Code Noelle: A tale of postpartum hemorrhage

The case A 45-year-old woman, gravida 4 para 3, presents at 38 weeks' gestation for cesarean section. The patient has had three previous cesarean sections. Obstetrical colleagues inform you that she has placenta previa and strong possibility for placenta accreta. The patient is originally from Pakistan and speaks only Punjabi and had general anesthesia without complications for her previous three cesarean sections, which were performed in Pakistan. Nursing staff has had a difficult time placing an appropriately sized peripheral IV. The patient's airway examination is unremarkable and her body mass index is within normal limits. After discussion with colleagues about the risks and benefits of regional versus general anesthesia for this case, a decision is made to recommend regional anesthesia with spinal anesthesia. The patient is reluctant about having a spinal and inquires about general anesthesia. Fortunately, one of the obstetrician residents also speaks Punjabi and facilitates communication. Discussion takes places, informing the patient about the reasons for preferring regional anesthesia, and the patient agrees to this anesthetic plan. Arrangements are made for blood salvage equipment for use in the operating room. The patient is brought to the operating room and spinal anesthesia is administered successfully. There is routine delivery of a healthy infant. However, after delivery of the placenta, a peek over the field reveals a uterus sitting in a large pool of blood that is steadily growing faster than anyone would like.