Blood loss occurs when a blood vessel is damaged, allowing blood to escape the circulatory system. Midwives must quickly identify the source of bleeding based on how the blood looks and flows.
Estimating blood loss visually is notoriously difficult, especially on dark skin or when blood mixes with amniotic fluid or other body fluids. Midwives should rely heavily on systemic vital sign changes rather than just pooling blood on the floor or bed.
Initial signs of moderate blood loss include a slightly raised heart rate and mild anxiety as the body tries to compensate. As blood volume drops further, the body pulls blood away from the skin and limbs to protect the brain and heart. This causes the skin to turn pale, cool, and clammy. Blood pressure remains normal at first due to vasoconstriction, but eventually drops sharply when the body can no longer compensate, leading to a weak, thready pulse and confusion.
The first and most effective step to control external bleeding is direct physical pressure. Place a clean gauze pad, cloth, or sterile dressing directly over the wound and press down firmly using the palm of the hand. If blood soaks through the first layer, do not remove it; simply add another pad on top and continue pressing. Removing the initial pad disrupts fragile clots that have already begun forming.
Once bleeding slows or stops, secure the dressing with a pressure bandage wrapped snugly—but not too tightly—to maintain continuous pressure without cutting off distal circulation.
A tourniquet is a life-saving device used only when direct pressure fails to control severe, life-threatening limb bleeding, or in mass-casualty situations where multiple injuries demand immediate triage.
Place the tourniquet two to three inches above the bleeding site on the limb, making sure never to place it directly over a joint like the knee or elbow. Tighten the windlass rod until the bleeding completely stops and the distal pulse disappears. Note the exact time of application on the strap or the patient's skin. Once applied, a tourniquet should not be loosened or removed by field personnel, as releasing it can cause a sudden surge of toxins and a fatal drop in blood pressure.
Internal bleeding occurs inside body cavities or tissues, often resulting from trauma, ruptured ectopic pregnancies, or severe postpartum hemorrhage involving concealed uterine bleeding. Because blood is trapped inside, midwives cannot apply direct pressure.
As blood pools internally, circulating volume plummets, leading to hypovolemic shock. Warning signs include a rapid, weak pulse, falling blood pressure, extreme thirst, pale skin, restlessness, and eventually unresponsiveness. Management focuses on keeping the patient warm, administering high-flow oxygen if available, establishing intravenous access, and arranging immediate transport to a surgical facility.
When stabilizing a patient with severe hemorrhage, time is tissue and life. Once basic life-saving interventions like pressure dressings or intravenous lines are in place, prepare the patient for immediate transfer to a higher-level facility.
Keep the patient warm with blankets to prevent hypothermia, which worsens bleeding disorders. Ensure any applied tourniquets remain fully exposed and visible to receiving medical staff. During the handoff, provide a clear, concise report detailing the estimated blood loss, interventions performed, and the time tourniquets were applied.