What is the appropriate action for a pregnant woman in the delivery room who is experiencing severe bleeding and hypotension, and is at risk of fainting, after refusing a blood transfusion?

Immediate Resuscitation Takes Priority—Transfuse Without Additional Consent

In a pregnant woman experiencing life-threatening hemorrhage with impending loss of consciousness during delivery, you should immediately initiate blood transfusion and aggressive resuscitation without seeking additional consent from the patient, her husband, or an ethics committee. The medical emergency exception to informed consent applies when a patient loses decision-making capacity and immediate intervention is necessary to prevent death or serious harm 1.

Legal and Ethical Framework

The patient's advance refusal of blood transfusion does not apply once she loses consciousness and faces imminent death. While a competent pregnant woman retains full decision-making capacity throughout labor and delivery under normal circumstances, this capacity is lost when she becomes unconscious or unable to communicate 2. At that point, the emergency exception permits life-saving treatment without explicit consent 1.

Key Principles:

• The pregnant woman—except under extremely limited circumstances—retains legal competence during labor, but loss of consciousness from hemorrhagic shock represents one of those rare exceptions where capacity is lost 2
• The medical emergency exception permits healthcare practitioners to provide life-saving treatments in the absence of explicit assent when the patient cannot consent and delay would result in serious harm or death 1
• Aggressive resuscitation of the mother is the best management for the fetus, as fetal outcome is directly related to maternal outcome 3

Immediate Management Protocol

First-Line Interventions (Within Seconds):

Apply direct pressure to any visible bleeding source while simultaneously initiating the following 1:

• Establish large-bore IV access above the diaphragm (two 16-gauge or larger catheters) 1, 4
• Activate massive transfusion protocol immediately 5, 6
• Position patient with left uterine displacement to relieve aortocaval compression 1
• Administer 100% oxygen 1

Hemorrhage-Specific Resuscitation:

Transfuse blood products in 1:1:1 ratio (packed red blood cells:fresh frozen plasma:platelets) rather than crystalloid alone to avoid dilutional coagulopathy 5. Do not wait for laboratory results—treat based on clinical presentation of hypotension and active bleeding 5.

Administer tranexamic acid 1 gram IV immediately if not already given, as it must be given within 1-3 hours of bleeding onset (number needed to treat: 276 to prevent one maternal death) 4, 6. Delaying beyond 3 hours significantly reduces effectiveness 6.

Give slow IV oxytocin (<2 U/min or 5-10 IU IM) to promote uterine contraction while avoiding systemic hypotension 4, 5, 6.

Critical Monitoring:

• Keep patient warm (temperature >36°C) as hypothermia impairs clotting factor function 5
• Prepare for potential disseminated intravascular coagulopathy (DIC), which occurs in >80% of severe hemorrhage cases 5
• Have low threshold for surgical intervention including hysterectomy if bleeding is uncontrollable 5

Why Other Options Are Incorrect

Option A (Take consent before she faints): This is impractical and dangerous. A patient experiencing hemorrhagic shock with impending loss of consciousness cannot provide valid informed consent due to altered mental status from hypoperfusion 1, 7. Attempting to obtain consent delays life-saving treatment.

Option B (Call husband for consent): This is legally and ethically incorrect. The husband has no legal authority to consent or refuse treatment on behalf of his conscious or unconscious wife 2. Even if the patient had expressed wishes while competent, the emergency exception supersedes advance refusals when death is imminent 1.

Option C (Press on wound until ethics committee contacted): This is dangerous and inappropriate. Ethics committees are not designed for real-time emergency decision-making 1. Direct pressure alone is insufficient for managing severe obstetric hemorrhage, which requires immediate transfusion, uterotonics, and potential surgical intervention 4, 5, 7.

Common Pitfalls to Avoid

Do not delay transfusion waiting for "one more attempt" to obtain consent—maternal mortality from obstetric hemorrhage is largely preventable with immediate aggressive resuscitation 7. Most deaths due to hemorrhage occur because clinicians fail to react immediately with effective resuscitative measures 7.

Do not assume the patient's advance refusal applies during unconsciousness—the physical pain, emotional stress, or medical interventions of childbirth do not remove a laboring woman's legal competence, but loss of consciousness does 2.

Failure to recognize that aggressive maternal resuscitation is the primary treatment for fetal distress leads to poor outcomes for both mother and baby 3. Stabilizing the mother will typically stabilize the fetus 1.

Post-Resuscitation Management

Transfer to ICU for intensive hemodynamic monitoring for at least 24 hours 5. Monitor for ongoing coagulopathy, DIC, renal failure, and unrecognized organ injury 5. Have a low threshold for re-exploration if bleeding continues despite initial intervention 5.