Most women will accept blood transfusion if there is a clinical need and they are fully informed. Some women may refuse transfusion because of specific personal or religious beliefs. The main group of women, who refuse transfusion of allogenic blood or primary blood components (red cells, white cells, plasma and platelets), are practising Jehovah’s Witnesses.

Applicable Unit Policies

• PPH Management
• Tranexamic Acid
• Cell Salvage   
• Care Plan for women refusing transfusion.  

Antenatal Management

• At booking Identify women who may decline blood transfusion and transfer to RED pathway. (Highlight in Alerts and Management plan on Badgernet.)
• Women declining blood transfusion should be booked for hospital delivery in a Consultant led unit. All women should be seen antenatally by  their  Consultant  preferably  before  24+0 weeks,  and advised  about the risk of haemorrhage, including management options and the increased risk of hysterectomy. This must be carefully documented.
• Complete the refusal of Blood Transfusion Consent Form in file in the base notes. A copy should be given to the woman.(Appendix A) Complete the Advanced Directive. (Appendix B) and again put copy in basenotes and give woman copy.. Ideally by 24+0 weeks.
• Ensure that the woman’s wishes are documented, ensuring that blood and primary blood components that the woman would not accept, and treatments that she will accept, are clearly documented and consented to. (Appendix A)
• Arrange anesthetic review antenatally.
• Blood group and antibody status should be checked routinely and the haemoglobin and serum ferritin should be checked every 6 weeks. Haematinics  should  be  given  throughout  pregnancy  to maximise iron stores. If the ferritin remains low despite oral iron then intravenous iron should be considered.

Elective Delivery

If elective induction is indicated aim to achieve this Monday, Tuesday or Wednesday in order that completed in weekdays. Elective caesarean section must be on a Consultant list. (Appendix D) Cell Salvage should ideally be available.

Intrapartum / Delivery Management

• Inform Consultant Obstetrician and Anaesthetist when a woman declining blood transfusion is admitted in labour.
• The labour should be managed routinely, by the most senior medical and midwifery staff available. Student midwives and junior medical staff should not conduct these deliveries.
• The third stage of labour should be actively managed and routine prophylactic oxytocin should be given.
• A Consultant Obstetrician should be present at any operative delivery (vaginal or caesarean section) if this is possible.
• Cell salvage should ideally be available for elective deliveries.

Postnatal Management

• The woman should not be left alone for at least an hour after delivery – one to one midwifery care.
• A postnatal MEWS chart should be commenced.
• After discharge women should be advised to report promptly if they have concerns about bleeding during the puerperium. Haematinics should be continued.

Management of Haemorrhage

• The principle of management of haemorrhage is to minimise blood loss and avoid delay. Rapid decision-making may be necessary, particularly with regard to surgical intervention.
• If significant bleeding occurs at any time during pregnancy, labour or the puerperium, the Consultant Obstetrician, Anaesthetist and Haematologist should immediately be informed. A second Obstetric &  Gynaecology Consultant  should  be  contacted  if laparotomy required.  This surgeon must  be suitably  skilled  to aid major surgery.
• Start the standard management promptly (pdf link to Appendix E). The threshold for intervention should be lower than in other patients. Extra vigilance should be exercised to quantify any abnormal bleeding and to detect complications, such as clotting abnormalities, as promptly as possible.

• Intravenous crystalloid should be used. Do not use Dextran
• If available cell salvage may be life-saving if there is substantial blood loss. A cell sa ver set with additional leucocyte depletion filter to remove amniotic fluid components (order code RS1VAE) together with separate suction has been reported as a potential life-saving technique during caesarean section.
• The woman and her family should be kept fully informed about what is happening  by  an informed  member  of  Massive obstetric  haemorrhage  can rapidly  become life threatening.  If standard treatment is not controlling the bleeding, she should be advised that blood transfusion is strongly recommended.
• Surgical management of bleeding should include use of a B-Lynch Suture, intrauterine balloon, interventional radiology techniques, internal iliac artery ligation and hysterectomy. The woman’s life may be saved by timely hysterectomy, though even this does not guarantee   If hysterectomy  is  performed  the  uterine arteries  should  be  clamped  as  early  as  possible  in the procedure. Subtotal hysterectomy can be just as effective as total hysterectomy, as well as being quicker and safer. The timing of hysterectomy is a decision for the consultant on site. A second Consultants presence is advised only if this does not cause undue delay in definitive treatment.
• If the woman requires transferred to an intensive care unit, the management there should include erythropoetin, parenteral iron therapy and adequate protein for haemoglobin Hyperbaric oxygen therapy is an option in life threatening anaemia due to PPH but availability is limited.
• If, in spite of all care, the woman dies, her relatives require support like any other bereaved family. It is very distressing for staff to have to watch a woman bleed to death while refusing effective treatment. Support should also be promptly available for staff in these circumstances. Early contact with the Perinatal Counselling Service.

Legal and Ethical Aspects

Any patient is entitled to change her mind about a previously agreed treatment plan.

• The doctor  must be  satisfied  that the woman is  not being subjected to pressure from others (including staff). It is reasonable to ask the accompanying persons to leave the room so that the doctor (with a midwife or other colleague) can ask her whether she is making her decision of her own free will. If she maintains her refusal to accept blood or blood products, her wishes should be respected. The legal position is that any adult patient (i.e. 16 years old or over) who has the necessary mental capacity  to do  so is entitled to refuse treatment, even if it is likely that  refusal will result in the patient’s death. No other person is  legally able to consent to treatment for that adult or to refuse treatment on that person’s behalf.

Note: This document does not apply to the neonate.