Postpartum Haemorrhage in a Woman Who Declines Blood Products
A 29-year-old woman, gravida 3 para 2, delivers a 4.1 kg baby after a prolonged second stage. She has had two previous caesarean sections. Active management of the third stage is given, but 20 minutes later she has heavy vaginal bleeding with a boggy uterus. Estimated blood loss is 1200 mL and ongoing. Pulse is 118/min, blood pressure 95/60 mmHg, respiratory rate 24/min, and she is pale and anxious. She has a documented advance decision refusing all blood products on religious grounds, made antenatally and discussed with the obstetric team. Intravenous access is secured, and oxytocin and tranexamic acid have been given. The labour ward has uterotonics, balloons, and access to theatre, but no on-site interventional radiology; the regional unit is 45 minutes away.
1. List the causes of postpartum haemorrhage you must consider in this specific woman and explain how the history raises the probability of each.
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Use the four T's, tailored to this history:
- Tone (uterine atony): the most common cause overall. A 4.1 kg baby and a prolonged second stage overdistend and fatigue the uterus, impairing contraction after delivery. The boggy uterus supports this.
- Trauma: two previous caesareans create scar tissue and raise the risk of uterine rupture, especially with a prolonged second stage and a large baby; also consider cervical or vaginal lacerations and retained placenta.
- Tissue (retained products): a prolonged third stage and heavy bleeding raise the possibility of retained placental fragments, which prevent sustained contraction.
- Thrombin (coagulopathy): massive haemorrhage itself causes dilutional and consumptive coagulopathy; she may also have an underlying disorder. This becomes more likely as bleeding continues.
The prior caesareans are the key discriminator: they make uterine rupture and placenta accreta spectrum more likely, and they change both the examination and the decision to move to theatre. I would examine the genital tract, check placental completeness, and consider ultrasound or examination under anaesthesia rather than assuming atony alone.
2. She is deteriorating and refuses blood products. Outline your management priorities, including how you would respect her refusal while trying to save her life.
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The priorities are to stop the bleeding, restore circulating volume with what is acceptable to her, and plan escalation early.
- Resuscitate: two large-bore cannulae, warmed crystalloid, oxygen, monitoring, catheter to measure urine output, and keep her warm. Avoid over-filling with crystalloid, which worsens dilutional coagulopathy.
- Mechanical and pharmacological haemostasis: bimanual uterine massage and compression, continued oxytocin infusion, additional uterotonics per protocol, tranexamic acid, and balloon tamponade if available. Repair any genital tract laceration.
- Escalate to theatre early for examination under anaesthesia and, if needed, laparotomy - do not delay because of the transfusion question. Surgical options include uterine artery ligation, B-Lynch suture, and, as a last resort, hysterectomy.
- Respect the advance decision: she has capacity and a documented, antenatally discussed refusal of blood products. Do not give them covertly. Discuss acceptable alternatives explicitly - crystalloid, colloid, tranexamic acid, iron, erythropoietin, cell salvage if she accepts it and it is consistent with her beliefs, and recombinant factor VIIa where appropriate and agreed. Clarify with her, while she can participate, exactly which products are refused and which are permitted, and document this.
- Involve the team: senior obstetrician, anaesthetist, haematologist, and the regional unit; consider transfer if local options are exhausted.
- If she loses capacity, follow her valid advance decision and involve her family and the legal/ethics framework; do not substitute your own preference.
The judgement is that refusal of blood does not mean refusal of care - the full surgical and medical armamentarium should be used promptly.
3. Two hours later she has received 3 L of crystalloid, is drowsy, with pulse 130/min, blood pressure 85/50 mmHg, and oozing from cannula sites. What does this suggest and what are your next steps?
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Drowsiness, tachycardia, hypotension despite 3 L of crystalloid, and oozing from puncture sites indicate shock with developing coagulopathy - likely a combination of ongoing haemorrhage, dilutional coagulopathy from crystalloid, and consumptive coagulopathy. Oozing from cannula sites is a clinical clue to coagulopathy and should not be dismissed as a local problem.
Next steps:
- Reassess for an ongoing surgical cause: uterine rupture, retained products, or a genital tract injury must be excluded; this woman's prior caesareans make rupture a real possibility. Move to theatre if not already there.
- Send bloods: full blood count, coagulation screen, fibrinogen, urea and electrolytes, crossmatch (even if she refuses transfusion, the laboratory needs to know and alternatives such as fibrinogen concentrate or factor concentrates may be acceptable and should be discussed with her and the haematologist).
- Correct what can be corrected within her wishes: tranexamic acid, fibrinogen or factor concentrates if agreed, calcium, warming, and avoidance of further dilution.
- Mechanical control: balloon tamponade, compression sutures, vessel ligation, or hysterectomy as indicated.
- Anaesthetic and critical care involvement, and urgent discussion with the regional unit about transfer once stabilised, or about what the regional unit can offer if transfer is too hazardous.
- Revisit the advance decision with her if she is lucid, and involve family and the ethics/legal team if she is not. The judgement is to treat the coagulopathy and the surgical cause aggressively while continuing to honour a valid refusal of blood products.