December 8, 2023 • 36 mins
Are you already familiar with the life-saving role of blood transfusions in obstetrics? If not, get ready for an enlightening journey into this critical aspect of maternity care. This episode is packed with insights about the ins and outs of transfusions, from packed red cells to platelets, plus everything else a woman might need to replace following excessive bleeding during pregnancy or childbirth. We also introduce you to the role of a hematologist and a game-changing device called TEG.
Pregnancy and childbirth can sometimes bring along unforeseen complications. Here, we delve into potential reactions during transfusions, the significance of monitoring and consent, and the intricacies of platelet transfusions. We also discuss the importance of knowing a woman's blood group and the use of O negative blood in emergencies. Wrapping up, we extend an invite to engage more with the topic and seek your support to keep the ObsPod alive and kicking. Tune in and immerse yourself in the world of obstetrics!
Want to know more?
https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/blood-transfusions-in-obstetrics-green-top-guideline-no-47/
https://nhsbtdbe.blob.core.windows.net/umbraco-assets-corp/23998/inf1580-1-receiving-a-blood-transfusion-print-friendly.pdf
https://www.nhs.uk/conditions/blood-transfusion/
https://epostersonline.com/oaa2022/poster/p9?view=true
Willing to donate blood in the uk?
https://www.nhsbt.nhs.uk/
Thank you all for listening, My name is Florence Wilcock I am an NHS doctor working as an obstetrician, specialising in the care of both mother and baby during pregnancy and birth. If you have enjoyed my podcast please do continue to subscribe, rate, review and recommend my podcast on your podcast provider.
If you have found my ideas helpful whilst expecting your baby or working in maternity care please spread the word & help theobspod reach other parents or staff who may be interested in exploring all things pregnancy and birth.
Keeping my podcast running without ads or sponsorship is important to me. I want to keep it free and accessible to all but it costs me a small amount each month to maintain and keep the episodes live, if you wish to contribute anything to support theobspod please head over to my buy me a coffee page https://bmc.link/theobspodV any donation very gratefully received however small.
Its easy to explore my back catalogue of episodes here https://padlet.com/WhoseShoes/TheObsPod I have a wide range of topics that may help you make decisions for yourself and your baby during pregnancy as well as some more reflective episodes on life as a doctor.
If you want to get in touch to suggest topics, I love to hear your thoughts and ideas. You can find out more about me on Twitter @FWmaternity & @TheObsPod as well as Instagram @TheObsPod and e...
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Hello, my name is Florence.
Welcome to the ObsPod.
I'm an NHS obstetrician hopingto share some thoughts and
experiences about my workinglife.
Perhaps you enjoy Call theMidwife.
Maybe birth fascinates you, oryou're simply curious about what
exactly an obstetrician is.
You might be pregnant andpreparing for birth.
(00:21):
Perhaps you work in maternityand want to know what makes your
obstetric colleagues tick, oryou want some fresh ideas and
inspiration.
Whichever of these is the caseand, for that matter, anyone
else that's interested, theObsPod is for you.
(00:49):
Episode 161 Blood Transfusion.
It might seem odd to pick thetopic of blood transfusion.
Not many women will need ablood transfusion, but for some
women, in some situations whichmay or may not be anticipated, a
(01:10):
blood transfusion at some pointduring their maternity care may
be absolutely essential andlife-saving.
I have previously touched onthis in episode 41, blood Loss,
so you may like to go back andlisten to that to understand a
bit of context about why a womanmight need a blood transfusion.
(01:33):
But today I'm going to focus abit on blood transfusion itself.
What do we mean by a bloodtransfusion and also why?
One of the questions we'll askat the beginning of pregnancy is
would you accept a bloodtransfusion?
Because for some women, a bloodtransfusion will be
(01:57):
unacceptable and given that,I've just said, a blood
transfusion can be life-saving,these women need particular care
and planning during theirpregnancy to make sure they have
a safe outcome.
Often, what we refer to as ablood transfusion is packed red
(02:23):
cells, the cells that carry theoxygen around the blood.
That's what we most commonlyuse, but this isn't actually
blood.
As I've just mentioned, it'spacked red cells, so it's a
component of the blood, andactually quite a lot of other
(02:44):
components of the blood areremoved.
When a woman is bleeding, she'snot just losing her packed red
cells, she's losing all herblood.
So that's red blood cells,white blood cells, platelets the
(03:05):
little cells that clot theblood and plasma, and within the
plasma are all sorts ofimportant proteins such as
clotting factors.
So, depending on what thereason is that a woman needs a
blood transfusion and whethershe's actively bleeding, at that
(03:25):
point in time we may need toreplace more than just the red
blood cells that we casuallyrefer to as blood.
We may need to add in otherblood products, other elements
of the blood that have beenremoved from those packed red
(03:47):
cells.
The commonest situation in whichwe may need to give blood in
obstetrics is because ofexcessive bleeding after the
birth of the baby, excessiveblood loss, and the reasons for
that I've talked about back inepisode 41, so I'm not going to
(04:09):
go into them here.
But a woman can bleed very fast, particularly if she's bleeding
from the placental bed, wherethe placenta has been attached
to the wall of the womb.
And if a woman is unstable soshe's putting up her heart rate
(04:31):
and dropping her blood pressureand she's got ongoing bleeding,
we will need to think about ablood transfusion on the basis
of her hemodynamics.
That's how her body isresponding to that loss of blood
volume.
An adult on average, of averagesize, will have about seven
(04:55):
litres of blood.
If a woman is losing perhapstwo litres or more, that's a
significant proportion of herwhole circulating blood volume.
And therefore, although we mayreplace that with fluid so water
(05:18):
, with salts in such asheartmans or saline, that
increases the volume but itdoesn't increase the blood cells
that help carry oxygen and itdoesn't replace the proteins
that I just mentioned or theplatelets that are needed to
(05:40):
help clot the blood.
So in an active bleedingsituation where large amounts of
blood loss are occurring, wewill be much more likely to give
not only packed red blood cellsbut also possibly platelets and
(06:04):
something called FFP freshfrozen plasma, which contains
all the proteins the clottingfactors that I mentioned that
are essential in part of ourtreatment to help stop bleeding.
So when an active bleedingsituation is happening, one of
(06:27):
the key people we need tocontact is the hematologist, the
blood specialist, who can workwith the lab, look at the
clotting results and tell usexactly what we need to give to
not only replace the red bloodcells that are carrying oxygen,
(06:49):
but also replace the othercomponents of the blood that are
needed to maintain normalclotting levels.
These days we also have accessto a new device, so-called TEG,
which stands forThrombo-Elastography System, and
(07:11):
that is a little point of caretest.
So that is a test where theanesthetist can take some blood
in the operating theatre and,within about 10 minutes, get a
little graph of what's happeningwithin the clotting cascade and
(07:31):
how clot is or isn't forming.
It gives a little picture thatlooks like a wine glass on its
side, and from this we can workout which elements of the
clotting cascade aren't workingand therefore what bits of the
(07:53):
clotting cascade we might needto replace.
This would seem obviouslybeneficial but reviewing some
documents to record this episode, there isn't yet clear evidence
that it improves outcomes.
But it gives us a clear andquick picture in real time in
(08:21):
the operating theatre which wecan then respond to.
The other situation in which wemay use a blood transfusion may
be after excessive bleeding.
The bleeding has settled, thewoman is relatively stable, but
she's significantly dropped herblood count.
(08:42):
She may be feeling extremelydizzy, exhausted, drained.
We may look at her on the wall,drowned, and notice that she's
very pale and we may recommend ablood transfusion because while
she will produce her own bloodcells, to eventually top herself
(09:04):
up that could take weeks.
So we work on what her bloodcount is.
We'd expect a woman to have ahemoglobin that's the oxygen
carrying protein in the redblood cell of hopefully above
(09:25):
110 grams per litre at the endof pregnancy, and women can
tolerate significantly lowerblood counts.
But if acutely a woman's bloodcount drops below 80 grams per
(09:46):
litre, she's likely to be verysymptomatic breathless,
exhausted, high pulse and reallystruggling.
And that's usually the level atwhich we think about blood
transfusion.
If it's above 80 or 90, thenoften iron tablets and a bit of
(10:08):
time will be sufficient In thesesituations, a woman has much
more choice about whether shehas a transfusion, and we will
usually give her a very niceinformation leaflet, produced by
the NHS Blood TransfusionService, that explains exactly
(10:29):
what having a blood transfusioninvolves, what the point of it
is, what it will feel like andwhat risks there are.
And yes, blood transfusion isnot without risk.
I think the thing people worryabout is mainly infection, and
(10:54):
actually, if you look at theinformation leaflet, the risk of
infection is unbelievably lowbecause blood transfusions blood
that is given is all tested, sothe chance of getting hepatitis
(11:14):
B, hiv is less than one in amillion, and then less than one
in 10 million.
What is much more likely to bean issue is a reaction to a
blood transfusion, and that'sbecause it's incredibly
important that the blood ismatched up to the person, so it
(11:39):
needs to be the correct bloodgroup and we need to be sure
that the person receiving theblood transfusion doesn't have
any unusual antibodies.
So actually, the risks relatedto blood transfusion are more to
do with incorrectly identifyingthe patient.
(12:01):
When we take a sample for whatwe call group and save, we're
ascending the patient's bloodoff to the lab to be matched up.
It's absolutely essential thatwe are sending the correct
sample, it hasn't got muddled upwith anyone else's sample,
we've written all the correctpatient identifying information
(12:24):
on the bottle and on the requestform and that we check the
identification name band of thepatient before we give the blood
and the blood is correctlymatched.
So sometimes it drives ustotally mad in an emergency
situation when we send somethingoff to the lab and the lab say
(12:46):
we've spelt something wrong, thepatient name doesn't match or
they can't read the writing.
But actually they're doing thatwith good cause.
And the reason I say it drivesus mad is we have to retake the
sample, have to rewrite it.
(13:08):
And you might think in this dayand age, why are we writing?
Why isn't it all automated?
Well, the reason is that forall our other blood tests it is
automated.
We can print a sticker and slapit on the tube of blood.
But actually that could beprone to far more errors than us
writing and correctlyidentifying the sample because
(13:34):
it's so easy to put a sticker onthe wrong tube.
So the risks of bloodtransfusion are small, but are
our responsibility as clinicianswhen we're taking those group
and save or cross match samplesMost people will not have a
(13:56):
reaction to blood, but somepeople will.
And you may feel when you'rehaving a blood transfusion is if
you've got a slight temperature, feel a bit flushed, and that
can be due to a mild immunereaction.
And this means that whilesomeone is having a blood
(14:18):
transfusion, we'll be doingregular observations pulse,
blood pressure, temperature andmaking sure that they're not
having a reaction.
And if you are having areaction, we have to stop the
blood transfusion immediately,send it back to the lab to see
what's happened.
Reactions are very carefullymonitored and then of course,
(14:38):
we'll be giving paracetamol ormaybe some anti-histamines, and
it depends what the reaction is.
So if a woman is being offereda blood transfusion in not an
emergency situation, we'll giveher this information leaflet so
that she can decide, just likeanything else, whether she gives
(14:59):
us her consent to have thatblood transfusion.
Rarely, we might use a bloodtransfusion in the anti-natal
period if we've got women thatare getting very anemic.
Their iron levels are low,perhaps they haven't responded
to iron treatment or maybe theyhave a condition that means that
(15:22):
they can't actually have irontreatment and therefore we might
give them an anti-natal bloodtransfusion, top them up prior
to giving birth to try and getthem in good shape for birth and
(15:42):
so that they're at a safe levelin case they should have that
unexpected excessive blood lossafter the baby's born.
Some women will have lower thanaverage platelets the cells
that clot the blood duringpregnancy and I've talked
(16:04):
previously about this in episode107, so you can find out a bit
more there.
It's unusual for us to give aplatelet transfusion, but if a
woman's platelets have droppedvery low, either because of
pregnancy or because she hasanother condition separate from
pregnancy that means herplatelets are very low, then we
(16:27):
may prepare and plan and giveher a platelet transfusion
around the time of birth.
Platelets don't last very longin the bloodstream.
A red blood cell lastsapproximately 120 days.
Platelets actually drop offwithin about 72 hours of when
(16:52):
the transfusion was given.
Coming back down to theprevious platelet count.
So for women with very lowplatelets usually at a level of
50 or lower is when we'rethinking about giving platelet
transfusion.
We will give that platelettransfusion maybe immediately
(17:16):
prior to performing anintervention such as a plan
cesarean birth, immediatelybefore and then during and then
immediately after, depending onhow many pools of platelets
we're going to give.
So the timing of givingplatelets needs much more
(17:40):
fine-tuning and platelets aren'talways necessarily available in
every hospital all the time.
So many of us will work in ahospital where we have a
laboratory which will provideblood and match us up blood, but
(18:04):
we won't necessarily haveaccess to all the blood products
.
They may need to come from aregional transfusion centre.
So certainly in my hospital ifwe need an excessive amount of
platelets or very specific, morerare blood group types, we will
(18:27):
need to get blood sent overfrom our local regional
transfusion centre.
So this needs a bit moreplanning and if we're in an
emergency situation, obviouslywe don't have the ability to do
that.
But if we have a more plannedsituation, like a planned
(18:48):
cesarean birth or a plannedinduction of labour, then
matching up and getting readyfrom our regional transfusion
lab the blood products that wethink a woman might need is
really critical and sometimes ifwe absolutely have to and we
haven't got this ready, we willdecide it's not safe to go ahead
(19:10):
and we may postpone thingsuntil such time as we can get
the right blood products in theright place.
Many years ago this wasactually a stipulation for an
obstetric unit that you had aworking lab with access to blood
products because, like I said,blood loss can be of such an
(19:36):
unpredictable nature inmaternity care.
So I mentioned there a littlebit about matching and getting
blood ready.
Most of the blood we give thered cells that I mentioned are
what we call fully cross-matchedblood.
We will have a record of thewoman's blood group and type.
(19:58):
But we will take a sample atthat point when a blood
transfusion is necessary.
We'll send it to the lab andthey'll match it up and they'll
give her red cells from a donorthat is compatible with her
group.
They fully matched up and thatgives her the least chance of a
(20:19):
reaction to the bloodtransfusion.
If we've got a little bit lesstime we're in a bit more of an
emergency situation we mightgive group specific blood.
So the full cross-matched bloodtakes usually around an hour
(20:42):
and a woman can lose a lot ofblood in that time.
But if she's stable and we'reon top of it, we can wait for
that fully cross-matched blood.
If actually things are a bitmore unstable and we haven't got
that time, we have on recordthat woman's blood group and
(21:02):
they can give us what's calledgroup specific blood a bit
faster.
So they've matched it up.
They know it's compatible withthe blood group we have on
record for her and that shedidn't have any antibodies at
that time, and they can give usthe relevant blood group group
(21:23):
specific blood a bit quicker Ina dire emergency.
Maybe we don't have thiswoman's blood group on record,
maybe she wasn't booked forantenatal care with us or she's
literally just come in off thestreet, or it's a dire emergency
.
She's losing blood so fast thatwe just simply do not have time
(21:46):
for that matching process.
We will give O negative blood,what's known as the universal
donor.
It should be compatible witheverybody, unless there are
antibodies we don't know about.
So it's termed the universaldonor and this is what we give
(22:09):
in extreme situations.
Because there's some ready inthe lab, it can literally be
issued and in our case in myhospital, we can literally send
someone over and within five, 10minutes we can have the O
negative blood in the operatingtheater.
So this is the reason why wetake blood group as part of the
(22:33):
booking blood tests at the startof pregnancy and then again at
28 weeks.
We're checking the woman'sblood group, but we're also
checking for the development ofany antibodies, things that may
make giving a blood transfusionmore challenging, so that we
know, if there is thatunexpected emergency situation,
(22:56):
what's the best thing that wecan do.
At the beginning of the episodeI mentioned that we will ask
women at that first bookingappointment whether they're
willing to have blood products.
What do we do if they say no?
The commonest reason I've comeacross to say no is if the woman
(23:19):
is a member of the Jehovah'sWitnesses.
Jehovah's Witnesses have areligious objection to being
given blood and blood products.
We have a responsibility.
If a woman says she doesn'twant to have blood products and
(23:39):
would decline them even in alife-threatening situation, we
have a responsibility to explorethis thoroughly and tenately.
Most trusts will have someguidance and an advanced
directive that women can sign.
(24:01):
We can go through with them.
All the different components ofblood remember we've talked
about red blood cells, platelets, fresh frozen plasma and there
are some other alternatives thatmay or may not be helpful in an
(24:23):
extreme situation.
There's a green top guidelineon this and I've put it in the
show notes so you can have alittle browse.
One of the key things alongsidehaving these very detailed
conversations about what a womanwill or won't accept, is to
(24:45):
consider what is herindividualised chance of having
excessive bleeding.
If she's got an otherwiseuncomplicated pregnancy, there's
a relatively low chance.
You'll go through things indetail with her but hopefully
what will happen is she willhave a chance to have excessive
(25:07):
bleeding.
You can do things duringpregnancy, such as iron
supplementation, to make surethat she's in good shape when
she's coming up to the time ofbirth, that her hemoglobin is at
a good level, that she's notanemic and she's doing well.
Then, if something does happenand she has excessive blood loss
(25:31):
, she's starting off in the bestpossible physical shape.
But some women who don't want tohave blood products in any
situation will have a majorchance of bleeding.
For example, over the yearsI've cared for women who are
(25:55):
Jehovah's Witnesses, who havelarge fibroids that may make
them very difficult and increasethe risk of bleeding,
regardless of whether they haveintervention or not, and also
women with placenta previa, alow-lying placenta, which is a
major risk factor for excessiveblood loss.
These women we need to thinkvery carefully about where they
(26:22):
give birth.
Some hospitals will have accessto cell salvage, that is, as a
woman is bleeding, the blood canbe collected in the operating
theatre, washed, processed andreturned back into the woman's
body.
It isn't a trivial procedure.
(26:44):
It's a very important procedureand also staff to have the
technical expertise to work thatmachinery.
Not all maternity units havethis available and again, it's
(27:10):
personal because not everyonewill accept this either.
But for some Jehovah's Witnessescell salvage is an acceptable
option and if you're caring fora woman who has a high chance of
excessive bleeding around thetime of birth, then it is our
(27:31):
responsibility to explain tothem what is or isn't available
at the maternity unit they'vechosen to book at.
In some situations I haveadvised women actually it would
be better for you to have yourbaby at this neighboring
(27:52):
hospital that has the abilityfor cell salvage.
It would be safer.
Perhaps you're not going toneed anything, perhaps excessive
bleeding is not going to occur,but given the fact you have a
higher chance, it would beprudent for you to transfer care
(28:13):
there and I will help them makethe necessary arrangements.
Again, of course, it's theirchoice.
They may not wish to move and Ihave in some situations been
involved in major obstetrichemorrhage, hugely excessive
(28:35):
blood loss in a number of womenwho absolutely did not want to
have a blood transfusion underany circumstances, and therefore
I've witnessed firsthand theimpact this can have on the
patient dropping a blood countto levels almost incompatible
(28:58):
with life and the extremelydebilitating recovery, intensive
care, admissions, separationfrom baby and very long journey
to health that this cansometimes entail.
(29:20):
It is difficult for us asprofessionals sometimes to
relate to these choices, but, aswith everything in maternity
care, there is a choice.
We may not understand orappreciate the choice a woman is
making, but all we can do isgive her information.
(29:43):
So if at the beginning ofpregnancy, a woman says to us
she absolutely, under nocircumstances, would accept
blood products or bloodtransfusion, then it's
absolutely essential early on inthe pregnancy for her to see an
(30:04):
obstetrician, possibly ananesthetist too, and have very
detailed, extensiveconversations, give her time to
think about it, give her therelevant advanced directive to
look at, come back to anotherappointment, sign it, discuss it
(30:25):
and have it very thoroughlythought through so that in the
advent of a situation wherebleeding may become likely, we
know exactly what we're doingand we'll be much more
preemptive giving other drugsand medication earlier, perhaps
(30:51):
at a lower threshold, to try andprevent bleeding in those
situations and go above andbeyond with all the other things
we have up our sleeve to dealwith excessive bleeding, to try
and make things as safe aspossible, given the context of
her decision.
(31:12):
What's my zesty bit?
I think there are a couple ofaspects of my zesty bit the
importance of blood beingpotentially a life-preserving
intervention, understanding whenwe're talking about blood we
need to be a bit more accurateabout exactly what blood product
(31:37):
we're talking about, and beingaware of the importance of being
aware that women who do notwant to have blood products
under any circumstance need verycareful thought and preparation
.
But the other aspect of it isthere is a massive shortage of
(32:02):
blood.
There's a national shortage ofblood products, particularly
rare blood groups that have someassociations with some of our
ethnic minority population, andtherefore we have a
responsibility as cliniciansusing blood to also try and
(32:28):
encourage people to donate blood.
I used to be a blood donor whenI was young, when I was younger,
and then I stopped after aperiod of time when I had my own
children.
Recently, one of my relativesneeded an emergency blood
(32:49):
transfusion and it got methinking I really ought to sign
up again.
So I have.
So I guess the other aspect ofmy zesty bit is to encourage you
.
If you can't give bloodyourself, encourage friends,
(33:10):
colleagues, relatives, otherpeople that can to give this
very, very precious commodity.
Go on the National BloodTransfusion website, which I've
put in the show notes, and younever know, that precious pint
(33:36):
you give might help a new mum ina time of crisis.
Thanks for listening.
I very much hope you found thisepisode of the OBS pod
interesting.
If you have, it'd be fantasticIf you could subscribe, rate and
(33:57):
review, on whatever platformyou find, your podcasts, as well
as recommending the OBS pod toanyone you think might find it
interesting.
There's also tons of episodesto explore in my back catalog
from clinical topics, my careerand journey as an obstetrician
and life in the NHS moregenerally.
(34:20):
I'd like to assure women I carefor that.
I take confidentiality veryseriously and take great care
not to use any patientidentifiable information unless
I have expressly asked thepermission of the person
involved on that rare occasionwhen it's been absolutely
(34:43):
necessary.
If you found this episodeinteresting and want to explore
the subject a little more deeply, don't forget to take a look at
the programme notes where I'veattached some links.
If you want to get in touch tosuggest topics for future
(35:03):
episodes, you can find me at theOBS pod on Twitter and
Instagram and you can email metheobspod at gmailcom.
Finally, it's very important tome to keep the OBS pod free and
accessible to as many people aspossible, but it does cost me a
(35:27):
very small amount to keep itgoing and keep it live on the
internet.
So if you've enjoyed myepisodes and, by chance, you do
have a tiny bit to spare, youcan now contribute to keep the
podcast going and keep it freevia my link to buy me a coffee.
Don't feel under any obligation, but if you'd like to
(35:52):
contribute, you can do it.
Thank you for listening.
Hello, my name is Florence.
Welcome to the ObsPod.
I'm an NHS obstetrician hopingto share some thoughts and
experiences about my workinglife.
Perhaps you enjoy Call theMidwife.
Maybe birth fascinates you, oryou're simply curious about what
exactly an obstetrician is.
You might be pregnant andpreparing for birth.
(00:21):
Perhaps you work in maternityand want to know what makes your
obstetric colleagues tick, oryou want some fresh ideas and
inspiration.
Whichever of these is the caseand, for that matter, anyone
else that's interested, theObsPod is for you.
(00:49):
Episode 161 Blood Transfusion.
It might seem odd to pick thetopic of blood transfusion.
Not many women will need ablood transfusion, but for some
women, in some situations whichmay or may not be anticipated, a
(01:10):
blood transfusion at some pointduring their maternity care may
be absolutely essential andlife-saving.
I have previously touched onthis in episode 41, blood Loss,
so you may like to go back andlisten to that to understand a
bit of context about why a womanmight need a blood transfusion.
(01:33):
But today I'm going to focus abit on blood transfusion itself.
What do we mean by a bloodtransfusion and also why?
One of the questions we'll askat the beginning of pregnancy is
would you accept a bloodtransfusion?
Because for some women, a bloodtransfusion will be
(01:57):
unacceptable and given that,I've just said, a blood
transfusion can be life-saving,these women need particular care
and planning during theirpregnancy to make sure they have
a safe outcome.
Often, what we refer to as ablood transfusion is packed red
(02:23):
cells, the cells that carry theoxygen around the blood.
That's what we most commonlyuse, but this isn't actually
blood.
As I've just mentioned, it'spacked red cells, so it's a
component of the blood, andactually quite a lot of other
(02:44):
components of the blood areremoved.
When a woman is bleeding, she'snot just losing her packed red
cells, she's losing all herblood.
So that's red blood cells,white blood cells, platelets the
(03:05):
little cells that clot theblood and plasma, and within the
plasma are all sorts ofimportant proteins such as
clotting factors.
So, depending on what thereason is that a woman needs a
blood transfusion and whethershe's actively bleeding, at that
(03:25):
point in time we may need toreplace more than just the red
blood cells that we casuallyrefer to as blood.
We may need to add in otherblood products, other elements
of the blood that have beenremoved from those packed red
(03:47):
cells.
The commonest situation in whichwe may need to give blood in
obstetrics is because ofexcessive bleeding after the
birth of the baby, excessiveblood loss, and the reasons for
that I've talked about back inepisode 41, so I'm not going to
(04:09):
go into them here.
But a woman can bleed very fast, particularly if she's bleeding
from the placental bed, wherethe placenta has been attached
to the wall of the womb.
And if a woman is unstable soshe's putting up her heart rate
(04:31):
and dropping her blood pressureand she's got ongoing bleeding,
we will need to think about ablood transfusion on the basis
of her hemodynamics.
That's how her body isresponding to that loss of blood
volume.
An adult on average, of averagesize, will have about seven
(04:55):
litres of blood.
If a woman is losing perhapstwo litres or more, that's a
significant proportion of herwhole circulating blood volume.
And therefore, although we mayreplace that with fluid so water
(05:18):
, with salts in such asheartmans or saline, that
increases the volume but itdoesn't increase the blood cells
that help carry oxygen and itdoesn't replace the proteins
that I just mentioned or theplatelets that are needed to
(05:40):
help clot the blood.
So in an active bleedingsituation where large amounts of
blood loss are occurring, wewill be much more likely to give
not only packed red blood cellsbut also possibly platelets and
(06:04):
something called FFP freshfrozen plasma, which contains
all the proteins the clottingfactors that I mentioned that
are essential in part of ourtreatment to help stop bleeding.
So when an active bleedingsituation is happening, one of
(06:27):
the key people we need tocontact is the hematologist, the
blood specialist, who can workwith the lab, look at the
clotting results and tell usexactly what we need to give to
not only replace the red bloodcells that are carrying oxygen,
(06:49):
but also replace the othercomponents of the blood that are
needed to maintain normalclotting levels.
These days we also have accessto a new device, so-called TEG,
which stands forThrombo-Elastography System, and
(07:11):
that is a little point of caretest.
So that is a test where theanesthetist can take some blood
in the operating theatre and,within about 10 minutes, get a
little graph of what's happeningwithin the clotting cascade and
(07:31):
how clot is or isn't forming.
It gives a little picture thatlooks like a wine glass on its
side, and from this we can workout which elements of the
clotting cascade aren't workingand therefore what bits of the
(07:53):
clotting cascade we might needto replace.
This would seem obviouslybeneficial but reviewing some
documents to record this episode, there isn't yet clear evidence
that it improves outcomes.
But it gives us a clear andquick picture in real time in
(08:21):
the operating theatre which wecan then respond to.
The other situation in which wemay use a blood transfusion may
be after excessive bleeding.
The bleeding has settled, thewoman is relatively stable, but
she's significantly dropped herblood count.
(08:42):
She may be feeling extremelydizzy, exhausted, drained.
We may look at her on the wall,drowned, and notice that she's
very pale and we may recommend ablood transfusion because while
she will produce her own bloodcells, to eventually top herself
(09:04):
up that could take weeks.
So we work on what her bloodcount is.
We'd expect a woman to have ahemoglobin that's the oxygen
carrying protein in the redblood cell of hopefully above
(09:25):
110 grams per litre at the endof pregnancy, and women can
tolerate significantly lowerblood counts.
But if acutely a woman's bloodcount drops below 80 grams per
(09:46):
litre, she's likely to be verysymptomatic breathless,
exhausted, high pulse and reallystruggling.
And that's usually the level atwhich we think about blood
transfusion.
If it's above 80 or 90, thenoften iron tablets and a bit of
(10:08):
time will be sufficient In thesesituations, a woman has much
more choice about whether shehas a transfusion, and we will
usually give her a very niceinformation leaflet, produced by
the NHS Blood TransfusionService, that explains exactly
(10:29):
what having a blood transfusioninvolves, what the point of it
is, what it will feel like andwhat risks there are.
And yes, blood transfusion isnot without risk.
I think the thing people worryabout is mainly infection, and
(10:54):
actually, if you look at theinformation leaflet, the risk of
infection is unbelievably lowbecause blood transfusions blood
that is given is all tested, sothe chance of getting hepatitis
(11:14):
B, hiv is less than one in amillion, and then less than one
in 10 million.
What is much more likely to bean issue is a reaction to a
blood transfusion, and that'sbecause it's incredibly
important that the blood ismatched up to the person, so it
(11:39):
needs to be the correct bloodgroup and we need to be sure
that the person receiving theblood transfusion doesn't have
any unusual antibodies.
So actually, the risks relatedto blood transfusion are more to
do with incorrectly identifyingthe patient.
(12:01):
When we take a sample for whatwe call group and save, we're
ascending the patient's bloodoff to the lab to be matched up.
It's absolutely essential thatwe are sending the correct
sample, it hasn't got muddled upwith anyone else's sample,
we've written all the correctpatient identifying information
(12:24):
on the bottle and on the requestform and that we check the
identification name band of thepatient before we give the blood
and the blood is correctlymatched.
So sometimes it drives ustotally mad in an emergency
situation when we send somethingoff to the lab and the lab say
(12:46):
we've spelt something wrong, thepatient name doesn't match or
they can't read the writing.
But actually they're doing thatwith good cause.
And the reason I say it drivesus mad is we have to retake the
sample, have to rewrite it.
(13:08):
And you might think in this dayand age, why are we writing?
Why isn't it all automated?
Well, the reason is that forall our other blood tests it is
automated.
We can print a sticker and slapit on the tube of blood.
But actually that could beprone to far more errors than us
writing and correctlyidentifying the sample because
(13:34):
it's so easy to put a sticker onthe wrong tube.
So the risks of bloodtransfusion are small, but are
our responsibility as clinicianswhen we're taking those group
and save or cross match samplesMost people will not have a
(13:56):
reaction to blood, but somepeople will.
And you may feel when you'rehaving a blood transfusion is if
you've got a slight temperature, feel a bit flushed, and that
can be due to a mild immunereaction.
And this means that whilesomeone is having a blood
(14:18):
transfusion, we'll be doingregular observations pulse,
blood pressure, temperature andmaking sure that they're not
having a reaction.
And if you are having areaction, we have to stop the
blood transfusion immediately,send it back to the lab to see
what's happened.
Reactions are very carefullymonitored and then of course,
(14:38):
we'll be giving paracetamol ormaybe some anti-histamines, and
it depends what the reaction is.
So if a woman is being offereda blood transfusion in not an
emergency situation, we'll giveher this information leaflet so
that she can decide, just likeanything else, whether she gives
(14:59):
us her consent to have thatblood transfusion.
Rarely, we might use a bloodtransfusion in the anti-natal
period if we've got women thatare getting very anemic.
Their iron levels are low,perhaps they haven't responded
to iron treatment or maybe theyhave a condition that means that
(15:22):
they can't actually have irontreatment and therefore we might
give them an anti-natal bloodtransfusion, top them up prior
to giving birth to try and getthem in good shape for birth and
(15:42):
so that they're at a safe levelin case they should have that
unexpected excessive blood lossafter the baby's born.
Some women will have lower thanaverage platelets the cells
that clot the blood duringpregnancy and I've talked
(16:04):
previously about this in episode107, so you can find out a bit
more there.
It's unusual for us to give aplatelet transfusion, but if a
woman's platelets have droppedvery low, either because of
pregnancy or because she hasanother condition separate from
pregnancy that means herplatelets are very low, then we
(16:27):
may prepare and plan and giveher a platelet transfusion
around the time of birth.
Platelets don't last very longin the bloodstream.
A red blood cell lastsapproximately 120 days.
Platelets actually drop offwithin about 72 hours of when
(16:52):
the transfusion was given.
Coming back down to theprevious platelet count.
So for women with very lowplatelets usually at a level of
50 or lower is when we'rethinking about giving platelet
transfusion.
We will give that platelettransfusion maybe immediately
(17:16):
prior to performing anintervention such as a plan
cesarean birth, immediatelybefore and then during and then
immediately after, depending onhow many pools of platelets
we're going to give.
So the timing of givingplatelets needs much more
(17:40):
fine-tuning and platelets aren'talways necessarily available in
every hospital all the time.
So many of us will work in ahospital where we have a
laboratory which will provideblood and match us up blood, but
(18:04):
we won't necessarily haveaccess to all the blood products
.
They may need to come from aregional transfusion centre.
So certainly in my hospital ifwe need an excessive amount of
platelets or very specific, morerare blood group types, we will
(18:27):
need to get blood sent overfrom our local regional
transfusion centre.
So this needs a bit moreplanning and if we're in an
emergency situation, obviouslywe don't have the ability to do
that.
But if we have a more plannedsituation, like a planned
(18:48):
cesarean birth or a plannedinduction of labour, then
matching up and getting readyfrom our regional transfusion
lab the blood products that wethink a woman might need is
really critical and sometimes ifwe absolutely have to and we
haven't got this ready, we willdecide it's not safe to go ahead
(19:10):
and we may postpone thingsuntil such time as we can get
the right blood products in theright place.
Many years ago this wasactually a stipulation for an
obstetric unit that you had aworking lab with access to blood
products because, like I said,blood loss can be of such an
(19:36):
unpredictable nature inmaternity care.
So I mentioned there a littlebit about matching and getting
blood ready.
Most of the blood we give thered cells that I mentioned are
what we call fully cross-matchedblood.
We will have a record of thewoman's blood group and type.
(19:58):
But we will take a sample atthat point when a blood
transfusion is necessary.
We'll send it to the lab andthey'll match it up and they'll
give her red cells from a donorthat is compatible with her
group.
They fully matched up and thatgives her the least chance of a
(20:19):
reaction to the bloodtransfusion.
If we've got a little bit lesstime we're in a bit more of an
emergency situation we mightgive group specific blood.
So the full cross-matched bloodtakes usually around an hour
(20:42):
and a woman can lose a lot ofblood in that time.
But if she's stable and we'reon top of it, we can wait for
that fully cross-matched blood.
If actually things are a bitmore unstable and we haven't got
that time, we have on recordthat woman's blood group and
(21:02):
they can give us what's calledgroup specific blood a bit
faster.
So they've matched it up.
They know it's compatible withthe blood group we have on
record for her and that shedidn't have any antibodies at
that time, and they can give usthe relevant blood group group
(21:23):
specific blood a bit quicker Ina dire emergency.
Maybe we don't have thiswoman's blood group on record,
maybe she wasn't booked forantenatal care with us or she's
literally just come in off thestreet, or it's a dire emergency
.
She's losing blood so fast thatwe just simply do not have time
(21:46):
for that matching process.
We will give O negative blood,what's known as the universal
donor.
It should be compatible witheverybody, unless there are
antibodies we don't know about.
So it's termed the universaldonor and this is what we give
(22:09):
in extreme situations.
Because there's some ready inthe lab, it can literally be
issued and in our case in myhospital, we can literally send
someone over and within five, 10minutes we can have the O
negative blood in the operatingtheater.
So this is the reason why wetake blood group as part of the
(22:33):
booking blood tests at the startof pregnancy and then again at
28 weeks.
We're checking the woman'sblood group, but we're also
checking for the development ofany antibodies, things that may
make giving a blood transfusionmore challenging, so that we
know, if there is thatunexpected emergency situation,
(22:56):
what's the best thing that wecan do.
At the beginning of the episodeI mentioned that we will ask
women at that first bookingappointment whether they're
willing to have blood products.
What do we do if they say no?
The commonest reason I've comeacross to say no is if the woman
(23:19):
is a member of the Jehovah'sWitnesses.
Jehovah's Witnesses have areligious objection to being
given blood and blood products.
We have a responsibility.
If a woman says she doesn'twant to have blood products and
(23:39):
would decline them even in alife-threatening situation, we
have a responsibility to explorethis thoroughly and tenately.
Most trusts will have someguidance and an advanced
directive that women can sign.
(24:01):
We can go through with them.
All the different components ofblood remember we've talked
about red blood cells, platelets, fresh frozen plasma and there
are some other alternatives thatmay or may not be helpful in an
(24:23):
extreme situation.
There's a green top guidelineon this and I've put it in the
show notes so you can have alittle browse.
One of the key things alongsidehaving these very detailed
conversations about what a womanwill or won't accept, is to
(24:45):
consider what is herindividualised chance of having
excessive bleeding.
If she's got an otherwiseuncomplicated pregnancy, there's
a relatively low chance.
You'll go through things indetail with her but hopefully
what will happen is she willhave a chance to have excessive
(25:07):
bleeding.
You can do things duringpregnancy, such as iron
supplementation, to make surethat she's in good shape when
she's coming up to the time ofbirth, that her hemoglobin is at
a good level, that she's notanemic and she's doing well.
Then, if something does happenand she has excessive blood loss
(25:31):
, she's starting off in the bestpossible physical shape.
But some women who don't want tohave blood products in any
situation will have a majorchance of bleeding.
For example, over the yearsI've cared for women who are
(25:55):
Jehovah's Witnesses, who havelarge fibroids that may make
them very difficult and increasethe risk of bleeding,
regardless of whether they haveintervention or not, and also
women with placenta previa, alow-lying placenta, which is a
major risk factor for excessiveblood loss.
These women we need to thinkvery carefully about where they
(26:22):
give birth.
Some hospitals will have accessto cell salvage, that is, as a
woman is bleeding, the blood canbe collected in the operating
theatre, washed, processed andreturned back into the woman's
body.
It isn't a trivial procedure.
(26:44):
It's a very important procedureand also staff to have the
technical expertise to work thatmachinery.
Not all maternity units havethis available and again, it's
(27:10):
personal because not everyonewill accept this either.
But for some Jehovah's Witnessescell salvage is an acceptable
option and if you're caring fora woman who has a high chance of
excessive bleeding around thetime of birth, then it is our
(27:31):
responsibility to explain tothem what is or isn't available
at the maternity unit they'vechosen to book at.
In some situations I haveadvised women actually it would
be better for you to have yourbaby at this neighboring
(27:52):
hospital that has the abilityfor cell salvage.
It would be safer.
Perhaps you're not going toneed anything, perhaps excessive
bleeding is not going to occur,but given the fact you have a
higher chance, it would beprudent for you to transfer care
(28:13):
there and I will help them makethe necessary arrangements.
Again, of course, it's theirchoice.
They may not wish to move and Ihave in some situations been
involved in major obstetrichemorrhage, hugely excessive
(28:35):
blood loss in a number of womenwho absolutely did not want to
have a blood transfusion underany circumstances, and therefore
I've witnessed firsthand theimpact this can have on the
patient dropping a blood countto levels almost incompatible
(28:58):
with life and the extremelydebilitating recovery, intensive
care, admissions, separationfrom baby and very long journey
to health that this cansometimes entail.
(29:20):
It is difficult for us asprofessionals sometimes to
relate to these choices, but, aswith everything in maternity
care, there is a choice.
We may not understand orappreciate the choice a woman is
making, but all we can do isgive her information.
(29:43):
So if at the beginning ofpregnancy, a woman says to us
she absolutely, under nocircumstances, would accept
blood products or bloodtransfusion, then it's
absolutely essential early on inthe pregnancy for her to see an
(30:04):
obstetrician, possibly ananesthetist too, and have very
detailed, extensiveconversations, give her time to
think about it, give her therelevant advanced directive to
look at, come back to anotherappointment, sign it, discuss it
(30:25):
and have it very thoroughlythought through so that in the
advent of a situation wherebleeding may become likely, we
know exactly what we're doingand we'll be much more
preemptive giving other drugsand medication earlier, perhaps
(30:51):
at a lower threshold, to try andprevent bleeding in those
situations and go above andbeyond with all the other things
we have up our sleeve to dealwith excessive bleeding, to try
and make things as safe aspossible, given the context of
her decision.
(31:12):
What's my zesty bit?
I think there are a couple ofaspects of my zesty bit the
importance of blood beingpotentially a life-preserving
intervention, understanding whenwe're talking about blood we
need to be a bit more accurateabout exactly what blood product
(31:37):
we're talking about, and beingaware of the importance of being
aware that women who do notwant to have blood products
under any circumstance need verycareful thought and preparation
.
But the other aspect of it isthere is a massive shortage of
(32:02):
blood.
There's a national shortage ofblood products, particularly
rare blood groups that have someassociations with some of our
ethnic minority population, andtherefore we have a
responsibility as cliniciansusing blood to also try and
(32:28):
encourage people to donate blood.
I used to be a blood donor whenI was young, when I was younger,
and then I stopped after aperiod of time when I had my own
children.
Recently, one of my relativesneeded an emergency blood
(32:49):
transfusion and it got methinking I really ought to sign
up again.
So I have.
So I guess the other aspect ofmy zesty bit is to encourage you
.
If you can't give bloodyourself, encourage friends,
(33:10):
colleagues, relatives, otherpeople that can to give this
very, very precious commodity.
Go on the National BloodTransfusion website, which I've
put in the show notes, and younever know, that precious pint
(33:36):
you give might help a new mum ina time of crisis.
Thanks for listening.
I very much hope you found thisepisode of the OBS pod
interesting.
If you have, it'd be fantasticIf you could subscribe, rate and
(33:57):
review, on whatever platformyou find, your podcasts, as well
as recommending the OBS pod toanyone you think might find it
interesting.
There's also tons of episodesto explore in my back catalog
from clinical topics, my careerand journey as an obstetrician
and life in the NHS moregenerally.
(34:20):
I'd like to assure women I carefor that.
I take confidentiality veryseriously and take great care
not to use any patientidentifiable information unless
I have expressly asked thepermission of the person
involved on that rare occasionwhen it's been absolutely
(34:43):
necessary.
If you found this episodeinteresting and want to explore
the subject a little more deeply, don't forget to take a look at
the programme notes where I'veattached some links.
If you want to get in touch tosuggest topics for future
(35:03):
episodes, you can find me at theOBS pod on Twitter and
Instagram and you can email metheobspod at gmailcom.
Finally, it's very important tome to keep the OBS pod free and
accessible to as many people aspossible, but it does cost me a
(35:27):
very small amount to keep itgoing and keep it live on the
internet.
So if you've enjoyed myepisodes and, by chance, you do
have a tiny bit to spare, youcan now contribute to keep the
podcast going and keep it freevia my link to buy me a coffee.
Don't feel under any obligation, but if you'd like to
(35:52):
contribute, you can do it.
Thank you for listening.
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