Women Declining Blood Products – Clinical Guideline for
Midwives
1. Aim/Purpose of this Guideline
1.1. Guideline for the care of women declining blood products.
2.
The Guidance
2.1
Introduction
A study from the Netherlands1 in 2009 found that:
 14/1000 Jehovah’s witness (JW) parturients experienced serious maternal morbidity
compared with 4.5/1000 of the total pregnant population ie a 3 fold increase in risk
 Jehovahs witness parturients have a 130 times increased risk of death from
maternal haemorrhage
 Transfusions of the 4 major components of blood; packed cells, white cells,
platelets and plasma are unacceptable as a matter of faith to JWs but some
fractions or minor components are accepted2
 There is variation amongst JWs as to which blood fractions and blood saving
techniques are acceptable3.
 Some JW will not accept Anti D as it is harvested from blood of sensitised
individuals
 All JW parturients should have the opportunity to talk to their obstetrician and if
appropriate the hospital Liaison Committee for JW away from members of the
family or religious community.
 There should be a recorded ante natal discussion and an advance directive should
have been completed and filed in the hand held and patient notes.
The site co-ordinator should be contacted if there is urgent need to obtain legal advice and
a judicial opinion.
2.2
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Minors
If a minor is pregnant, the right of her parents to determine medical treatment
terminates if she has sufficient understanding and intelligence to fully understand
what is proposed4.
In situations where there has been no prior consultation or documentation the
wishes of a competent child may be overruled by a court, if the consequences of
refusal are such that it would be inappropriate to comply with the child’s wishes 5.
If this is a life-threatening emergency affecting the child, blood should be transfused
without consulting the court6.
2.3
Antenatal care


Book with a consultant obstetrician
Refer to Day Assessment Unit for an anaesthetic ante-natal appointment.
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Full discussion of the issues with clear documentation in the notes.
Copy Advance Directive. and file a copy in the hospital notes- in front of front Sheet.
Inside cover of notes write “Advance Directive”.
Affix alert sticker to front of notes
Routine blood tests for group and screen to ascertain antibody status is useful
unless patient declines.
Regular haemoglobin check and routine haematinics. Anaemia should be treated
aggressively with haematological advice if haemoglobin unresponsive to oral iron.
Encourage the patient to complete a Healthcare Advance Directive specifying
which, if any, fractions of plasma or cellular components (e.g. clotting factors,
prophylactic anti-D, albumin) or procedures (e.g. intra-operative cell salvage) are
acceptable as a matter of personal choice. Worksheets to complete for fractions or
procedures, and instructions for completing advance directive available in
publication “Maternal Matters”. Produced by Plymouth and Truro Hospital Liaison
Committee.
Advise to deliver in a unit that has the ability to cope with major haemorrhage
Identify any specific risk factors and plan delivery accordingly
Notify consultant obstetrician and anaesthetist on admission in labour for discussion
of final care plan
Manage labour routinely
Recommend active management of the third stage
Close monitoring for first hour after delivery and early intervention if bleeding
Confidential Enquiry reports have consistently recommended that Caesarean
section should be performed by a consultant obstetrician with a consultant
anaesthetist 7,8 ,9
Inform anaesthetic practitioners early to set up cell salvage facility. Whenever
possible cell salvage collection should be offered and when applicable informed
consent obtained for intra-operative cell salvage 9.
2.4
Stopping blood loss

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See guidelines for massive obstetric haemorrhage.
Avoidance of delay in treatment of haemorrhage is even more crucial so there must
be meticulous attention to quantifying blood loss, detecting clotting abnormality and
monitoring vital signs. Rapid decision making is required
If the patient’s wishes have not been documented or are unclear, good medical
judgement should be exercised, treating the patient in accordance with what would
be considered appropriate by a responsible body of medical opinion5.
Involve obstetric, anaesthetic and haematology consultants early
Consultants to consider early the role of the interventional radiologist
Intravenous crystalloid should be used to replace blood volume
Blood products acceptable to the patient may be useful (e.g. cryoprecipitate)
Pharmacological, radiological and surgical techniques to arrest haemorrhage
Keep the woman fully informed and ensure she is not being subject to pressure
from relatives, friends or clinical staff
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2.5 Care plan for active haemorrhage in peripartum women refusing
transfusion
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Crystalloid IV infusion
Oxygen by face mask (15 litres/min with reservoir bag)
Oxytocic drugs, catheterise and monitor urine output
Early intervention to exclude retained products of conception or unsuspected genital
tract trauma
Apply bimanual compression; aortic compression may also be useful
Anticipate coagulation problems
2.6
Pharmacological methods
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Syntometrine may be more useful than oxytocin alone
Oxytocin if hypertensive
Oxytocin infusion
Carboprost (Hemabate) 250μg IM, can be repeated after 15 minutes
Oral misoprostol 600μg (3 tablets) and/or Rectal misoprostol 1000μg (5 tablets)
tranexamic
acid (Cyklokapron) 1gm within 30 minutes of start of bleed .
Recombinant factor VIIa (Novoseven) 40-60μg/kg is no longer recommended due to
Thrombotic risks 10.
Vitamin K IV
2.7
Surgical techniques
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Uterine packing
Rausch intrauterine balloon
Uterine artery embolisation
Uterine artery ligation
Internal iliac artery ligation
B-Lynch brace suture
Early recourse to hysterectomy may be life saving

3. Monitoring compliance and effectiveness
Element to be
monitored
Lead
Tool
Frequency
Reporting
arrangements
The care of women declining blood products.
Royal Cornwall Hospitals Supervisors of Midwives.
 The woman was booked under Obstetric consultant lead care.
 The woman had a mid-trimester anaesthetic review
 The woman had an advance directive filed in her notes.
 If additional risk factors are identified the woman had an
individual management plan filed in her notes.
 If the woman’s HB < 10.5 grams/dl appropriate management
was instigated.
Every 3 months the notes of women that have declined blood
products in the ante natal period will be reviewed by a member of
the anaesthetic team.
The results will be monitored every 3 months by the Maternity Risk
Management Forum and an action plan developed.
WOMEN DECLINING BLOOD PRODUCTS – CLINICAL GUIDELINE FOR MIDWIVES
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Acting on

recommendations
and Lead(s)

Change in
practice and
lessons to be
shared
Action leads will be identified and a time frame for the action to
be completed.
The action plan will be monitored by the Maternity Risk
Management Forum / Clinical Audit Forum until all actions
complete.
 Required changes to practice will be identified and actioned
within a time frame agreed on the action plan.
The results of the audits will be distributed to all staff through the
Risk Management Newsletter.
4. Equality and Diversity
4.1
This document complies with the Royal Cornwall Hospitals NHS Trust service
Equality and Diversity statement.
4.2
Equality Impact Assessment
The Initial Equality Impact Assessment Screening Form is at Appendix 2.
WOMEN DECLINING BLOOD PRODUCTS – CLINICAL GUIDELINE FOR MIDWIVES
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Appendix 1. Governance Information
Document Title
WOMEN DECLINING BLOOD PRODUCTS
– CLINICAL GUIDELINE FOR MIDWIVES
Date Issued/Approved:
2nd October 2014
Date Valid From:
2nd October 2014
Date Valid To:
2nd October 2017
Directorate / Department responsible
(author/owner):
Obs and Gynae Directorate
Contact details:
Dr Catherine Ralph
Consultant Anaesthetist
01872 253132
Guideline for the care of women declining
blood products.
Brief summary of contents
Suggested Keywords:
RCHT

Target Audience
PCH
CFT
KCCG
Executive Director responsible for
Policy:
Medical Director
Date revised:
June 2017
This document replaces (exact title of
previous version):
Guideline for the care of women declining
blood products.
Maternity Guidelines Group
Obs & Gynae Directorate
Divisional Board
Approval route (names of
committees)/consultation:
Divisional Manager confirming
approval processes
Head of Midwifery
Name and Post Title of additional
signatories
Not required
Signature of Executive Director giving
approval
Publication Location (refer to Policy
on Policies – Approvals and
Ratification):
{Original Copy Signed}
Internet & Intranet
 Intranet Only
Document Library Folder/Sub Folder
Clinical/Midwifery and Obstetrics
Links to key external standards
No
WOMEN DECLINING BLOOD PRODUCTS – CLINICAL GUIDELINE FOR MIDWIVES
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Related Documents:
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Maternal mortality and serious
maternal morbidity in Jehovahs
witnesses in the Netherlands. BJOG
2009 Jul;116(8);1103-8
Re W (A Minor) Medical treatment:
Court’s jurisdiction; Court of Appeal,
1992.
The Watchtower 1990; June 1:30-1.
How can blood save your life.
The Watchtower 2004; June 15: 2931 Blood fractions –elements of
blood extracted through fractionation
Gillick v West Norfolk and Wisbech
AHA. All England Law Reports 1985;
3:402-37.
Gilmartin G. Jehovah’s Witnesses. In
Scott WE, Vickers MD, Draper, H.
eds. Ethical Issues in Anaesthesia.
Butterworth Heinemann 1994;10513.
Re T. All England Law Reports 1992;
4:647-70.
Why Mothers Die 1991-1993. Report
of the Confidential Enquiry into
Maternal Deaths. Haemorrhage,
HMSO, London. Chapter 3: Annex;
44-47
Why Mothers Die 2001-2003. Report
of the Confidential Enquiry into
Maternal Deaths and Child Health.
RCOG, London. Chapter 4: Annex A;
94-95
Saving Mothers Lives 2003-2005.
CEMACH. Chapter 5 pg 80.
PROMPT communication 10th Dec
2007.
Royal College of Surgeons Code of
Practice
for
the
Surgical
Management
of
Jehovah’s
Witnesses (RCS 2002)
Care Plan for Women in Labour
Refusing a Blood Transfusion
(RCOG News October 2000 and
MOET course manual 2003)
Clinical Strategies for Managing
Haemorrhage and Anaemia without
Blood Transfusion (January 2002,
available from the JW Hospital
Liaison Committee)
Maternal Matters- Plymouth and
Truro Liaison Committee
WOMEN DECLINING BLOOD PRODUCTS – CLINICAL GUIDELINE FOR MIDWIVES
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Training Need Identified?
Management of ANAESTHESIA
FOR Jehovah’s Witnesses. AAGBI
Nov 2005.
www.cemach.org.uk
No
Version Control Table
Date
Version
No
Summary of Changes
15th July
2009
1.2
5th June
2014
1.3
2nd
October
2014
1.4
Updated Jehovah Witness outcome
references
V1.5
Interim addition: Approved my Maternity
Guideline Group. Appendix 3 now includes:
‘Contact details for Jehovah's Witnesses
advisers / elders are included as a courtesy
to the JW community. If these details are
passed to a patient or their representative it
should be explained that the JW advisors /
elders are not employees of the RCHT
Trust, and that the Trust carries no
responsibility for their advice or actions’.
14th
October
2015
Under pharmacological methods Cervagen
has been removed.
Update of contact numbers
Changes Made by
(Name and Job Title)
Cathy Ralph
Consultant
Anaesthetist
Cathy Ralph
Consultant
Anaesthetist
Cathy Ralph
Consultant
Anaesthetist
Elizabeth Anderson
Practice Development
Midwife
All or part of this document can be released under the Freedom of Information
Act 2000
This document is to be retained for 10 years from the date of expiry.
This document is only valid on the day of printing
Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust
Policy on Document Production. It should not be altered in any way without the
express permission of the author or their Line Manager.
WOMEN DECLINING BLOOD PRODUCTS – CLINICAL GUIDELINE FOR MIDWIVES
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Appendix 2. Initial Equality Impact Assessment Form
Name of Name of the strategy / policy /proposal / service function to be assessed (hereafter
referred to as policy) (Provide brief description): WOMEN DECLINING BLOOD PRODUCTS –
CLINICAL GUIDELNE FOR MIDWIVES
Directorate and service area:
Is this a new or existing Policy?
Obs and Gynae Directorate
Existing
Name of individual completing
Telephone:
assessment: Elizabeth Anderson
01872 252879
1. Policy Aim*
To provide guidance to obstetricians and midwives on the
Who is the strategy /
management of a pregnant woman declining blood products
policy / proposal /
service function
aimed at?
2. Policy Objectives*
To ensure evidence based advice and management of a pregnant
woman declining blood products.
3. Policy – intended
Outcomes*
Safe outcome for women and baby
4. *How will you
measure the
outcome?
5. Who is intended to
benefit from the
policy?
6a) Is consultation
required with the
workforce, equality
groups, local interest
groups etc. around
this policy?
Compliance Monitoring Tool
b) If yes, have these
*groups been
consulted?
N/A
C). Please list any
groups who have
been consulted about
this procedure.
N/A
Women and new-born
No
7. The Impact
Please complete the following table.
Are there concerns that the policy could have differential impact on:
Equality Strands:
Age
Sex (male, female, trans-
Yes
No
X
Rationale for Assessment / Existing Evidence
X
gender / gender
reassignment)
WOMEN DECLINING BLOOD PRODUCTS – CLINICAL GUIDELINE FOR MIDWIVES
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Race / Ethnic
communities /groups
X
Disability -
X
learning
disability, physical
disability, sensory
impairment and
mental health
problems
Religion /
other beliefs
X
Marriage and civil
partnership
X
Pregnancy and maternity
X
Sexual Orientation,
X
Bisexual, Gay, heterosexual,
Lesbian
You will need to continue to a full Equality Impact Assessment if the following have been
highlighted:
 You have ticked “Yes” in any column above and
 No consultation or evidence of there being consultation- this excludes any policies
which have been identified as not requiring consultation. or
 Major service redesign or development
No
8. Please indicate if a full equality analysis is recommended.
Yes
X
9. If you are not recommending a Full Impact assessment please explain why.
N/A
Signature of policy developer / lead manager / director
Cathy Ralph
Names and signatures of
members carrying out the
Screening Assessment
Date of completion and submission
5th June 2014
1. Elizabeth Anderson
2.
Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead,
c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa,
Truro, Cornwall, TR1 3HD
A summary of the results will be published on the Trust’s web site.
Signed: Elizabeth Anderson
Date: 14th October 2015
WOMEN DECLINING BLOOD PRODUCTS – CLINICAL GUIDELINE FOR MIDWIVES
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Appendix 3. Contact Numbers for Jehovah’s Witnesses
Contact details for Jehovah's Witnesses advisers / elders are included as a courtesy to the
JW community. If these details are passed to a patient or their representative it should be
explained that the JW advisors / elders are not employees of the RCHT Trust, and that the
Trust carries no responsibility for their advice or actions.
Name
Mr Michael
Passmore
Fax
Mobile
Phone
Email 1
Email 2
01752
511345
07977
879897
01752
511345
mike@plymouthtrurohlc.org
michaelpassmore@sky.co
Barry
Gardiner
07890
177160
01726
77757
barry@plymouthtrurohlc.org
barryhlc@hotmail.com
Royston
Mumford
07552
435562
01752
823279
roy@plymouthtrurohlc.org
Christophe
r Schmid
07984
336717
01752
823632
chris@plymouthtrurohlc.org
christopherschmid@think
Peter
Sharratt
07553
944599
01752
317938
peter@plymouthtrurohlc.org
peterandcharlie@aol.com
Paul White
07771
528326
01579
386973
paul@plymouthtrurohlc.org
120flo@sky.com
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