Responding to Postpartum Hemorrhage

Scenario

Immediately following delivery, your patient’s pad and bed are saturated with blood.
You estimate blood loss at over 800 mL. The uterus is boggy despite firm massage, and bleeding continues.
Vital signs: HR 122, BP 84/52, RR 24, skin pale and clammy.

Question: What are your immediate priorities and sequence of interventions?

Best Practice Answer

1. Recognize the Emergency:

   • This is postpartum hemorrhage (PPH) — defined as >500 mL after vaginal or >1000 mL after cesarean delivery, or any blood loss causing hemodynamic instability.
   • Rapid recognition is critical because delays of even minutes can lead to shock or DIC.

2. Perform Immediate Nursing Actions (Simultaneously if Possible):

   • Call for help / activate obstetric emergency response.
     Announce clearly: “Postpartum hemorrhage, Room X.”
   • Massage the uterine fundus continuously until firm — this is your first physical intervention.
   • Ensure the bladder is empty — insert a straight catheter if necessary, as a full bladder prevents uterine contraction.
   • Assess for retained products or perineal lacerations if uterus remains firm but bleeding persists.

3. Initiate the PPH Medication Sequence: (Follow institutional protocol or the “uterotonic ladder.”)

   • 1st: Oxytocin (Pitocin) — continuous IV infusion (10–40 units in 1 L NS or LR).
   • 2nd: Misoprostol 800–1000 mcg per rectum if bleeding continues.
   • 3rd: Carboprost (Hemabate) 250 mcg IM q15–90 min (max 8 doses) unless asthmatic.
   • 4th: Methylergonovine (Methergine) 0.2 mg IM q2–4h unless hypertensive.
   • Note contraindications and ensure each is documented per order set.

4. Establish Circulatory Support:

   • Insert two large-bore IV lines (18G or larger).
   • Begin rapid fluid resuscitation with warmed isotonic crystalloids (NS or LR).
   • Draw labs: CBC, coagulation panel, type & crossmatch.
   • Monitor urine output with Foley catheter (target ≥30 mL/hr).
   • Prepare for massive transfusion protocol if bleeding continues (1:1:1 ratio of RBC:FFP:platelets).

5. Ongoing Assessment and Communication:

   • Reassess fundal tone and bleeding every 5 minutes during active intervention.
   • Continuously monitor VS for tachycardia, hypotension, decreasing LOC.
   • Report estimated and quantified blood loss (QBL) precisely.
   • Document time of recognition, interventions, and provider notifications.

6. Anticipate Escalation of Care:

   • If uterotonics fail → prepare for Bakri balloon, surgical exploration, or hysterectomy.
   • Maintain emotional support for the patient and family throughout.

Real-World Application

This question tests your ability to act decisively and sequentially under pressure.
Interviewers assess whether you understand:

• The first-line physical response (fundal massage),
• The correct order of uterotonics,
• And the importance of rapid communication and documentation.

PPH is a top cause of maternal morbidity worldwide — timely nursing response is literally life-saving.
This question is common for L&D, ER cross-training, and critical care interviews.

Tip: State your sequence clearly in interviews:
“I’d call for help, massage the fundus, empty the bladder, start oxytocin, and prepare additional uterotonics and IV fluids — documenting and communicating throughout.”
This structured answer demonstrates both technical precision and leadership under crisis.