Obstetric

Postpartum haemorrhage with haemodynamic instability

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Adult · 35yr · female

Patient Information

Dispatch	You are called to a patient (Sarah Nguyen, 35-year-old female) who has just given birth at a community family festival. Bystanders report she has delivered a baby and is now bleeding heavily.
Patient	Sarah Nguyen — 35yr (65kg)
Incident History	Pt delivered a baby approximately 10 minutes ago in the event medical tent. Bystanders assisted with delivery. Pt is now pale, weak and there is a large amount of blood visible on the ground and on the mat beneath her. The placenta has not yet been delivered.
Emergency Contact	Michael Nguyen (Husband) — 0412 774 391

Initial Rapid Assessment

Response	Voice
Airway	Patent. Nil airway obstruction. Nil stridor. Patient able to speak in short sentences.
Breathing	Tachypnoeic. RR 22. Shallow effort. Nil wheeze or crackles. SpO2 96% on room air.
Circulation	Rapid and weak radial pulse. Skin pale, cool and clammy peripherally. Visible blood pooling beneath patient — estimated > 500 mL on mat and pad. CRT 3 seconds. BP 84/56.
Disability	GCS 13 (E3V4M6). Confused, not oriented to time. Oriented to person and place. Anxious and distressed.
Exposure	Perineum visible — ongoing haemorrhage from perineal area. Uterine fundus palpable but soft and poorly contracted. Placenta not yet delivered. Newborn wrapped and breathing spontaneously beside patient.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	96% (RA)	Mild	22	118	84/56	3s	13	4 4 ++	36.1	–	6
10 mins	98% (O2 NRB 15L)	Mild	24	132	74/48	4s	11	4 4 ++	35.8	–	7

History Taking

Treatment Response

Diagnosis

This patient is suffering from Postpartum Haemorrhage (PPH) with haemodynamic instability — estimated blood loss exceeding 500 mL following vaginal delivery with an undelivered placenta and a soft, poorly contracted uterus (uterine atony).

Facilitator Triggers — if trainees miss a critical step

! (If EHS officer does not call for CSP support within the first 2 minutes, the patient's GCS drops to 11 and she becomes increasingly confused and stops responding to questions appropriately.)
! (If the officer does not apply high-flow oxygen via non-rebreather mask within 3 minutes, SpO2 falls to 93% on room air and respiratory distress increases to moderate.)
! (If direct pressure is not applied to the perineal bleed, bleeding visibly increases — have facilitator state 'the blood-soaked pads are saturating faster now.')
! (If trainee does not recognise haemodynamic instability and fails to call for CSP support, patient BP falls to 68/40 at 10 minutes.)
! (If trainee attempts fundal massage — facilitator intervenes: 'Uterine massage is not within EHS scope. Maintain direct pressure on the perineum and call for CSP support.')
! (If trainee does not keep the patient warm, add 'patient is now shivering, temperature 35.4°C' to prompt thermoregulation management.)
! (If trainee does not reassess vitals at 5 minutes, BP and GCS will deteriorate faster — facilitator states: 'the patient is now asking where she is and reaching for the baby weakly.')

Treatment Objectives

1. Don appropriate PPE — gloves, eye protection — given blood and body fluid exposure risk.
2. Perform Primary Survey — confirm airway patent, assess breathing and circulation, identify catastrophic haemorrhage.
3. Control visible perineal haemorrhage — apply direct firm pressure to the perineum using sterile/non-adherent pad.
4. Position patient supine — do not sit patient upright given hypotension.
5. Administer Oxygen via non-rebreather mask at 10–15 L/min targeting SpO2 94–98%.
6. Keep patient warm — wrap with blankets or Ready-Heat blanket to prevent heat loss and reduce hypothermia risk.
7. Perform and document full Vital Sign Survey — BP, HR, RR, SpO2, GCS, temperature, CRT — repeat every 5 minutes given time-critical status.
8. Recognise haemodynamic instability — BP 84/56, HR 118, GCS 13, CRT 3s, blood loss > 500 mL — classify as time-critical.
9. Contact CSPSOC for management advice — document all advice on ePCR.
10. DO NOT perform fundal massage — uterine massage is beyond EHS scope.
11. Ensure newborn is assessed, kept warm, and monitored — allocate a bystander or second officer if available.
12. Call for CSP support immediately — this is a time-critical haemorrhage requiring advanced care.
13. Continuously reassure patient — provide calm, clear communication throughout.
14. Perform Secondary Survey and CNS Survey as clinically indicated and time permits.
15. Complete IMISTAMBO handover to receiving crew — include estimated blood loss, time of delivery, placenta status, vitals trend, interventions performed, and CSPSOC advice received.
16. Scenario ends on arrival of ambulance and IMISTAMBO handover.
17. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Postpartum Haemorrhage · Hypovolemic Shock · Oxygen Delivery · Primary Survey · Secondary & CNS Survey · Ready Heat Blanket · Blood Pressure · Pulse & Respirations · Pulse Oximetry

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Signs/Symptoms	Heavy vaginal bleeding post delivery. Feeling faint, dizzy and weak. Complaining of lower abdominal cramping.
Allergies	Nil known drug allergies.
Medications	Iron supplements during pregnancy. No other regular medications.
Pertinent History	G2P2. Uncomplicated pregnancy. No known placenta praevia or pre-eclampsia. Previous vaginal delivery 3 years ago with no complications. No known bleeding disorders. Attended antenatal appointments. Estimated gestation 39 weeks.
Last Oral Intake	Small meal approximately 4 hours ago. Water 1 hour ago.
Events Leading	Patient attended a community family festival at Whiteman Park. Went into labour at the event. Delivered in the medical tent with bystander assistance before EHS arrival. Placenta not yet delivered.
Treatment Prior	Bystanders applied gentle pressure with pads from first aid kit. Newborn has been wrapped and placed skin-to-skin briefly but separated when bleeding worsened.

Onset	Bleeding began approximately 5 minutes after delivery of the baby, approximately 10 minutes ago. Has been increasing in volume since.
Pain	Lower abdominal cramping pain rated 6/10. Describes it as constant and diffuse.
Quality	Cramping, constant.
Radiates	Nil radiation.
Severity	6/10