North Staffordshire Hospital NHS Trust
Obstetric haemorrhage in women who refuse blood transfusion
by Dr M Khadra MB BCh MRCOG, Specialist Registrar adapted from Report on
Confidential Enquiries into Maternal Deaths in the United Kingdom 1991-1993
Date: FEBRUARY 2002
Reviewed by Peter Warren, Stoke on Trent Liaison Committee for Jehovah’s Witnesses
Introduction
The vast majority of women accept blood transfusion if the clinical reasons for it’s necessity
are fully and appropriately explained. However, a few women may continue to refuse
transfusion because of specific personal or religious beliefs. The main group of women
who may refuse for religious reasons are members of the Jehovah’s Witnesses, who
believe that the Bible forbids the consumption of blood or blood components. There are
about 125,000 Jehovah’s Witnesses in Britain. In 1991-3, assuming normal fertility rates,
the death rate from haemorrhage in this group was approximately 1 in 1000 maternities
compared with an expected incidence of less than 1 in 100,000 maternities.
Jehovah’s Witnesses’ Position on Medical Treatment




Will accept all other kinds of medical treatment except blood
Are not exercising a right to die
Are keen to co-operate with medical professionals
Do not try to stop others having blood
What Jehovah’s Witnesses Won’t Accept
1)
2)
3)
4)
5)
Transfusions of whole blood
Packed red cells
White cells
Plasma
Platelets
What Jehovah’s Witnesses Will Accept
1)
2)
3)
4)
5)
6)
Ringer’s Lactate
Normal Saline
Hypertonic Saline
Dextran
Gelatin (Gelofusine/Haemaccel)
Hetastarch
Matters of Patient Choice
1)
2)
3)
4)
Vaccines containing minor blood fractions
Immunoglobulins
Use of minor blood fractions
Dialysis
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North Staffordshire Hospital NHS Trust
Obstetric haemorrhage in women who refuse blood transfusion by Dr M Khadra, Specialist Registrar
Date written: September 2001
Date of next updat e: September 2002
5)
6)
7)
Intra-operative cell salvage
Haemodilution
Organ transplant
Massive obstetric haemorrhage is often unpredictable and can become life threatening in a
short time. In most cases, blood transfusion can save the woman’s life and very few
women refuse blood transfusion 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 management of women refusing blood transfusion
Consent and Communication
Booking/Antenatal period
1)
At the booking clinic, all women are normally asked their religious beliefs, and
should also be asked if they have any objections to blood transfusion. If a woman is
a Jehovah’s Witness or likely to refuse blood transfusion for other reasons, this
should be noted in the case notes. She should be asked if she is willing to receive
blood transfusion if necessary, and her reply should be noted and consent obtained.
2)
If she asks about the risks of refusing blood transfusion, she should be given all
relevant information. This must be done in a non-confrontational manner. She
would be advised that if massive haemorrhage occurs, there is an increased risk that
hysterectomy will be required (see para 23-24), and the woman and her partner
should be offered the opportunity to read and discuss the treatment guidelines in this
Annexe.
3)
If she decides against accepting blood transfusion in any circumstances, she should
be booked for delivery in a unit which has all facilities for prompt management of
haemorrhage, including hysterectomy as outlined in this Annexe.
4)
The woman’s blood group and antibody status should be checked in the usual way
and the haemoglobin and serum ferritin should be checked regularly. Haematinics
should be given throughout pregnancy to maximise iron stores.
5)
An ultrasound scan should be carried out to identify the placental site.
6)
Blood storage should not be suggested to pregnant women, as the amounts of blood
required to treat massive obstetric haemorrhage are far in excess of the amount that
could be donated during pregnancy.
7)
If any complications are noted during the antenatal period, the Consultant
Obstetrician must be informed.
Haemorrhage
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North Staffordshire Hospital NHS Trust
Obstetric haemorrhage in women who refuse blood transfusion by Dr M Khadra, Specialist Registrar
Date written: September 2001
Date of next updat e: September 2002
8)
The woman should be kept fully informed about what is happening. Information
must be given in a professional way, ideally by someone she knows and trusts. If
standard treatment is not controlling the bleeding, she should be advised that blood
transfusion is strongly recommended. Any patient is entitled to change her mind
about a previously agreed treatment plan.
9)
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.
10)
If she maintains her refusal to accept blood or blood products, her wishes should be
respected. The legal position is that any adult patient (i.e. 18 years old 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. No other person is legally able
to consent to treatment for that adult or to refuse treatment on that person’s behalf.
However, unlike adults, the refusal of a competent person aged 16-17 may in certain
circumstances be over-ridden by either a person with parental responsibility or a
court.(1)
11)
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.
12)
If, in spite of all care, the woman dies, her relatives require support like any other
bereaved family.
13)
It is very distressing for staff to have to watch a woman bleed to death while refusing
effective treatment. Support should be promptly available for staff in these
circumstances.
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North Staffordshire Hospital NHS Trust
Obstetric haemorrhage in women who refuse blood transfusion by Dr M Khadra, Specialist Registrar
Date written: September 2001
Date of next updat e: September 2002
General medical management
Labour
14)
The Consultant Obstetrician should be informed when a woman who will refuse
blood transfusion is admitted in labour. Consultants in other specialities need not be
alerted unless complications occur.
15)
The labour should be managed routinely, by experienced staff.
16)
Oxytocics should be given when the baby is delivered. The woman should not be
left alone for at least an hour after delivery.
17)
If caesarean section is necessary, it should be carried out by a Consultant
Obstetrician if possible.
18)
The majority of pregnancies will end without serious haemorrhage. When the
mother is discharged from hospital, she should be advised to report promptly if she
has any concerns about bleeding during the puerperium.
Haemorrhage
19)
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.
20)
If unusual bleeding occurs at any time during pregnancy, labour or the puerperium,
the Consultant Obstetrician should be informed and the standard management
should be commenced promptly. The threshold for intervention should be lower
than in other patients. Extra vigilance should be exercised to quantify any abnormal
bleeding and to detect complications, such as clotting abnormalities, as promptly as
possible.
21)
Consultants in other specialties, particularly anaesthetics and haematology, are
normally involved in the treatment of massive haemorrhage. When the patient is a
woman who has refused blood transfusion, the Consultant Anaesthetist should be
informed as soon as possible after abnormal bleeding has been detected. The
Consultant Haematologist should also be informed, even though the options for
treatment may be severely limited. Intensive care may need to be warned.
22)
Dextran should be avoided for fluid replacement because of its possible effects
on haemostasis. Intravenous crystalloid and artificial plasma expanders such as
Haemaccel should be used. Albumin can be useful and requires consent.
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North Staffordshire Hospital NHS Trust
Obstetric haemorrhage in women who refuse blood transfusion by Dr M Khadra, Specialist Registrar
Date written: September 2001
Date of next updat e: September 2002
Surgical
Haemorrhage
23)
Hysterectomy is normally the last resort in the treatment of obstetric haemorrhage,
but with such women delay may increase the risk. The woman’s life may be saved
by timely hysterectomy, though even this does not guarantee success.
24)
When hysterectomy is performed the uterine arteries should be clamped as early as
possible in the procedure. Subtotal hysterectomy can be just as effective as total
hysterectomy, as well as being quicker and safer. In some cases there may be a
place for internal iliac artery ligation.
25)
The timing of hysterectomy is a decision for the consultant on the spot. When
making this decision it may be helpful to note that the shortest time from delivery to
death recorded in these Reports was in 1985-7, when a woman died within 3 hours
of delivery with a haemoglobin concentration of 3.4g/dl. Survival without
hysterectomy has been recorded with a haemoglobin concentration of 4.9g/dl (2).
APPENDIX
CARE PLAN FOR WOMEN IN LABOUR REFUSING A BLOOD TRANSFUSION
(as referred to in the RCOG News (October 2000) of the Royal College of Obstetricians and
Gynaecologists)
Please ensure that the consultant obstetrician is aware a Jehovah’s Witness is being
admitted in labour.
All such patients should have the third stage of labour actively managed with oxytocic
drugs together with early cord clamping and controlled cord traction after placental
separation. Do not leave the patient alone for the first hour after delivery.
Risk factors predisposing to postpartum haemorrhage
If the patient has any of the risk factors below, an IV infusion of Syntocinon should
be considered after delivery of the baby
Previous history of bleeding, post or antepartum haemorrhage
Multiple pregnancy and/or  4 children
Large baby (>3.5kg)
Prolonged labour (especially when augmented with syntocinon
Polyhydramnios
Difficult operative delivery
Actively haemorrhaging:
First steps: Establish IV colloid infusion e.g. Haemaccel or Gelofusine. Give oxygen.
Consider CVP line. Catheterise & monitor urine output. Give oxytocic drugs first, then
exclude retained products of conception or trauma (this could save time). Proceed with
bimanual uterine compression. A useful emergency measure to buy time is aortic
compression, using a fist just above the umbilicus directed back against the spine. Slow
but persistent blood loss requires action. Anticipate coagulation problems. Involve
consultant anaesthetist and haematologist. Keep patient fully informed. Proceed with
following strategies if bleeding continues:
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North Staffordshire Hospital NHS Trust
Obstetric haemorrhage in women who refuse blood transfusion by Dr M Khadra, Specialist Registrar
Date written: September 2001
Date of next updat e: September 2002

Syntometrine marginally more effective than oxytocin alone. If patient is
hypertensive, use oxytocin, 10U IV, not 5U.

Oral Misoprostol 600μg (prostalgnadin E1 analogue). Use when unresponsive to
oxytocin and ergometrine (3). Intrauterine Misoprostol 800μg (4 tablets, has
been successfully used when unresponsive to oxytocin and carboprost (4). Rectal
Misoprostol (1000μg) rapid absorption and control of haemorrhage reported, avoids
oral problems (5). Does not appear to cause hypertension.

Carboprost (Hemabate) 250μg/ml IM, can be repeated after 15min. Direct intramyometrial injection is faster (less hazardous at open operation). If not available,
use 1 or 2 Gemeprost pessaries (Beacon Pharmaceuticals) in the uterus (6;6).

Aprotinin (Trasylol) 2,000,000 U followed by 500,000 U/hr or tranexamic acid
(Cyklokapron) 1gm IV x 3 daily (7);(8);(9). Both agents are fibrinolytic inhibitors
used to control serious haemorrhage including PPH, have been used in
combination. Recombinant factor VIIa (Novoseven) 90μg/kg, provides site
specific thrombin generation. Successfully used to treat 5 reported cases of
uncontrollable bleeding associated with DIC, in one case following caesarean
section (10). Experience with this drug is limited. Should only be used in lifethreatening bleeding under consultant guidance. Expert advice available from local
Haemophilia Comprehensive Care Centre or Novo Nordisk 24-hour medical advice
line: 0845 600 5055 (with emergency delivery).

Uterine packing (11) or intrauterine balloon catheter (6). Purpose-designed 500
ml J-SOS Bakri balloon available (Cook [UK] Ltd Ted. 01462 473100).
Embolisation or ligation of internal iliac artery or bilateral mass ligation of
uterine arteries and veins (6).

B-Lynch brace suture (12);(13). Simple surgical technique to control massive
haemorrhage. Has been used to avoid hysterectomy.

Hysterectomy, subtotal hysterectomy can be just as effective, also quicker and
safer (8). Consider blood salvage if surgical blood loss anticipated (blood salvage
with leucocyte depletion fillers also reported as potential life-saving technique
during caesaean section).
Post haemorrhage

For severe anaemia, give oxygen and use erythropoietin 300 U/kg x 3 per week
subcutaneously, without delay (14);(15). Shortens lag period of erythropoiesis and
accelerates haemoglobin recovery. Dosage for renal anaemia (50 U/kg), ineffective
for severe blood loss anaemia (14).

Iron supplementation essential. Oral iron is slow and unreliable, use IV iron
sucrose (Venofer) which is not associated with anaphylaxis, 200mg x 3 per week
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North Staffordshire Hospital NHS Trust
Obstetric haemorrhage in women who refuse blood transfusion by Dr M Khadra, Specialist Registrar
Date written: September 2001
Date of next updat e: September 2002
(8);(14);(15). Augment with vitamin B-12 and folic acid. Consider elective ventilation
on intensive care unit.

Hyperbaric oxygen therapy is an option in life-threatening anaemia (8);(16) – contact
Hospital Information Services for Jehovah’s Witnesses Tel: 020 8906 2211
(his@wtbts.org.uk)
References and sources:
1 Department of Health. Reference Guide to consent for examination or treatment.
2001. London, Department of Health.
2 Reid MF, Nohr K, Birks RJS. Eclampsia and haemorrhage in a Jehovah's Witness.
Anaesthesia 1986; 41:324-325.
3 El-Refaey H, O'Brien P, Morafa W, Walder J, Rodeck C. Use of oral misoprostol in the
prevention of postpartum haemorrhage. Br J Obstet Gynaecol 1997; 104:336-339.
4 Adekanmi OA, Purmessur S, Edwards G, Barrington JW. Intrauterine misoprostol for
the treatment of severe recurrent atonic secondary postpartum haemorrhage. Br J
Obstet Gynae 2001; 108:541-542.
5 O'Brien P, El-Refaey H, Gordon A, Geary M, Rodeck CH. Rectally administered
misoprostol for the treatment of postpartum hemorrhage unresponsive to oxytocin and
ergometrine. A descriptive study. Obstet Gynaecol 1998; 92:212-214.
6 Drife J. Management of primary postpartum haemorrhage. Br J Obstet Gynaecol
1997; 104:275-277.
7 Valentine S, Williamson P, Sutton D. Reduction of acute haemorrhage with aprotinin.
Anaesthesia 1993; 48:405-406.
8 Department of Health. The treatment of obstetric haemorrhage in women who refuse
blood transfusion. Report on confidential enquiries into maternal deaths in the United
Kingdom 1991-1993. London: HMSO, 1996: 44-47.
9 Alok KA, Hagen P, Webb JB. Tranexamic acid in the management of postpartum
haemorrhage. Br J Obstet Gynaecol 1996; 103:1250-1251.
10 Moscardo F. Successful treatment of severe intra-abdominal bleeding associated with
disseminated intravascular coagulation using recombinant activated factor VII. Br J
Haematol 2001; 113:174-176.
11 Maier RC. Control of postpartum hemorrhage with uterine packing. Am J Obstet
Gynaecol 1993; 169(2 (1)):317-323.
12 B-Lynch C, Coker A, Lawal AH, Abu J, Cowen MJ. The B_Lynch surgical technique
for the control of massive postpartum hemorrhage: an alternative to hysterectomy?
Five cases reported. Br J Obstet Gynaecol 1997; 104:372-375.
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North Staffordshire Hospital NHS Trust
Obstetric haemorrhage in women who refuse blood transfusion by Dr M Khadra, Specialist Registrar
Date written: September 2001
Date of next updat e: September 2002
13 Ferguson JEI, Bourgeois FJ, Underwood PB. B-Lynch suture for postpartum
hemorrhage. Obstet Gynaecol 2000; 95(6(2)):1020-1022.
14 Buscuttil D, Copplestone A. Management of blood loss in Jehovah's Witnesses. BMJ
1995; 311:1115-1116.
15 Breymann C, Richter C, Huttner C, Huch R, Huch A. Effectiveness of recombinant
erythropoietin and iron sucrose vs iron therapy only, in patients with postpartum
anaemia and blunted erythropoiesis. Europ J Clin Invest 2000; 30:154-161.
16 McLoughlin PL, Cope TM, Harrison JC. Hyperbaric oxygen therapy in the
management of severe acute anaemia in a Jehovah's Witness. Anaaesthesia 1999;
54:891-895.
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North Staffordshire Hospital NHS Trust
Obstetric haemorrhage in women who refuse blood transfusion by Dr M Khadra, Specialist Registrar
Date written: September 2001
Date of next updat e: September 2002