Postpartum haemorrhage remains a leading cause of maternal mortality across Nigeria. Clinically, bleeding is classified based on timing following delivery. Primary postpartum haemorrhage occurs within the first 24 hours after birth, typically involving blood loss exceeding 500 mL following a vaginal delivery or 1,000 mL following a Caesarean section. Secondary postpartum haemorrhage, alternatively termed late postpartum haemorrhage, develops between 24 hours and 12 weeks postpartum. While primary PPH is frequently driven by uterine atony, secondary cases often stem from retained products of conception or subinvolution complicated by infection.
A structured framework helps midwives rapidly identify the root cause of excessive postpartum bleeding. The mnemonic represents four distinct categories:
Active management significantly reduces the incidence of primary postpartum haemorrhage. Midwives should routinely practice AMTSL for every birth unless contraindicated.
When bleeding escalates, simultaneous resuscitation and medical intervention are mandatory. Call for assistance immediately and summon the multidisciplinary team. Secure large-bore intravenous access, draw blood for a complete blood count and coagulation profile, and begin rapid crystalloid fluid resuscitation.
Pharmacological management steps up systematically when oxytocin infusion fails to control atony. Second-line agents include ergometrine, carboprost, and misoprostol. Midwives must check maternal blood pressure before administering ergometrine, as it causes severe hypertension and is strictly contraindicated in women with pre-eclampsia.
If medical therapies fail to stop bleeding caused by uterine atony, mechanical options like uterine balloon tamponade provide a safe, effective, and conservative next step before resorting to major surgery. A specialized balloon catheter or an improvised alternative, such as a condom catheter tied to a Foley catheter, is inserted into the uterine cavity under aseptic technique. Once inside, the balloon is filled with sterile fluid until it exerts direct pressure against the bleeding myometrial walls. Successful tamponade compresses the open blood vessels and halts the haemorrhage within minutes, preserving future fertility.
When conservative measures and balloon tamponade fail, surgical intervention becomes necessary to save the patient's life. Surgical options range from uterine artery ligation to compression sutures. The B-Lynch brace suture is a well-known technique where continuous sutures compress the anterior and posterior walls of the uterus together mechanically. When compression sutures and vessel ligations fail to control life-threatening haemorrhage, an emergency hysterectomy remains the definitive, life-saving procedure of last resort.
Managing a severe postpartum haemorrhage requires seamless collaboration among midwives, obstetricians, anaesthetists, and laboratory personnel. Clear communication ensures rapid blood product delivery and surgical readiness. Once the acute crisis resolves, accurate and timely documentation is legally and clinically essential; the midwife must record exact timelines of estimated blood loss, medications given, fluid volumes, and vital signs. Finally, post-crisis care demands compassionate psychological support, as traumatic deliveries frequently trigger postpartum post-traumatic stress disorder or severe anxiety.