Obstetric anaesthesia15 / 17
Jehovah's Witness refusing blood for emergency caesarean27-year-old woman, 64 kg, at 40 weeks, a Jehovah's Witness with a signed advance directive refusing blood
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Know this first
- Acceptance varies: some accept components, fractions such as albumin or PCC, or cell salvage in continuous circuit.
- A valid advance directive is respected; seek ethics and legal advice if in doubt.
- Tranexamic acid in the first 3 hours after birth; another gram if she still bleeds at 30 minutes.
- Cell salvage helps when a patient refuses donor blood.
- If uterotonics and conservative measures fail, hysterectomy.
The patient
27-year-old woman, 64 kg, at 40 weeks, a Jehovah's Witness with a signed advance directive refusing blood.
Obstructed labour; emergency caesarean (category 2). Labour epidural working.
Mild anaemia, Hb 10.1 g/dL despite oral iron.
Vitals: BP 120/76, HR 98, SpO2 99% on air, RR 18.
The examiner asks
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Consider
What are your concerns?
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- A 27-year-old Jehovah's Witness refusing blood, for emergency caesarean after obstructed labour. Patient
- At term: caval compression, aspiration and airway risks, and a large potential blood loss.
- A prolonged labour raises her atony risk, and obstructed labour makes incision extensions likely. Disease
- Her Hb of 10.1 leaves little reserve before bleeding becomes dangerous.
Prepare
How do you prepare her?
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- A private conversation, away from family, to confirm her wishes and her capacity. Patient
- Product by product: red cells, plasma, platelets, cryoprecipitate, albumin, factor concentrates.
- Cell salvage kept in continuous circuit is acceptable to some; I ask her directly.
- Her valid advance refusal is respected, even if she may die.
- Everything documented; ethics and legal advice if any doubt arises.
- Most senior obstetrician operating, consultant anaesthetist present. Surgery
Plan
What is your anaesthetic plan?
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- Extend her working epidural to T4 for surgery. (Disease)
- Cell salvage running from skin incision, if she accepted it.
- After delivery, oxytocin 1–3 IU slowly, then an infusion; second-line drugs drawn up.
- Tranexamic acid at the first sign of heavier bleeding.
- Warmth and normocalcaemia maintained to protect her clotting.
Crisis
The uterine incision extends laterally; brisk bleeding, 1500 mL so far. BP 88/50, HR 130. What do you do?
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- Help called; the surgeon gets control with pressure and sutures, early hysterectomy if needed. Crisis
- Uterotonics: oxytocin infusion up, carboprost 0.25 mg IM, methylergonovine 0.2 mg IM.
- Tranexamic acid 1 g over 10 minutes; repeat if bleeding continues at 30 minutes or recurs inside 24 h.
- Salvaged blood returned through the leucocyte filter, if she agreed.
- Fibrinogen concentrate or PCC only if they are on her accepted list.
- No transfusion against her valid refusal.
- Interventional radiology or early hysterectomy rather than waiting on drugs. After surgery
Fatal mistakes
- Transfusing against her valid refusal.
- No agreed list of acceptable products before surgery.
- Late escalation to surgical control.
Checked against: Barash 9e · Miller 10e · WHO recommendation on tranexamic acid for postpartum haemorrhage (2017)
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