Skip to content
Browse cases

Case 09 · Obstetrics

Atonic postpartum haemorrhage

Twenty minutes after her fourth baby, an anaemic mother in a district hospital labour room will not stop bleeding, and the pads hide how much she has lost. Measure the loss, work through the four Ts, give the right uterotonics and tranexamic acid, transfuse in time, and escalate when drugs fail.

PlayableClinical review pendingIntermediateAbout 30–90 simulated minutesHindi · English · both
Start Case 09All cases

About this case

What you will practise

Learning objectives

  • Recognise postpartum haemorrhage early, measure the blood loss and use the shock index.
  • Work through the four Ts: tone, tissue, trauma and thrombin, and empty the bladder.
  • Give oxytocin, then second-line uterotonics in order, checking their contraindications.
  • Give tranexamic acid early, within 3 hours of birth.
  • Replace blood and clotting factors in time without overloading her with clear fluid.
  • Escalate to bimanual compression, balloon tamponade and theatre when drugs fail.

Key decisions this case tests

  • How much blood has she really lost?
  • How fast should IV oxytocin go?
  • Ergometrine or carboprost, and what do you check first?
  • When to stop clear fluid and start blood.
  • When is it time for a balloon, or for theatre?

Reference basis

  • World Health Organization. Recommendations for the prevention and treatment of postpartum haemorrhage, 2012, and recommendation on tranexamic acid for PPH, 2017.
  • WOMAN Trial Collaborators. Lancet 2017;389:2105–16.
  • Gallos I et al. E-MOTIVE trial. N Engl J Med 2023;389:11–21.
  • RCOG Green-top Guideline No. 52: Prevention and management of postpartum haemorrhage.

Content version 1.0 · November 2026 · clinical review pending. See the Clinical content policy.

Before you start

The physiology is a simplified teaching model: uterine tone, bleeding rate, coagulation and volume responses are timed for learning, not prediction. Doses follow the cited guidelines but have not yet been signed off by a clinician.

Visle is for education only and is not medical advice. Heavy bleeding after childbirth is an emergency: get skilled help immediately.

Ready for another emergency?

Case 08 puts you beside a 36-week mother who fits on the trolley.

Play Case 08Case library