(*Hypothetical Case)

You are an obstetrician (or anaesthetist) and you work in a peripheral hospital in a metropolitan city. You are not on call but despite this you get woken by a phone call at 2am one night. It is a junior obstetric registrar who is very keen for you to come and give them some help. They tell you the on call obstetric consultant is already busy in theatre with an urgent caesarean for fetal distress and isn't currently available. They are on the labour ward with a women who has just had vaginal delivery of twins following a relatively long labour augmented with oxytocin. She now has an atonic uterus and despite oxytocin / ergometrine has bled about 2 litres - she has just reminded everyone that she is a jehovah's witness and reiterates that she will not accept blood under any circumstances. Unfortunately she never had any formal antenatal discussion about blood products - this is the first time she has mentioned it! The registrar sounds very scared and they want your advice about what to do next!

What are you going to advise over the phone?

What should have been done differently in the antenatal period?

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Thanks to Graeme for again being a good sport and agreeing to join in this podcast to make it more of a conversation and easier to listen to! He had to ad-lib, completely off the cuff, without any warning (I literally grabbed him in the corridor).

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The Most Important Points to Consider:

ANTENATAL

Optimise the haemoglobin and iron stores before delivery

Discuss and document what the patient will and won't accept - make sure you understand

Decide on the best place for delivery - consider availability of theatre and resources to manage haemorrhage (cell salvage, surgical expertise, radiology etc)

INTRAPARTUM

stop any bleeding AS SOON AS POSSIBLE

oxytocics - get control of tone rapidly

Tranexamic acid - consider prophylactically or as soon as any bleeding occurs.

theatre access immediately

senior / experienced staff early

hysterectomy early (not late).

Manual aortic occlusion.

Cell salvage - this can include vaginal bleeding and blood with amniotic fluid

POSTPARTUM

What is they have significant anaemia?

ICU/HDU

give oxygen

give haematinics (iv iron / EPO) to rapidly replace the lost Hb

minimise any further blood loss - including iatrogenic blood tests!

paralysis & ventilation - usually needed around Hb 30-40g/L

hyperbaric O2 - case series and reports of successful use

polymerised Hb - can be accessed for compassionate use but manufactured in the US

USEFUL RESOURCES

Best Reference on this topic:

Kidson-Gerber, G., Kerridge, I., Farmer, S., Stewart, C. L., Savoia, H. and Challis, D. (2016), Caring for pregnant women for whom transfusion is not an option. A national review to assist in patient care. Aust N Z J Obstet Gynaecol, 56: 127–136. doi:10.1111/ajo.12420

For a good explanation and diagram explaining the Jehovah's witnesses' basic position on blood and blood products :

http://ajwrb.org/watchtower-approved-blood-transfusions

Tranexamic Acid

Tranexamic acid for prophylaxis in Caesarean

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5228660/

Tranexamic Acid for PPH

WOMAN study

Hyperbaric Oxygen to treat severe anaemia in a JW after abruption:

https://www.ncbi.nlm.nih.gov/pubmed/23380087

Case report of use of hemopure for postpartum anaemia

https://www.tandfonline.com/doi/pdf/10.1080/22201173.2009.10872581

Case report of the use of hemopure in severely anaemic JW trauma patient in Melbourne

https://www.mja.com.au/journal/2011/194/9/synthetic-haemoglobin-based-oxygen-carrier-and-reversal-cardiac-hypoxia

Vaginal Cell Salvage

Cell salvage for postpartum haemorrhage during vaginal delivery: a case series

http://www.bloodtransfusion.