Postpartum haemorrhage after home birth and a family that refuses transfusion

This is postpartum haemorrhage from uterine atony with hypovolaemic shock. Act simultaneously, not sequentially. Call for help, place the patient flat with legs elevated, give high-flow oxygen, and start rapid crystalloid infusion through the existing line while a second large-bore line is placed. Give tranexamic acid 1 g intravenously over 10 minutes as early as possible, ideally within 3 hours of birth. Give oxytocin 10 international units intramuscularly or by slow intravenous infusion, then start a continuous oxytocin infusion; add misoprostol 800 micrograms sublingually or rectally if oxytocin alone is insufficient. Perform bimanual uterine massage and compression and empty the bladder with a catheter. Monitor pulse, blood pressure, urine output, and mental status continuously. Do not delay blood products while waiting for consent discussions; the patient is in shock and the estimated loss already exceeds 1000 mL. At the same time, identify the cause of atony: retained placenta, genital tract trauma, or bladder distension. If the uterus remains boggy despite these measures, escalate to balloon tamponade or surgical compression, and arrange transfer to a facility with intensive care and surgical capacity.

The patient is an adult with capacity when well, but she is currently confused and hypotensive, so she cannot give informed consent or refusal at this moment. Her husband is not automatically her legal decision-maker for a life-saving intervention, and a relative's religious objection cannot override the patient's own previously expressed wishes or, in their absence, the clinician's duty to preserve life in an emergency. The correct sequence is: (1) treat the reversible causes and stabilize as far as possible with uterotonics, tranexamic acid, compression, and fluids; (2) make repeated, documented attempts to ascertain the patient's own wishes, including asking whether she has a written advance statement or previously stated a view; (3) explain to the husband in plain language that his wife is dying and that transfusion is the indicated treatment, and record his response; (4) if the patient remains unable to decide and the situation is immediately life-threatening, proceed with transfusion under the emergency necessity principle, documenting the reasoning, the attempts at communication, and the involvement of the hospital's ethics or legal authority. This is not a decision to be made silently or by one junior clinician; escalate to the most senior physician on site and to hospital administration. The ethical justification is beneficence and non-abandonment, with the least intrusive effective option chosen.

Document a time-stamped record of arrival, vital signs at each stage, estimated blood loss and how it was estimated, every drug with dose and route, every procedure, the response to treatment, and the exact content of the discussions with the husband including who was present. Record the patient's mental status over time and the point at which she regained capacity, and obtain her own account of her wishes afterwards. Notify the case through the required maternal mortality and near-miss reporting channel, and report the home birth attended by an unskilled attendant to the territorial health authority so that the circumstances can be reviewed. Quality actions: audit the interval from arrival to first uterotonic and to tranexamic acid, check whether active management of the third stage was used at the home birth, review the availability of blood products and the absence of intensive care at this hospital, and feed the findings into staff training and into the referral pathway for high-risk pregnancies. The case also tests whether the team can separate a legitimate religious discussion from an unlawful delay in emergency care, and that distinction should be written into the debrief.