Declining blood or blood products in pregnancy

A blood transfusion is when you are given blood from a donor (someone that donates blood).

Healthcare professionals will aim to manage your care during pregnancy and birth to reduce the risk of low iron and blood loss without the use of blood products. However, there may be situations when a blood transfusion is recommended for example, if you have had a large loss of blood or you have a very low iron level. This can sometimes be lifesaving.

Yes. We treat everyone in a way that recognises and respects their individual choices, religious, cultural and personal beliefs.

Before giving you a blood transfusion or blood product, the risks and benefits of having or not having blood products will be discussed with you. You will be fully informed so that you can decide if you are willing to accept blood products in your treatment or not.

The care you receive during your pregnancy and childbirth will not be affected by your decision to decline a blood transfusion or blood products.

It is important for you to understand that if you have significant heavy blood loss in pregnancy, at delivery or after birth and decline a blood transfusion, your life may be put at risk.

If you are thinking of becoming pregnant and may not want to use blood products you can speak to your GP to find out more about how you will be cared for during your pregnancy.

If you are one of Jehovah’s Witnesses and know in advance that you will want to decline the use of blood products, please contact your local Hospital Liaison Committee for further guidance.

When you are pregnant, you must make sure that your doctor and midwife are aware of your decision for no blood or blood products to be used as part of your care.

When you have your booking appointment with your midwife (your first main appointment) you will be asked about all aspects of your general health, previous pregnancies, your religious beliefs and if you have any objections to receiving a blood transfusion or blood products like the Anti-D immunoglobulin injection if your blood group is Rhesus Negative.

If you choose not to receive blood, we will advise you to have your baby in hospital rather than at home. Your midwife will refer you for care at the hospital under a Consultant Obstetrician, who will discuss your pregnancy and make a plan of care with you that will be recorded in your hospital and hand held maternity record. You will be asked to sign a consent form stating that you wish to decline blood and specific blood products.

If you are one of Jehovah’s Witnesses you will receive extra information from your local Hospital Liaison Committee; please ensure you contact them as soon as possible.

If you decline blood transfusion and blood products, you will need to sign an ‘Advanced Decision Form’ in advance, in the presence of 2 witnesses as well as a consent form. To help us respect your wishes, carry your ‘Advanced Decision Form’ with you at all times.

You can change your mind at any point even with an Advanced Decision Form in place, but your advanced decision instructions will be followed if you are unconscious or lack capacity.

During your pregnancy, you will be seen regularly by your local Midwife and the Doctor at the hospital Antenatal Clinic (Greenoaks). You may also be invited to talk with the Anaesthetist as well. When you see the Doctor, a plan of care will be made and you will be advised:

• to take iron and folic acid supplements (tablets or liquid medicine) throughout your pregnancy to build up your iron stores.
• to have monthly blood tests to check your blood count (iron levels). If they are low, you will be offered tablets (or liquid if you prefer), if you are not taking them already, to increase your iron levels. If you are already taking iron supplements but your iron levels remain low, you may be offered an iron infusion.

You will be offered a scan at around 12 weeks of pregnancy and a detailed scan that looks at all the major baby organs at around 20 weeks. At the 20 week scan we will check the position of your placenta (temporary organ attached to the uterus (womb)) to make sure it is not low in your uterus, which can increase your risk of bleeding. If your placenta is low then you will need more scans in your pregnancy.

Your wishes for labour and delivery will be discussed and documented in your notes. We will also discuss what facilities and treatments we can offer if you were to have significant bleeding, so that you can decide whether to give birth in Rotherham or at another maternity unit. You will be asked what treatments and procedures you are willing to have and this will all be documented in your maternity notes.

Intraoperative blood salvage (cell salvage) which involves the collection of blood lost during surgery may be available in the unit and this will be discussed with you in antenatal clinic.

Your discussion will be documented as part of your ‘Advance Decision Form’ and a consent form signed if not already complete.

If your blood group is RhD Negative, we will recommend non-invasive prenatal testing. This is a blood test taken from you in pregnancy and finds out your baby’s RhD status.

If your baby is RhD Positive we would usually recommend:

• an injection of Anti-D during events which could cause mother or baby to bleed, or cause their blood to mix even the smallest amount during pregnancy.
• to give Anti-D, at around 28 weeks of pregnancy
• to give Anti-D after the birth of your baby.

Anti-D is a protein that is obtained from blood plasma (the liquid part of blood). There is not an alternative that is not made from blood. If you wish to decline Anti-D it will be clearly documented in your hospital and hand held maternity records. We will be happy to discuss any concerns you have regarding Anti-D.

If you are declining because you are one of Jehovah’s Witnesses, you may wish to discuss this further with a member of your Hospital Liaison Committee. Your wishes will always be respected by us. Please ask your Midwife or Doctor for the ‘Antenatal prophylaxis with Anti-D’ patient information leaflet for more details.

When you are admitted to hospital in labour, we will inform the Consultant Obstetrician and Anaesthetist on-call so that they are aware of your admission and your request to decline blood and blood products.

The care you receive during labour will be managed in the same way as any other person. You can have the usual choices for pain relief unless there are other reasons why these may not be appropriate.

You will be given an injection into your leg of a hormone-type drug called syntocinon as your baby is born. Syntocinon does not contain blood products. This speeds up the process of separation and delivery of the afterbirth (placenta) and reduces the amount of blood lost in comparison to not having the drug and waiting for the afterbirth to deliver naturally. Sometimes we also start a drip into your arm with the same drug to further help your womb contract and stop bleeding.

If you need a caesarean section (elective / planned or emergency operation to deliver your baby) this should be carried out by a Consultant Obstetrician. However, if a caesarean section is needed urgently, the specialist Doctor on the labour ward will start the surgery, but the Consultant will be told to come in case any bleeding problems arise. Senior Midwives and Doctors are available at all times on the labour ward to identify and manage problems quickly.

An Anaesthetist will give you a regional anaesthetic (spinal or epidural).

Before any operation you will be asked to sign an additional consent form. You will be consenting only to treatment you are willing to accept, that you have already discussed with the Obstetrician.

You will be told if there are any problems. We will discuss all your options with you and respect your wishes. We will know what to do even if you bleed more than usual and have declined blood and blood products.

Yes. You can change your mind at any time and choose to receive a blood transfusion or blood product. This choice will be respected and documented in your records.

If your Doctor feels from your medical situation, that you need a blood transfusion to treat severe bleeding or anaemia (low red blood cell count), they will discuss the reasons for this with you and allow you to make an informed decision.

If you will get more poorly without treatment with blood and blood products, the senior doctor will talk to you and your relatives in detail, to make sure you are aware of the possible consequences.

At all times, even if an emergency arises’ we will respect your wishes.

You can be confident that you will receive the best possible care and treatment during your time with us.

If you have any further questions or are worried about any aspects of your pregnancy and birth, please talk to your Midwife or Doctor.

For Jehovah’s Witnesses, your Hospital Liaison Committee can give you further help.

The NHS website has information on iron.

For information on Anti-D injection, type in a search engine: ‘Antenatal prophylaxis with Anti-D patient information leaflet. ZLB Behring UK Ltd.’

Greenoaks Ante-Natal Clinic

01709 424347

Wharncliffe Ward

01709 424348

Labour Ward

01709 424491

Your local midwife and GP contact numbers will be on your handheld maternity notes.