Mrs. Stewart, a 27-year old female, presents to the Emergency Department (ED) two days postpartum. She is complaining of severe abdominal pain and reports some vaginal bleeding.  She reports an uncomplicated pregnancy and a normal vaginal delivery. She and her husband both appear very anxious.

Upon further assessment, Mrs. Stewart is pale and weak. Pulses are 1+ bilaterally in radial and pedal arteries.  The UAP obtained vital signs and assisted Mrs. Stewart to the bathroom and noted a sanitary pad saturated with bright red blood.

Her vital signs were as follows:

• BP 116/72 mmHg
• Urine Dark yellow and clear
• HR 92 bpm and regular
• Ht 158 cm
• RR 22 bpm
• Wt 71 kg
• Temp 36.6°C
• SpO2 96% on Room Air

The ED provider has called the obstetrics team to assess Mrs. Stewart, he tells you they will be down shortly, but to go ahead and start two large-bore IVs, just in case. You notice Mrs. Stewart is more diaphoretic than before, and she is slower to respond to you when you try to wake her up. She is still oriented x 3, just drowsy.  You take another set of vital signs and note the following:

• BP 108/68 mmHg
• HR 108 bpm and regular
• RR 28 bpm
• Temp 36.4°C
• SpO2 94% on Room Air

You notice Mrs. Stewart has already saturated another sanitary pad and is bleeding through her patient gown.  You immediately notify the ED provider that you believe Mrs. Stewart is decompensating due to hemorrhage.

You receive the following orders for Mrs. Stewart from the ED provider:

• Give 1,000mL Lactated Ringers IV, rapid bolus, now

• Administer Oxygen via nasal cannula to keep SpO2 > 92%

• Type and Crossmatch

• Transfuse 2 units Packed Red Blood Cells

• Give Morphine 2 mg IV push, q4h, PRN moderate pain

Mrs. Stewart responds well to the first liter of fluids, but is still bleeding profusely. The Obstetrics team arrives and tells you to obtain 2 units of emergency release blood instead of waiting for a type and crossmatch. You also receive orders to transfuse a 2nd liter of LR, which you initiate.  After examining the patient, the Obstetrics team determines that this patient may need to go to the OR, but they want to monitor her in ICU first. The ED physician places an arterial line and a central line while you initiate the first two units of packed red blood cells. Mrs. Stewart’s hemodynamic readings are as follows:

• Art. Line BP 90/58 mmHg
• MAP 66 mmHg
• HR 122 bpm and regular
• CVP 4 mmHg
• RR 32 bpm
• SpO2 90% on Room Air

You note she is extremely pale, sweating bullets, very drowsy and confused.

The Obstetrics team returns and agrees that Mrs. Stewart is too unstable to be transferred. They agree to take her to the OR right away.  In the OR, Mrs. Stewart is found to have a uterine wall tear, which is repaired successfully. She spends 1 night in the ICU and 2 nights recovering on the post-partum unit before being transferred home to be with her new baby.