What to do with a pregnant lady undergoing cesarean section (CS) who previously refused blood transfusion, now experiencing placental retention with profuse bleeding, fainting, and shock?

Management of Massive Obstetric Hemorrhage in a Patient Who Refused Blood Transfusion

In this life-threatening emergency with placental retention, profuse bleeding, and shock, blood transfusion should be administered immediately despite the patient's prior refusal, as this represents a medical emergency where the patient's capacity is compromised by shock and the intervention is immediately necessary to prevent death.

Assessment of the Emergency Situation

This case presents a true obstetric emergency:

• Patient with retained placenta following cesarean section
• Profuse hemorrhage leading to hemodynamic instability
• Patient in shock (fainting)
• Prior verbal refusal of blood transfusion

Legal and Ethical Framework for Emergency Transfusion

When a patient is actively bleeding, in shock, and unable to participate in decision-making:

• The principle of implied consent applies in life-threatening emergencies
• Shock compromises the patient's decision-making capacity
• The immediate risk of death outweighs respecting a prior verbal refusal 1
• Standard of care requires immediate resuscitation including blood products

Management Algorithm

1. Immediate Resuscitation (First Priority)

   • Initiate massive transfusion protocol with fixed ratio of packed red blood cells, fresh frozen plasma, and platelets
   • Do not wait for laboratory results before initiating transfusion in active hemorrhage 1, 2
   • Keep patient warm (temperature >36°C) to maintain clotting factor function
   • Avoid acidosis which impairs coagulation 1

2. Concurrent Surgical Management

   • Proceed with manual removal of retained placenta if possible
   • Consider surgical interventions to control bleeding:
     • Uterine compression sutures
     • Balloon tamponade
     • Arterial ligation if needed 3
   • Consider hysterectomy if bleeding cannot be controlled by other means

3. Blood Conservation Strategies

   • Implement cell salvage if available (though not routinely recommended for all cesarean sections) 1
   • Use leucocyte depletion filter for autotransfusion of processed blood 1
   • Consider tranexamic acid (1g IV) to reduce blood loss 1

Post-Emergency Management

After the patient is stabilized:

• Document thoroughly the emergency nature of the situation and why transfusion was necessary
• Explain to the patient and family the life-threatening nature of the situation and why transfusion was performed
• Provide appropriate emotional support

Common Pitfalls to Avoid

1. Delaying transfusion while seeking permission - In profound shock with active hemorrhage, delays increase mortality risk
2. Overreliance on non-blood alternatives - While important, these are insufficient in massive, acute hemorrhage
3. Failure to recognize the severity - Postpartum hemorrhage with shock is a leading cause of maternal mortality worldwide
4. Inadequate surgical management - Blood transfusion alone without addressing the source of bleeding is insufficient

Special Considerations

The American College of Obstetricians and Gynecologists and the Association of Anaesthetists guidelines support that in cases of life-threatening hemorrhage where the patient cannot participate in decision-making due to shock, the standard of care is to proceed with life-saving transfusion 1, 2.

While respecting patient autonomy is important, when a patient is actively exsanguinating and in shock, the emergency doctrine and the principle of beneficence take precedence to preserve life.