16.8 Jehovas Witness parturient

Question 1

You are asked to review a woman in the anaesthetic antenatal clinic.

She is 30 weeks pregnant and a Jehovah’s Witness.

She requires an elective caesarean section at 39 weeks due to a low-lying placenta and a fibroid uterus.

a) What specific issues should be discussed with this patient based on the history outlined above?
(10 marks)

Answer 1

1. > > Ensure no coercion from family or fellow-witnesses.
2. > > Discuss what advice the patient
   has received from fellow-witnesses, the
   hospital liaison team or other sources.
3. > > Preoperative optimisation if necessary:
   check current haemoglobin and haematinics,
   liaise with haematologist if optimisation is
   required with iron (intravenous if rapid response required), folate, erythropoietin.**
4. > > Potential for bleeding:
   discuss the greatly increased risks due to fibroids
   AND placenta praevia.
5. > > Risks of untreated haemorrhage:
   mortality and major morbidity, including
   prolonged ICU stay, prolonged ventilation and its complications, poor wound healing, infection, hysterectomy, consequent difficulties with
   caring for newborn.

> > Specific wishes regarding blood products:

whole blood, red blood cells,
plasma and platelets are generally
not acceptable to Jehovah’s

Witnesses, whereas albumin,
immunoglobulins, individual clotting factors
and anti-D are up to personal preference.

Do not make assumptions –
check the acceptability of all blood products
and document.

> > Appreciate that there are no true blood ‘alternatives’: Jehovah’s Witnesses’ website refers to
blood substitutes.
It is important that the woman understands
that there are no true blood alternatives in
existence.

> > Understanding of techniques that
can be employed to minimise risk of
bleeding:

• Elective caesarean delivery.

• Consultant obstetrician and anaesthetist.

• Regional technique.

• Possibility of need for uterine artery
catheters to be sited ready for
deployment if excessive bleeding occurs.

• Use of oxytocics to minimise postpartum haemorrhage.

• Tranexamic acid use if bleeding occurs.

> > Acceptability of cell salvage:
description of process,
up to the individual patient whether it
complies with their beliefs and whether they can
view the extracorporeal circuit as an extension
of their own and ‘uninterrupted’.

> > Risks of cell salvage: see part (b).

> > Advance decision:
patient may have one already –
ensure that it reflects the discussed
wishes and copy taken for inclusion in patient’s notes

Any hospital-specific paperwork must also be completed.

> > Ability to change mind: free to reverse decision, including verbally, at any time. However, in an emergency, the patient may not be capable or conscious. No one else can change the patient’s mind on her behalf in such a situation.

Question 2

b) Give the advantages and disadvantages of using intra-operative cell salvage during caesarean section.
(10 marks)

Advantages:

Answer 2

Advantages:

> > Avoidance of risks of allogenic transfusion:
ABO incompatibility and other
transfusion reactions,
viral, bacterial and prion transmission,
blood errors.

> > Good value: consumables cost
slightly more than one unit of donated
blood.

> > Blood reinfused at room temperature,
reduces the risk of hypothermia
associated with transfusion.

> > Often acceptable to Jehovah’s Witnesses.

> > Useful in patients with atypical
antibodies where cross-match may be
difficult to achieve.

> > Normal 2,3 DPG levels and, thus,
oxygen-carrying behaviour.

Question 3

Disadvantages of Cell salvalge

Answer 3

Disadvantages:
» In the case of Rhesus-positive baby
with Rhesus-negative mother, there
is a risk of alloimunisation.

However, this risk occurs in any delivery of
positive baby to negative mother and anti-D administration is routine in such cases anyway.

> > Leucodepletion filter may result in
release of vasoactive substances
causing hypotension.

> > Air embolism.

> > High cost per use in centres where
cell salvage infrequently used.

> > Staff training necessary,
may be difficult to maintain staff competency if
infrequently used.

> > Risk of bacterial contamination.

> > Risk of electrolyte imbalance.

> > No platelets or coagulation factors
so does not eliminate need for
allogenic blood products in
significant haemorrhage.

> > Red cell lysis due to ‘skimming’
(suctioning of surface of shed blood)
reduces the availability of whole cells
for reinfusion and increases the
quantity of free haemoglobin,
which may cause renal damage.

> > Slow flow rate through
leucodepletion filter, may not be
adequate during
massive haemorrhage.

> > Risk of circulatory overload