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Case
The patient is illustrative. Ms. R., 29, gave birth vaginally to a 4.2 kg baby after a 19-hour labor augmented with oxytocin. Twenty minutes after the placenta delivered, the nurse notices a steady trickle of blood and a soft, boggy uterus above the umbilicus. Ms. R. says she feels lightheaded. Her heart rate has risen from 84 to 112 and her blood pressure has fallen from 118/72 to 100/60.
Definition and risk factors
The American College of Obstetricians and Gynecologists (ACOG, 2017) defines postpartum hemorrhage as cumulative blood loss of 1,000 mL or more, or blood loss with signs or symptoms of hypovolemia, within 24 hours after birth. Hemorrhage is the leading cause of maternal death worldwide, and uterine atony is its most common cause. Ms. R. has several risk factors for atony: a large baby, a long labor and oxytocin augmentation.
Signs of hypovolemia can appear late in healthy young women, so a rising heart rate deserves attention even while blood pressure still looks acceptable.
Why measure blood loss
Estimating blood loss by eye tends to underestimate it, which delays treatment. In the E-MOTIVE trial, 80 hospitals in Kenya, Nigeria, South Africa and Tanzania (210,132 vaginal births) were randomly assigned to usual care or to a calibrated blood-collection drape plus a bundle of first-response treatments: uterine massage, oxytocic drugs, tranexamic acid, intravenous fluids, examination and escalation. Hemorrhage was detected in 93.1% of patients in the intervention hospitals versus 51.1% with usual care, and the bundle was used in 91.2% versus 19.4%. The composite of severe hemorrhage, laparotomy for bleeding or death from bleeding fell from 4.3% to 1.6% (risk ratio 0.40; Gallos et al., 2023).
Nursing actions for Ms. R.
| Priority | Action |
|---|---|
| Call for help | Activate the unit's hemorrhage protocol and notify the provider; one nurse stays with the patient |
| Treat atony | Massage the fundus firmly until it contracts; empty the bladder, since a full bladder pushes the uterus up and stops it contracting |
| Medications | Increase the oxytocin infusion and give other uterotonics as ordered, checking contraindications (for example, methylergonovine in hypertension and carboprost in asthma); give tranexamic acid as ordered |
| Circulation | Two large-bore IV lines, warmed crystalloid as ordered, and blood drawn for a type and crossmatch and complete blood count |
| Measure | Weigh pads and drapes and record cumulative blood loss every few minutes; track vital signs every 5 to 15 minutes |
| Escalate | If bleeding continues, prepare for an exam for retained tissue or trauma and for transfusion |
Evaluation
After fundal massage, a full bladder emptied and additional uterotonics, Ms. R.'s uterus becomes firm at the umbilicus, her bleeding slows and her heart rate falls to 96. Her cumulative measured blood loss is 1,150 mL. The nurse continues close monitoring, checks her hemoglobin as ordered, and explains to her and her partner what happened and what to watch for.
Learning point
The bundle works because it turns recognition into action. Measuring blood loss, knowing the warning signs and starting all first-line treatments together, rather than one at a time, is where nursing care makes the difference.
References
American College of Obstetricians and Gynecologists. (2017). Practice bulletin no. 183: Postpartum hemorrhage. Obstetrics & Gynecology, 130(4), e168–e186. https://doi.org/10.1097/AOG.0000000000002351
Gallos, I., Devall, A., Martin, J., Middleton, L., Beeson, L., Galadanci, H., Alwy Al-beity, F., Qureshi, Z., Hofmeyr, G. J., Moran, N., Fawcus, S., Sheikh, L., Gwako, G., Osoti, A., Aswat, A., Mammoliti, K.-M., Sindhu, K. N., Podesek, M., Horne, I., . . . Coomarasamy, A. (2023). Randomized trial of early detection and treatment of postpartum hemorrhage. New England Journal of Medicine, 389(1), 11–21. https://doi.org/10.1056/NEJMoa2303966
