Protocol for the Management of women who refuse blood ......8.0 Active haemorrhage The principle of management of haemorrhage in these cases is to avoid delay. Rapid decision-making

Author: L Williams, S Bailey, T Hawkins Date: September 2018

Job Title: Consultant anaesthetist, Matron for Hospital Services, Blood transfusion SN

Review Date: September 2020

Policy Lead: Group Director Urgent Care Version: V7.0 ratified 7/9/18

Location: Policy hub /Clinical/ Maternity/ Intrapartum/ CG477

This document is valid only on date last printed Page 1 of 10

Protocol for the Management of women who refuse blood transfusions and related blood products during the Antenatal and Intrapartum period

(CG477)

Approval and Authorisation

Approved by Job Title Date

Maternity & Children’s Services Clinical Governance Committee

Chair, Maternity Clinical Governance Committee

7th September 2018

Change History

Version Date Author Reason

4.0 June 2012 L Rough & G Jackson Reviewed

5.0 Sept 2014 L Rough (Matron for Hospital & OP Services), Dr G Jackson (Consultant Anaesthetist), T Hawkins (Blood Transfusion Nurse specialist)

Reviewed

6.0 June 2016 L Rough (Matron for Hospital & OP Services), Dr G Jackson (Consultant Anaesthetist), T Hawkins (Blood Transfusion Nurse specialist)

Reviewed – pg 7 & 8 terminology updated pg 9 references updated

7.0 July 2018 S Bailey (Matron for Hospital & OP services, Dr L Williams (Consultant Anaesthetist), T Hawkins (Blood Transfusion Nurse specialist)

Reviewed – pg 4 FDNA testing added Pg 5 leaflet title updated Pg 9/10 - Appendix 1 replaced by updated version



Review Date:

September 2020




Protocol for the management of women who refuse blood products (CG477) September 2018

Contents 1.0 Purpose ........................................................................................................... 3

2.0 Guides ............................................................................................................. 3

2.1 A guide to what Jehovah’s Witnesses will not accept. .................................... 3

2.2 A guide to what Jehovah’s Witnesses may accept on an individual basis ...... 3

2.3 A guide to what is acceptable to all Jehovah’s Witnesses............................... 4

3.0 Booking ........................................................................................................... 4

4.0 Antenatal Care ................................................................................................ 4

5.0 Risk Factors Predisposing to Postpartum Haemorrhage................................. 5

6.0 Labour ............................................................................................................. 5

7.0 Cell Salvage .................................................................................................... 6

8.0 Active haemorrhage ........................................................................................ 6

9.0 Communication with the patient ...................................................................... 6

10.0 Blood Components and products .................................................................... 7

11.0 Dissemination .................................................................................................. 8

12.0 References: ..................................................................................................... 8

Appendix 1 – Care plan ............................................................................................. 8



Review Date:

September 2020





1.0 Purpose

Women who refuse blood transfusion/primary blood products/non primary blood products should be identified antenatally and situations likely to lead to blood loss should be anticipated and if possible avoided. Massive obstetric haemorrhage is often unpredictable and can become life threatening in a short time. In most cases blood transfusion/primary blood products/non primary blood products can save the woman’s life and very few women refuse blood transfusion/primary blood products/non primary blood products in these circumstances. If it is thought likely that a woman may do so, the management of massive haemorrhage should be considered in advance. The vast majority of women accept blood transfusion/primary blood products/non primary blood products if the clinical reasons for its necessity are fully explained. However, a few women may continue to refuse transfusion/primary and non-primary blood products because of specific personal or religious beliefs (e.g. Jehovah’s witnesses) PLEASE NOTE The products listed below are specific to Jehovah’s witnesses, but this protocol is applicable to any person refusing blood products on religious or personal grounds. 2.0 Guides

2.1 A guide to what Jehovah’s Witnesses will not accept.

Transfusions of whole blood

Packed red cells

White cells

Plasma

Platelets 2.2 A guide to what Jehovah’s Witnesses may accept on an individual basis

In June 2004 the Association of Jehovah’s Witnesses published a new policy regarding use of blood products by Jehovah’s Witnesses. It is now a personal decision of the Jehovah’s Witness if they wish to accept:

Red cell fractions – Haemoglobin based substances

White cell fractions – Interferon’s, Interleukins.

Plasma fractions – Albumin, Globulins, Clotting factors

Platelet fractions – Wound-healing factor

Anti-D

Hepatitis B Vaccination

Cell Salvage

Cryoprecipitate



Review Date:

September 2020





2.3 A guide to what is acceptable to all Jehovah’s Witnesses.

Compound sodium lactate (Hartmanns)

Normal Saline (0.9% Saline)

Hypertonic Saline

Dextrose

Gelatins (Gelofusine/Haemaccel)

Plasmalyte 3.0 Booking

At booking all women are asked their religious beliefs, and should be asked if they have any objections to blood transfusion/primary blood products/non primary blood products this should be clearly documented in their notes. Refer the woman to the consultant obstetric and anaesthetic antenatal clinic, as their care requires multi-disciplinary input If she decides against accepting blood transfusion/primary blood products/non-primary blood products in any circumstances, she should be booked for delivery in the consultant unit. 4.0 Antenatal Care

The woman’s blood group and antibody status should be checked in the usual way and the haemoglobin and serum ferritin checked regularly. If a woman is Rhesus negative she should be counselled about FDNA testing and the need for Anti-D administration. Anaemia should be prevented by the use of antenatal iron and folic acid. Oral and /or intravenous iron (Ferinject) should be used. See Guidelines for Management of Iron Deficiency Anaemia in Adults (GL750) and Anaemia – use of Ferinject in pregnancy (GL783) An ultrasound scan should be performed in the third trimester to identify placental site. The woman will be given an appointment to see the Consultant Obstetrician and Consultant Anaesthetist. The Anaesthetist will discuss with the patient their beliefs/wishes and their relevance to the proposed treatment. The woman should be given all relevant information. She should be informed of the risks she runs by refusing transfusion/primary blood products/and the non-primary blood products and the consequences to short term and long-term health. She should be advised that if massive haemorrhage occurs, there is an increased risk that hysterectomy will be required, and that there is a risk of death. The discussion should be documented and the woman given the NHS Blood & Transplant leaflet: Will I need a blood transfusion?

http://hospital.blood.co.uk/media/28307/160511-27360-will-i-need-a-blood-transfusion-final.pdf



Review Date:

September 2020





A ‘CARE PLAN FOR WOMEN IN LABOUR REFUSING A BLOOD TRANSFUSION”, (Appendix 1), should be placed in the patient notes and a copy given to the patient. This is a national document written by Jehovah’s Witness support groups. Consent form 5 (See Trust Intranet: Clinical Policies and Protocols: Trustwide Consent) will be completed by the doctor following the relevant discussions with the patient, and filed in the patient’s notes. A record of treatments that the woman will accept should be clearly made in the notes. If the woman has one, a copy of her Advance Health Directive should also be filed in the notes. There is an active Jehovah’s Witness support network in Reading and the patient should be encouraged to discuss the plans for delivery and refusal of blood products with the elders in their group. They can also be given the name of the hospital Jehovah’s Witness liaison representative, currently Christopher Marks. 5.0 Risk Factors Predisposing to Postpartum Haemorrhage

Previous history of bleeding, post or antepartum

Prolonged labour (especially when augmented with Syntocinon)

Multiple pregnancies

Maternal obesity (BMI greater than 35)

Increased maternal age >40 years

Four or more children

Polyhydramnios

Fibroids

Difficult operative delivery

Abnormal placental site/retained products

Large baby >4.5kg

Known coagulopathies, low platelets and Heparin therapy. If appropriate and the woman will accept it the use of a cell salvage system could be anticipated and organised in good time before an emergency arises. The availability of cell salvage cannot be guaranteed 24 hours a day, every day and depends on the availability of appropriately trained operators. 6.0 Labour

The consultant Obstetrician and Anaesthetist should be informed when a woman who will refuse blood transfusion/primary blood products/non primary blood products is admitted in labour. Staff should manage the labour routinely, avoiding a prolonged labour or difficult operative delivery.



Review Date:

September 2020





All patients should have the third stage of labour actively managed. Syntometrine should be given when the baby is delivered. The woman should not be left alone for at least an hour after delivery to observe for PPH. If Caesarean section is necessary, the consultant obstetrician should determine what the risk of PPH is likely to be and advise on the seniority of obstetrician to conduct the delivery. He or she may be required to operate themselves. The great majority of pregnancies will end without serious haemorrhage. When a mother is discharged from hospital, she should be advised to report promptly if she has any concerns about bleeding during the puerperium. 7.0 Cell Salvage

It may be possible to use cell salvage either at caesarean section or if the woman requires a laparotomy for management of post partum haemorrhage. However, it should not be used for vaginal blood loss due to possible bacterial contamination. The use of cell salvage should be discussed with a woman during the antenatal period as it is not accepted by all Jehovah’s Witnesses. It should also be made clear that it is impossible to ensure a ‘continuous loop’ such that the blood can always be viewed as in continuity with the circulation. Cell salvage is not always available due to issues with staff training. This should also be emphasised during counselling. See Cell salvage guideline (GL754) 8.0 Active haemorrhage

The principle of management of haemorrhage in these cases is to avoid delay. Rapid decision-making may be necessary, particularly with regard to surgical intervention. Inform Consultant Obstetrician and Anaesthetist. Follow guidance within lifesaving guideline: ‘Obstetric haemorrhage management ‘(minus the suggested blood components) The women should be kept fully informed about what is happening. If standard treatment is not controlling the bleeding, she should be advised that blood transfusion/primary blood products/non primary blood products are strongly recommended. Any patient is entitled to change her mind about a previously agreed treatment plan. 9.0 Communication with the patient

The doctor must be satisfied that the woman is not being subjected to pressure from others. It is reasonable to ask the accompanying persons to leave the room for a while, so that the doctor (with a midwife or other colleague) can ask her whether she is making her decision of her own free will.



Review Date:

September 2020





If she maintains her refusal to accept blood components and products, her wishes should be respected. The legal position is that any adult patient (i.e. 18 years 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. If the patient is under 18 and is deemed ‘Gillick competent’ – i.e. can understand the treatment proposed, the risks, benefits and alternatives of it and the outcome if nothing is done, then that person’s consent is valid. However, even in a competent under 18 year old, refusal of consent to treatment can be overridden by a person with parental responsibility. Equally, if the competent, under 18 year old wishes to receive medical treatment, including blood products/transfusion, the person with parental responsibility cannot override that and impose their beliefs on that patient. No other person is legally able to consent to treatment for that adult or to refuse treatment on that person’s behalf. (In dire circumstances an emergency Declaration to Treat can be sought (ref legal Dept) however we must accept that a competent patient has the absolute right to refuse treatment. All discussions with the mother should be fully recorded in the hospital notes. The staff must maintain a professional attitude. They must not lose the trust of the patient or her partner, as further decisions – for example, about hysterectomy – may have to be made. Massive obstetric haemorrhage normally occurs in the form of a post partum haemorrhage. In the case of life-threatening antepartum haemorrhage in which the baby is still alive, the baby should be delivered promptly by Caesarean section as long as the mother’s condition is stable enough for this to happen. 10.0 Blood Components and products

The following list is intended to be a guide as to which products are derived from whole blood and should be discussed with a woman before administration:

Red blood cell

Platelets

Fresh frozen plasma / Octaplas

Cryoprecipitate

Factor VIII concentrate

Albumin

Anti-D

Gamma globulin

The following are not primary blood products:

Erythropoietin

Novoseven

Tranexamic Acid

Rasylol (Aprotinin)

Desmopressin



Review Date:

September 2020





11.0 Dissemination

This protocol will be published on the Maternity Intranet site under Datix and will be available for all Trust employees. In addition, service users and GPs can access the site via the Intranet. 12.0 References:

1. Collis R, Collins P. Haemostatic management of obstetric haemorrhage. Anaesthesia 2015, 70 (Suppl. 1), 78–86

2. Lawson T, Ralph C. Perioperative Jehovah’s Witnesses: a review. British Journal of Anaesthesia, 115 (5): 676–87 (2015)

3. www.ajwrb.org Accessed 30.6.16

http://www.ajwrb.org/

Appendix 1 – Care plan


Appendix 1 – Care plan (pg 2)


Documents

Protocol for the Management of women who refuse blood ......8.0 Active haemorrhage The principle of management of haemorrhage in these cases is to avoid delay. Rapid decision-making