A 32 year old female presents to the ED with PV bleeding 8 hours post delivering a healthy baby girl at home. It’s her second pregnancy, and second child. She had no complications with her first pregnancy, or with this one, and was deemed low risk for a home delivery.
Initially she just noticed a little bit of spotting, but over the last hour the bleeding has become very heavy and she has started flooding.
Thankfully primary postpartum haemorrhage (PPH) is a rare presentation to the Emergency Department. However, it is the most common form of major obstetric haemorrage, and obstetric haemorrhage is the second leading cause of maternal death in the UK and Ireland.  When these patients do present with significant bleeding it can be pretty scary because although we know it is a time critical, high stakes presentation, we often don’t feel very prepared or very knowledgeable in dealing with them down in the ED.
Assessment (and management)
Primary postpartum haemorrhage is bleeding which occurs within the first 24 hours of giving birth. It is defined as minor if there is 500 -1000ml blood loss with no clinical sign of shock, and major if >1000mls of blood has been lost, or if there are signs of shock.  Quantifying how much blood has been lost is really difficult, and as such frequently inaccurate, so often we have to be guided more by clinical signs. However, it is also worth knowing that, due to the increased circulating volume that occurs with pregnancy, vital signs may not alter until 1000ml of blood has already been lost. Also, remember if your patient is very little, they will require less blood loss to get to the shocked stage!
If the patient has a minor PPH then your ED team may be able to manage the patient and transfer them to an obstetric area.
Let’s assume our patient is having a major PPH:
Get help. PPH can be difficult to manage, get senior help as soon as you suspect this diagnosis. If your hospital has maternity or obstetric services on site then alert the midwives and obstetric doctors and ask them to come to help in resus. Early anaesthetic involvement is also recommended as these patients can deteriorate very quickly and if medical treatment does not succeed the patient will need to go to theatre for further management.
Activate the major haemorrhage protocol, get your level 1 infuser set up (see video from Vicky) and start by treating as you would any other patient presenting with major haemorrhage.
Special measures then need to be considered for haemorrhage control, and these address the four potential causes of PPH. 
2) Tissue (retained products)
4) Thrombin (abnormalities of coagulation)
Management includes uterine massage, to remove any clots, and bimanual compression, until the uterus is contracted. Medications, such as oxytocin and ergometrine, can be given to encourage uterine contraction. Many vaginal tears can be sutured under local anaesthetic.If these methods do not succeed in stopping the bleeding, then the patient will need to go to theatre for further management. This could potentially include intrauterine balloon tamponade, interventional radiology or even hysterectomy. [1,2]
Accurate initial assessment of patients with PPH is really challenging – don’t be falsely reassured by “normal” looking vital signs, and let senior ED nursing and medical staff know about these patients early.
[RCN Emergency Nurse Competencies: CCT1, CD 1.7, CD2.4]
 Royal College of Obstetricians and Gynecologists. (2016) Prevention and Managament of Postpartum Haemorrhage. Green-top Guideline No.52. [online] Available at: https://obgyn.onlinelibrary.wiley.com/doi/epdf/10.1111/1471-0528.14178
 Baker, K. (2014) How to….manage primary postpartum haemorrhage. Midwives magazine, 4, pp 34-35 [online] Available at: https://www.rcm.org.uk/news-views-and-analysis/analysis/how-to-manage-primary-postpartum-harmorrhage