Postpartum haemorrhage remains a leading cause of maternal mortality across Nigeria. Recognizing the transition from normal physiological blood loss to a life-threatening emergency requires constant vigilance. Midwives must never rely solely on visual estimation, as blood loss is notoriously underestimated during delivery.
Immediate escalation saves lives. The moment blood loss crosses the threshold or maternal vital signs begin to drift, the midwife must sound the emergency alarm, mobilize the multidisciplinary team, and initiate the standardized PPH response bundle.
When major PPH strikes, systematic action replaces panic. The resuscitation bundle follows the MEMO or standard emergency checklist approach: Music to silence, or rather, communication that is clear and direct, focusing on the 4 Ts (Tone, Tissue, Trauma, Thrombin).
Two large-bore intravenous cannulas (16G or 18G) must be sited immediately. Draw blood for urgent laboratory investigations: full blood count, clotting profile, cross-matching at least four units of blood, and kidney function tests. Infuse warmed crystalloids rapidly while awaiting blood products.
Call for help early—inform the obstetrician, anaesthetist, blood bank, and senior nursing staff. Keep the mother warm using blankets to prevent hypothermia, which worsens coagulopathy. Administer high-flow oxygen via a face mask to maintain tissue perfusion.
Uterine atony accounts for the vast majority of postpartum haemorrhage cases. The initial mechanical response is bimanual compression and continuous bimanual uterine massage to stimulate muscular contraction.
Medical management follows a tiered pharmacological ladder:
When medical therapy fails to control uterine atony, mechanical tamponade provides a rapid, uterus-preserving solution. An intrauterine balloon applies outward hydrostatic pressure directly against the bleeding myometrial sinuses, halting capillary and venous oozing.
Specific devices like the Bakri balloon or improvised alternatives such as a condom catheter tied securely to a Foley catheter are utilized. The device is inserted transcervically into the uterine cavity under aseptic conditions. Once inside, the balloon is filled with sterile normal saline (typically between 300 to 500 mL) until resistance is felt or bleeding stops.
Continuous drainage through the central lumen of the device is vital. If blood accumulates silently above the balloon, the uterus can re-expand unnoticed, masking ongoing internal haemorrhage. Broad-spectrum prophylactic antibiotics are given to reduce infection risks during balloon retention, which usually lasts for 24 hours before gradual deflation.
If medical management and balloon tamponade fail, surgical conservation of the uterus remains a priority, especially for women desiring future fertility. The B-Lynch brace suture is a compression technique designed to mechanically compress the anterior and posterior walls of the uterus together.
Performed during laparotomy, the procedure involves using a large absorbable suture (such as No. 2 Chromic Catgut) on a round-bodied needle. The suture enters the lower uterine segment, loops over the fundus, compresses the cavity vertically, and ties securely.
Success depends on accurate placement and prior confirmation that the bleeding is purely atonic and not caused by uncorrected coagulopathy or trauma. Complications, though rare, can include uterine necrosis if stitches are tied excessively tight or tissue erosion.
When conservative surgical measures fail to achieve haemostasis, escalation is mandatory to save the mother's life. Delaying definitive surgery while a patient exsanguinates is a fatal error.
Clear communication with the operating theatre team and blood bank is critical as massive transfusion protocols are enacted simultaneously.
Managing major PPH requires seamless teamwork. The midwife manages the airway, monitors vitals, and administers drugs; the obstetrician performs surgical interventions; the anaesthetist manages fluid resuscitation and blood pressure; and laboratory scientists ensure rapid blood product availability.
Once the bleeding stops and the patient is stable, post-resuscitation care begins: