Whole blood or components of blood are introduced into the venous circulation, usually for the purposes of treating a clinical abnormality. Shortage of red blood cells results in hypoxia and the circulatory system needs to have sufficient blood within the vessels to sustain blood pressure, heart rate and all other circulatory functions. The DH (1994) recommend using whole blood quickly for the management of massive obstetric haemorrhage. UK maternity units have 2 units of O Rhesus-negative blood available for immediate transfusion to any woman while awaiting cross-matched blood, such is the significance of blood transfusion in saving lives.

Blood transfusion can be a controversial treatment: it is the transfer of live tissue from one person to another – a transplant. Some people will refuse transfusion; Lewis (2005) includes guidelines for the management of obstetric haemorrhage in women who decline blood transfusion. Despite careful screening, there is the possibility of disease or antibody transmission and blood is an expensive treatment that may vary in its availability.

There is a duty for UK Hospital Trusts to report transfusion incidents to the Medicines and Healthcare products Regulatory Agency (MHRA). This is done by the recognized person, often the transfusion practitioner or haematologist. While voluntary, >99% of UK Healthcare facilities also submit adverse (potential or actual) transfusion incident reports (anonymized) to the haemovigilence scheme, SHOT (Serious hazards of transfusion). Their annual report aims to improve practice standards and to educate practitioners (Hurrell 2014).

The responsibility for safe and effective transfusion rests with the multidisciplinary team, but especially with those directly administering it, e.g. the midwife. The stages of safe transfusion practice are considered in detail below.

Indications for maternal transfusion

Indications for transfusion include:

Blood can be administered in different forms: whole blood, packed red cells (plasma removed), platelet concentration, fresh frozen plasma, white blood cells and cryoprecipitate (clotting factors) (Jones & Heyes 2014, Watson & Hearnshaw 2010). Anti-D immunoglobulin is also a human blood product. Cell salvage and techniques such as autologous donation or erythropoiesis-stimulating agents are all aiming to reduce the need for external blood transfusion. The midwife should be aware of developing techniques; the inappropriate use of blood transfusion has a significant effect, both in human and financial terms. The midwife has a responsibility in the provision of effective antenatal care, and in the management of the third stage of labour, as well as obstetric haemorrhage emergencies, all to ensure that the need for transfusion is minimized. The need for transfusion should be reviewed on an individual and careful basis.

Understanding blood groups

Blood groups are defined as A, B, AB, or O Rhesus negative or positive. The group is determined by the presence of an antigen on the red cell surface and an antibody in the serum. Individuals with group A, for example, have A antigens on their surface and B antibodies in the serum (Table 49.1). Eighty-five percent of the population has an additional antigen on their red cells, the Rhesus factor. If Rhesus-positive blood is introduced into a Rhesus-negative person, antibodies then form, with a haemolyzing effect on the next introduction of Rhesus-positive blood. Blood group O is known as the universal donor (having no antigens for antibodies to fight), while group AB is known as the universal recipient (having no antibodies to fight foreign antigens). Therefore the true universal donor is O Rhesus negative (Rh−) and the true universal recipient is AB Rhesus positive (Rh+).

The presence of maternal antibodies (e.g. anti-D, anti-Kell, etc.) means that cross-matching should be undertaken carefully to ensure a safe match. Maternal antibodies can have life-threatening consequences to the fetus. In the UK, blood group and Rhesus factor screening of maternal blood should take place at booking and, if the woman is Rhesus negative, prophylactic anti-D (single dose, 1500 IU) is offered at 28–30 weeks’ gestation (Norfolk 2013 p. 113). SHOT (Bolton-Maggs et al 2014) reported that in 2013, 277 pregnant Rhesus-negative women in the UK developed, or were at risk of developing, anti-D antibodies because of delayed or omitted prophylaxis. If postnatal administration of anti-D is required it should be administered within 72 hours. SHOT should be informed if a woman develops a new immune anti-D at any time during maternity care (Bolton-Maggs et al 2014).

Safe transfusion practice: principles and procedures

There are potentially significant dangers associated with blood transfusion (see below). While many of them are avoidable, not all of them are (Hurrell 2014), those that are, are largely associated with human error (Bolton-Maggs 2014). The standard of care is set by the British Committee for Standards in Haematology (BCSH 2009), the standards are underpinned by:

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