A 28-year-old primigravida delivers vaginally. Within 10 minutes of delivery of the baby, she has brisk vaginal bleeding (estimated blood loss 600 mL). The placenta is still retained. What is the drug of choice for management of this postpartum hemorrhage?

Explanation

## First-Line Management of Postpartum Hemorrhage **Key Point:** Oxytocin is the first-line uterotonic agent for prevention and treatment of postpartum hemorrhage in the third stage of labor and immediate postpartum period. ### Mechanism of Action Oxytocin causes sustained uterine contraction (tetanic contraction) via oxytocin receptors on myometrial cells, which compresses bleeding vessels and controls hemorrhage. ### Dosing and Administration - **IV bolus:** 10 IU (preferred in hospital setting) - **IM injection:** 10 IU (if IV access unavailable) - **Onset:** 2–3 minutes (IV), 3–7 minutes (IM) - **Duration:** 15–20 minutes ### Why Oxytocin is First-Line | Feature | Oxytocin | Ergot Alkaloids | Misoprostol | |---------|----------|-----------------|-------------| | **Onset** | 2–3 min (IV) | 6–7 min | 8–10 min | | **Duration** | 15–20 min | 45–60 min | 60–90 min | | **Efficacy** | Excellent | Excellent | Good | | **Side effects** | Minimal | HTN, coronary vasospasm | GI upset, fever | | **Contraindications** | Few | Hypertension, preeclampsia | — | | **Cost** | Moderate | Low | Low | | **Stability** | Requires cold chain | Stable | Stable | **High-Yield:** Oxytocin is the WHO-recommended first-line agent for PPH in both hospital and community settings because of rapid onset, excellent efficacy, and minimal side effects. ### Clinical Pearl In this case, the placenta is retained (third stage prolonged). Oxytocin should be given immediately to control bleeding while preparing for manual removal of placenta or other interventions. ## Sequence of Uterotonic Use (Escalation) ```mermaid flowchart TD A[Postpartum Hemorrhage]:::outcome --> B[First-line: Oxytocin 10 IU IV/IM]:::action B --> C{Response adequate?}:::decision C -->|Yes| D[Continue oxytocin infusion]:::action C -->|No| E[Add second agent]:::action E --> F[Ergot alkaloid or Misoprostol]:::action F --> G{Still bleeding?}:::decision G -->|Yes| H[Tranexamic acid + surgical intervention]:::urgent G -->|No| I[Supportive care, monitor]:::outcome ``` **Mnemonic:** **OMEN** — Oxytocin (first), Methylergonovine (second), Ergot alkaloids (second), Nitroglycerin (if HTN issue) — though the standard escalation is Oxytocin → Ergot/Misoprostol → Tranexamic acid + surgery. **Warning:** Do NOT give ergot alkaloids before delivery of the baby or before placental delivery — risk of uterine tetany, retained placenta, and fetal compromise.