What is the appropriate action for a pregnant woman in the delivery room who is experiencing significant blood loss and hypotension after initially refusing a blood transfusion?

Emergency Blood Transfusion in Life-Threatening Hemorrhage

Order blood and start transfusions immediately (Option D) - when a patient is experiencing life-threatening hemorrhage with impending loss of consciousness, the duty to preserve life supersedes previously stated refusals, as the patient is losing decision-making capacity and faces imminent death without intervention. 1, 2

Ethical and Legal Framework

The critical distinction here is that the patient is actively losing consciousness from hemorrhagic shock, which fundamentally changes the ethical landscape:

• A patient who is fainting from blood loss is losing decision-making capacity and cannot provide informed refusal at that moment 1, 3
• The original refusal was made when the patient had full capacity, but life-threatening hemorrhage with altered consciousness represents an emergency exception to informed refusal 4, 3
• The primary duty is to prevent imminent death - obstetric hemorrhage remains a leading cause of preventable maternal mortality 5, 4

Why Other Options Are Inappropriate

Option A (consent before fainting) is impractical and dangerous:

• A patient in hemorrhagic shock with impending loss of consciousness cannot provide valid informed consent due to compromised decision-making capacity 3
• Delaying transfusion to obtain consent when the patient is actively dying wastes critical seconds 1, 2

Option B (relative consent) is legally and ethically wrong:

• Family members cannot override a competent adult's medical decisions, but this patient is no longer competent due to hemorrhagic shock 4
• More importantly, there is no time for this process when facing imminent exsanguination 1, 2

Option C (press wound, call ethics) will result in maternal death:

• Ethics committees cannot be convened in real-time during active resuscitation 1
• Hemorrhagic shock can be rapidly fatal - patients with severe postpartum hemorrhage can exsanguinate within minutes 5, 4, 3
• Direct pressure alone is insufficient for major obstetric hemorrhage requiring transfusion 1, 2

Immediate Management Protocol

Declare massive hemorrhage and activate team response:

• A senior clinician must immediately assume team leader role and coordinate multidisciplinary care 1
• Assign specific roles: communications lead for laboratory liaison, runner for blood products, team member for vascular access 1

Resuscitation strategy:

• Resuscitate with warmed blood products, not crystalloids, in massive hemorrhage 1, 6
• Use Group O blood immediately (fastest availability), then group-specific, then cross-matched 1, 6
• Establish large-bore IV access - ideally 8-Fr central venous catheter in adults 7

Hemorrhage control:

• Early surgical intervention for definitive hemorrhage control is essential 1
• Consider uterine compression, uterotonic agents, and surgical hemostasis techniques 5
• Tranexamic acid 1g IV over 10 minutes should be administered immediately 1, 7

Coagulopathy prevention:

• Target fibrinogen level >1.5 g/L using fibrinogen concentrate 3-4g or cryoprecipitate (15-20 units) 1, 7
• Monitor coagulation parameters continuously 1, 2

Hemodynamic management:

• Restore organ perfusion but do not aggressively normalize blood pressure until bleeding is controlled 1, 6
• Target urine output >30 mL/hour as marker of adequate perfusion 6

Post-Resuscitation Considerations

• Admit to critical care unit for continued monitoring after bleeding control 1, 7
• Document the emergency circumstances that necessitated overriding the patient's prior refusal 4
• Discuss the situation with the patient once she regains full consciousness and capacity 4
• Initiate venous thromboprophylaxis as soon as bleeding is controlled, as patients rapidly develop prothrombotic state 1, 7

Critical Pitfall to Avoid

The most dangerous error is prioritizing autonomy over life preservation when the patient has lost decision-making capacity from hemorrhagic shock. A stated preference made while competent does not bind clinicians to allow preventable death when the patient can no longer participate in decision-making due to the medical emergency itself. 4, 3