24 hours, and it remains the leading direct cause of maternal death in India. Uterine atony causes about seven in ten cases, so the first moves are always uterine massage, bladder emptying and an oxytocic — oxytocin 10 units IM is the drug of choice. Structured thinking uses the four Ts: tone, trauma, tissue and thrombin, and nursing care runs simultaneously — call for help, two wide-bore cannulas, crystalloid, crossmatch, quantified blood loss, vital signs every 15 minutes and preparation for escalation to balloon tamponade or surgery if pharmacological measures fail.
What you must remember
- Primary PPH occurs within 24 hours; secondary PPH bleeds from 24 hours up to 12 weeks, usually from retained products or infection.
- The four Ts: tone (atony, 70 to 80 per cent), trauma (cervical or vaginal tears), tissue (retained placenta or clots), thrombin (coagulopathy).
- At-risk mothers: prolonged or augmented labour, grand multipara, twins and polyhydramnios, anaemia, prior PPH and chorioamnionitis.
- Uterotonic sequence per standing orders: oxytocin 10 units IM (or 5 units slow IV); ergometrine 0.2 mg IM — contraindicated in hypertension and pre-eclampsia; carboprost (15-methyl PGF2 alpha) 250 micrograms IM every 15 minutes to a maximum of 8 doses — avoided in asthma; misoprostol 600 micrograms sublingual where others are unavailable.
- Visual estimation underestimates loss by 30 to 50 per cent, so quantify: weigh pads and swabs — one gram equals one millilitre — and collect in a calibrated drape.
- Bimanual compression and aortic compression buy time while the obstetric team responds; balloon tamponade and the non-pneumatic anti-shock garment are transfer stabilisers.
- Prevention is active management of the third stage: oxytocin within one minute of birth, controlled cord traction, and uterine massage after delivery of the placenta.
- Monitor the bleeding mother every 15 minutes: pulse, blood pressure, respiratory rate, SpO2, urine output above 30 mL per hour and level of consciousness; a rising pulse with normal blood pressure is early shock, and a falling blood pressure is late.
A typical exam case worked through
A 28-year-old grand multipara delivers a 3.8 kg baby; five minutes after the placenta, blood pools on the sheet. You call for help and start the clock. Massage the fundus — it is soft and boggy, confirming atony. A colleague catheterises — a full bladder alone can prevent contraction — while you give oxytocin 10 units IM and start normal saline through a 16-gauge cannula. The uterus firms, but the calibrated drape already reads 600 mL, so ergometrine is skipped (she was induced for pre-eclampsia) and carboprost 250 micrograms IM is drawn up after confirming no asthma. Blood is sent for group and crossmatch of two units, and vitals are recorded quarter-hourly: pulse 112, blood pressure 96/60, urine dribbling. Because bleeding continues despite a well-contracted uterus, the cause is no longer tone — the obstetrician examines for trauma and retained tissue under anaesthesia. The moment one cause is excluded you move to the next of the four Ts rather than repeating the same step harder.
Where students slip
Three traps recur. First, treating an estimated loss of "about 400 mL" as normal in an anaemic Indian mother — her tolerance is lower, and per current guidance 500 mL defines PPH regardless of route. Second, the ergometrine question: it is the wrong uterotonic in a hypertensive or pre-eclamptic woman, and choosing it in an MCQ stem with a blood pressure of 160/110 is the planted error. Third, ordering of first actions — the answer to "the nurse's initial intervention" is uterine massage with a call for help, not arranging theatre or starting the second drug. Also remember secondary PPH: bleeding after 24 hours with fever and tender uterus means retained products with sepsis — antibiotics and evacuation, not simply another uterotonic.
Frequently asked questions
How is postpartum haemorrhage defined?
Blood loss of 500 mL or more after vaginal delivery, or 1000 mL or more at caesarean, within 24 hours of birth; later bleeding up to 12 weeks is secondary PPH.
Which is the first-line uterotonic drug?
Oxytocin 10 units intramuscularly within one minute of delivery as part of active management of the third stage; effective, fast and safe in hypertension.
Why is carboprost avoided in asthmatic patients?
It is a prostaglandin F2 analogue that can provoke bronchospasm, so asthma is a contraindication and misoprostol or repeat oxytocin is preferred.
How is blood loss quantified at the bedside?
Weigh pads and swabs (1 g equals 1 mL) or use a calibrated drape; visual estimates miss 30 to 50 per cent of loss.
What are the four Ts used for?
Recall of causes: tone (atony), trauma, tissue (retained products) and thrombin (clotting failure), each demanding different intervention.
What constitutes active management of the third stage of labour?
Oxytocin within one minute of birth, controlled cord traction for the placenta, and uterine massage immediately after delivery, which together prevent most atonic PPH.