A 24-year-old woman, G1P0 at 41 weeks gestation, had an uneventful vaginal delivery facilitated by epidural analgesia at a medium-sized community hospital with an expanding labor and delivery service. Postpartum vaginal bleeding persisted despite administration of Pitocin and methergine. Attempts to place a Bakri uterine balloon for tamponade were unsuccessful at the bedside due to patient discomfort and agitation. Blood pressure declined despite administration of a fluid bolus, and the anesthesiologist was called for assistance with sedation and resuscitation.
At arrival of the anesthesiologist, blood pressure was 80/60 by automated cuff, with heart rate of 110. Postpartum blood loss was substantial but could not be accurately estimated. The anesthesiologist placed a second I.V., with difficulty, ordered transfusion of two units of red blood cells (RBCs), and requested equipment for an arterial line. Both the arterial line and the blood products were delayed as support personnel were called in from home.
“Young, previously healthy women are not expected to bleed to death, and it is easy to find experts willing to testify that the standard of care was not met in cases such as this one.”
Following two hours of resuscitation efforts in the postpartum unit, the obstetrician elected to take the patient to the OR for hysterectomy. General anesthesia was induced, and the patient was intubated without difficulty. No personnel were available to assist the anesthesiologist. The patient remained unstable, with ongoing hemorrhage and development of coagulopathy. Cardiac arrest ensued and the patient expired after prolonged resuscitative efforts, despite receiving a total of 20 units of RBCs and four units of plasma – all that was available from the hospital’s blood bank.
Issues alleged in the malpractice filing were failure to identify life-threatening hemorrhage, failure to transfer the patient in a timely manner to a more capable hospital, failure of timely surgery, and inadequate resuscitative efforts. The hospital, the obstetrician, and the anesthesiologist each ended up settling at the full limits of their respective malpractice insurance.
Management of hemorrhage has evolved over the past three decades, driven by clinical research in trauma care. Key principles of “hemostatic resuscitation” include the following (Br J Anaesth 2012;109 Suppl 1:i39-i46):
- Identification of life-threatening hemorrhage
- Transfer to a facility capable of definitive care
- Diagnosis of the anatomic source of hemorrhage
- “Damage control” surgery focused on control of bleeding
- Physiologic management to prevent and mitigate coagulopathy:
- Prophylactic administration of tranexamic acid (Eur J Anaesthesiol September 2022)
- Maintenance of normothermia
- Controlled hypotension
- Limited infusion of asanguineous fluids (crystalloid or colloid)
- Early 1:1:1 transfusion of RBCs, plasma, and platelets (JAMA 2015;313:471-82)
- Frequent laboratory assessment of lactate, calcium, pH, and coagulation parameters
- Completion of resuscitation in the ICU, emphasizing normalization of tissue perfusion
- Delayed or staged completion of surgery.
These same principles apply to obstetric hemorrhage, with a few modifications as seen in the American College of Obstetricians and Gynecologists maternal hemorrhage bundles (Obstet Gynecol 2006;108:1039-47). The Joint Commission requires institutional protocols regarding maternal care, including several that touch on management of postpartum hemorrhage. Creation of a massive transfusion protocol (already mandatory for level 1 trauma centers) is a starting point but may be modified for postpartum hemorrhage to include earlier use of cryoprecipitate or fibrinogen concentrate, recognizing that obstetric patients have a naturally higher normal level of fibrinogen. While most clinicians are reluctant to use uncrossmatched blood products (type O-RBC, type AB, or low-titer type A plasma), decades of experience in trauma have demonstrated the safety of these products and a strongly favorable risk-to-benefit ratio for their use in patients with life-threatening hemorrhage (J Trauma 2005;59:1445-9). One benefit of rapid transfer to a larger hospital is increased availability of both blood products and personnel for massive transfusion. Larger facilities are also more likely to support real-time viscoelastic assessment of clotting dynamics, enabling more precise resuscitation (Anaesthesia 2022;77:700-11).
In addition to committing early to postpartum hysterectomy (an obvious issue in the case presented), patients with obstetric hemorrhage can benefit from minimally invasive mechanisms for anatomic control of bleeding. These include angiographic embolization, placement of uterine artery balloon catheters, and resuscitative endovascular balloon occlusion of the aorta (“REBOA”) (Adv Anesth 2021;39:17-33). The latter therapy is specifically intended for rapid deployment in hemodynamically unstable patients; aortic balloon inflation in zone 3 can substantially slow obstetric hemorrhage, buying time – and a clear surgical field – for dissection and hysterectomy.
While anesthesia malpractice filings related to hemorrhage are rare in trauma cases, they are more common in obstetrical practice (Anesthesiology 2014;121:450-8). Young, previously healthy women are not expected to bleed to death, and it is easy to find experts willing to testify that the standard of care was not met in cases such as this one. Risks are especially high in community practice, where the anesthesiologist might be constrained by availability of resources such as an institutional blood bank, invasive monitoring equipment, laboratory capability, fluid-warming technology, and knowledgeable assistants, even when fully aware of what best practice should be.
Mitigation strategies include work at the institutional level to ensure that adequate resources are available to match the hospital’s intended patient population. For small facilities, this may mean creation and rehearsal of a robust capability for transferring high-risk patients to a higher level of care. For hospitals such as this one, with an expanding obstetrical service, this could mean multidisciplinary recognition of what might be required on the “worst day.” This would include development of an MTP, team-training for catastrophic care, a protocol for calling in additional help, and stockpiling of resuscitation equipment such as arterial pressure transducers, transfusion tubing, and fluid warmers.