UBP 2.1 (Short Form): Obstetrics – Massive Blood Loss

Question 1

Are you concerned that she is a Jehovah’s Witness?

(A 31-year-old, G6 P5, 112 kg, 5’5”, woman presents to the obstetric floor for a TOLAC (trial of labor after C/S). She has had some increased blood pressures over the last couple of weeks. The patient had a “bad experience” with her last epidural for vaginal delivery and wants to talk to you about options for pain control. She also states that she is a Jehovah Witness and will not accept blood. Vital Signs: P = 83; BP = 158/93; R = 16; T = 37 ºC. Lab: H/H = 13.5/38; Plt = 178; urine = 3+ protein.)

Answer 1

I am concerned because this patient, who may not accept the administration of blood products, is at increased risk for several complications that could result in significant blood loss. –

1. First, she plans to attempt a vaginal delivery, despite having had a previous cesarean section, placing her at increased risk of uterine rupture during active labor.
2. Second, adhesions and scarring from her previous section could potentially lengthen and complicate a cesarean section, should it be required.
3. Third, her elevated blood pressures and history suggest the possibility of preeclampsia, which may affect hemostasis.
4. Finally, she is at increased risk of uterine atony due to her grand multiparity
   
   • (The administration of magnesium for preeclampsia would also increase the risk of uterine atony following delivery.).

Question 2

What would you discuss with the patient given this information?

(A 31-year-old, G6 P5, 112 kg, 5’5”, woman presents to the obstetric floor for a TOLAC (trial of labor after C/S). She has had some increased blood pressures over the last couple of weeks. The patient had a “bad experience” with her last epidural for vaginal delivery and wants to talk to you about options for pain control. She also states that she is a Jehovah Witness and will not accept blood. Vital Signs: P = 83; BP = 158/93; R = 16; T = 37 ºC. Lab: H/H = 13.5/38; Plt = 178; urine = 3+ protein.)

Answer 2

I would have a frank discussion with her and the obstetrician about the risks of bleeding in this case and the increased risk of morbidity and mortality if the transfusion of blood products were not an option.

I would also ask them to consider the possibility of performing an elective cesarean section rather than attempting vaginal delivery to reduce the risk of uterine rupture (while bleeding is often minimal with cesarean scar dehiscence, the rupture can extend beyond the scar causing massive hemorrhage).

And finally, since some Jehovah’s Witnesses find them acceptable, I would ask the patient whether she would allow albumin administration or intraoperative blood salvage with the blood remaining in continuity with her circulatory system.

Question 3

She says that she experienced prolonged motor and sensory loss following a previous epidural for vaginal delivery. So, although she wants pain relief, she is afraid to have another epidural. What will you say to her?

(A 31-year-old, G6 P5, 112 kg, 5’5”, woman presents to the obstetric floor for a TOLAC (trial of labor after C/S). She has had some increased blood pressures over the last couple of weeks. The patient had a “bad experience” with her last epidural for vaginal delivery and wants to talk to you about options for pain control. She also states that she is a Jehovah Witness and will not accept blood. Vital Signs: P = 83; BP = 158/93; R = 16; T = 37 ºC. Lab: H/H = 13.5/38; Plt = 178; urine = 3+ protein.)

Answer 3

I would first review the chart and then ask the patient for details concerning the motor and sensory loss such as how long the deficit persisted and the specific area(s) of sensory and motor deficit.

Depending on my findings, I would then make a recommendation to the patient and explain my reasoning for that recommendation.

In any case, I would inform her that most peripheral nerve palsies are obstetric in origin due to the extreme positioning of the patient or instrumentation during vaginal delivery and/or secondary to compression of nerves as the baby’s head crosses the pelvic brim.

Anesthesia is only rarely the cause the persistent motor or sensory loss beyond the first 24 hours.

Additionally, I would let her know that there are alternative methods of pain control such as intravenous narcotics, NSAIDs, Lamaze, and transcutaneous electrical nerve stimulation.

However, epidural anesthesia tends to provide superior analgesia, may improve blood flow to the baby (by reducing circulating catecholamines), and, given the high-risk nature of this particular delivery, would provide a potential alternative to general anesthesia in the case of an emergency cesarean section.

Question 4

The patient, a nurse, asks you if there are any other options for regional analgesia. How would you explain the risks of these nerve blocks?

(A 31-year-old, G6 P5, 112 kg, 5’5”, woman presents to the obstetric floor for a TOLAC (trial of labor after C/S). She has had some increased blood pressures over the last couple of weeks. The patient had a “bad experience” with her last epidural for vaginal delivery and wants to talk to you about options for pain control. She also states that she is a Jehovah Witness and will not accept blood. Vital Signs: P = 83; BP = 158/93; R = 16; T = 37 ºC. Lab: H/H = 13.5/38; Plt = 178; urine = 3+ protein.)

Answer 4

Other options for regional anesthesia include – a paracervical block for the first stage of labor and a pudendal block with simultaneous infiltration of the perineum for the second stage of labor.

Paracervical blocks are not routinely performed due to the relatively high risk of fetal bradycardia and decreased uteroplacental perfusion.

The potential uteroplacental insufficiency associated with preeclampsia makes this an inappropriate regional choice for this patient.

On the other hand, since maternal or fetal complications from a pudendal block, such as intravascular injection, retroperitoneal hematoma, and retropsoas or subgluteal abscess are uncommon, this would be an acceptable alternative when coupled with other means of analgesia for the first stage of labor.

However, neither of these methods provide an alternative to general anesthesia should a cesarean section be required.

Question 5

A couple of hours later, she decides that she would like an epidural for pain control, but you are currently tied up with an emergency and will be unable to obtain patient consent or place her epidural for another 30-45 minutes. The nurse asks if she can give some nalbuphine to help with the patient’s discomfort until you arrive. What would you say?

(A 31-year-old, G6 P5, 112 kg, 5’5”, woman presents to the obstetric floor for a TOLAC (trial of labor after C/S). She has had some increased blood pressures over the last couple of weeks. The patient had a “bad experience” with her last epidural for vaginal delivery and wants to talk to you about options for pain control. She also states that she is a Jehovah Witness and will not accept blood. Vital Signs: P = 83; BP = 158/93; R = 16; T = 37 ºC. Lab: H/H = 13.5/38; Plt = 178; urine = 3+ protein.)

Answer 5

Ideally consent for any obstetric procedure would be obtained before the patient was in severe pain or under the influence of premedication (i.e. narcotics and/or anxiolytics).

However, recognizing that the provision of some pain relief may enhance her ability to provide adequate consent, I would not withhold medication to ease her suffering.

Instead, I would attempt to provide adequate pain control, while at the same time, avoiding excessive medication that may render her unable to understand the risks and benefits associated with the planned procedure.

This position has been supported by a number of studies that have confirmed the ability of laboring patients to provide adequate consent.