The Case of Mary Twale

last authored: Dec 2011, David LaPierre
last reviewed:




Mary is a 34 year-old pregnant woman who is admitted to the labour and delivery unit in a rural hospital. She is at 39 wees gestational age and this pregnancy has been uneventful. However, during her first pregnancy, she bleed sufficiently to require a transfusion.


She has been having contractions for the past eight hours, and she thinks her 'water broke' two hours ago. Her cervix is 6 cm dilated.

What is the definition of postpartum hemorrhage?

Postpartum hemorrhage (PPH) is defined as:

  • blood loss greater than 500 ml for vaginal delivery
  • blood loss greater than 1000 ml for Cesarean section

What are the causes and risk factors for postpartum hemorrhage?

Causes and risk factors for PPH include the four T's:

decreased Tone, also known as atony, when the uterus fails to appropriately contract after birth:

  • prolonged or precipitous labour
  • previous PPH
  • large infant
  • induction or augmentation
  • infection


  • retained placenta, blood clot
  • fibroids, other uterine anomalies



  • spontaneous laceration to the vagina or cervix
  • episiotomy
  • increased risk with instrument delivery
  • uterine rupture


  • coagulopathy
  • thrombocytopenia
  • sepsis
  • disseminated intrvascular coagulation
  • anti-coagulant medications


What may be done to prevent postpartum hemorrhage?

Steps to take to prevent PPH include:

  • administration of IM or IV oxytocin with delivery of the anterior shoulder
  • massage of the uterus to increase contraction
  • active delivery of the placenta, with adequate traction






Oxytocin was given during the delivery of the anterior shoulder, but after delivery of the placenta, Mary indeed begins bleeding profusely.

What are your initial managment steps?

PPH can be a life threatening emergency.

Steps to take include:

  • ask for help
  • provide IV fluids (normal saline or ringer's lactate)
  • begin or maintain an oxytocin IV infusion
  • remove the placenta if still present
  • provide bimanual compression of the uterus, feeling for and removing clots and placental tissue if found
  • ask for blood to be maintained in reserve
  • assess for, and repair, lacerations
  • insert a bladder catheter to assess fluid status and reduce pressure on the uterus

What investigations, if any, do you perform?

Send bloodwork for:

  • CBC
  • type and screen
  • consider coagulation studies

An ultrasound can be helpful in assessing for retained products in the uterus, especially in late-onset hemorrhage.




You have an IV running with normal saline bolus and oxytocin, and only a minor laceration of the vagina was noted. The uterus remains boggy.



What are your next management steps? What medications do you consider?

Along with oxytocin, other medications that can be used include:

  • misoprostol
  • ergometrine - caution with hypertension
  • methylergonovine (Methergine)
  • 15-methyl prostaglandin (Hemabate)

Inspect blood in an unheparinized tube for clotting; if blood remains liquid after x min, consider transfusion of platelets and coagulation factors.

If the uterus remains atonic, prepare for the OR. Surgical interventions can include:

  • hematoma drainage
  • uterine packing
  • B-lynch compression sutures following laparotomy
  • hysterectomy


Mary's bleeding settles with administration of misoprostol and ongoing bimanual compression. Her vitals remain stable, and her bloodwork is normal. Her hemoglobin at the time of delivery is 112, but the next morning is 76. After discussion, she receives a unit of packed red blood cells to treat her anemia.

She hs an otherwise uneventful recovery and is discharged two days after her delivery.


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