Blood transfusion in the context of maternity care

Clinical skills training

In England, the Department of Health (DH) advises the NHS on compliance with European blood safety and quality regulations (HM Government, 2005) i.e. ‘haemovigilance’. This is achieved by a coordinated, audited surveillance system in which midwives are central to improving the safety of BT (International Haemo-vigliance Network, 2012). In an attempt to improve safety across the NHS, several health circulars have focused on ‘Better Blood Transfusion’, with a final paper focusing on the safe and appropriate use of blood (DH, 1998; 2002; 2007). Midwives must be aware of safe and appropriate practice in BT highlighted by the latest SHOT (2015a) report, with notification of all BT errors to the Medicines and Healthcare products Regulatory Agency via the computerised Serious Adverse Blood Reactions & Events (SABRE) system. Maternity Trusts also implement SHOT recommendations e.g. electronic tracking, designed to reduce errors in patient identity (National Patient Safety Agency (NPSA), 2006).

Since the inception of SHOT in 1996, the incidence of wrong blood transfused to the wrong patient has remained consistent; therefore, all staff must receive approved training in safe administration and midwives must be assessed as clinically competent (British Committee for Standards in Haematology (BCSH), 2012). The Chief Medical Officer's National Transfusion Committee Network advises NHS Trusts on BT training pathways, with competency outcomes documented (BCSH, 2014). Midwives must ensure they remain clinically competent in the knowledge and skills required for safe BT, and must be periodically assessed every 3 years (Nursing and Midwifery Council (NMC), 2012; 2015). Currently, midwives are clinically assessed against national standards for safe administration of BT by the National Blood Transfusion Committee (NBTC, 2016).

Collection of blood

The midwife who will administer the BT should collect the blood component from the blood bank with all the necessary patient details. The blood component must never be left unattended and should be validated at the woman's bedside, as doing this away from the bedside has contributed to severe morbidity and mortality (SHOT, 2015a).

Bedside risk assessment and the midwife

There are risks associated with BT, which are increased if a woman receives an incorrect blood component. For this reason:

Although rare, risks include: infection, acute reactions, circulatory overload and haemolytic disease of fetus/newborn. Depending on the reaction, cardiopulmonary, renal and hepatic function may be adversely affected (Norfolk, 2013). Positive patient identification (PPID) i.e. asking the woman to state her full name and date of birth, is a key feature of bedside risk assessment; failure to undertake PPID is a major cause of acute BT reaction. Human error still figures largely in clinical practice (Health Education England, 2016); hence, midwives must undertake a full risk assessment prior to administering blood (SHOT, 2015b), and must note that transfusion of ABO-incompatible blood is an NHS ‘never event’ (DH, 2012). Wherever feasible, BT should be avoided at night, owing to reduced staff and laboratory resources.

Correct blood administered and transfusion record

To ensure the correct blood is administered to the correct patient, a formal identification must tally with information provided in the Transfusion Record. In this respect, midwives must:

At the woman's bedside, midwives should verify that:

Midwives must engage in a separate risk assessment prior to each unit transfused. Clarifying the need for each BT is crucial, as acute inflammatory response to BT can result in circulatory overload (SHOT, 2015a). Women may be more vulnerable to this complication owing to the normal plasma expansion of pregnancy. An important aspect of risk assessment is the establishment of informed consent and shared decision-making, so the midwife should confirm a valid consent prior to administration (Advisory Committee on the Safety of Blood, Tissues and Organs, 2011; NMC, 2015). Declining BT during pregnancy or childbirth should be a thoroughly discussed scenario, with a detailed plan of care documented in the woman's records. However distressing for staff, the woman's autonomy must be respected even where there is a deterioration in maternal condition. However, midwives may refer to guidelines in this respect (RCOG, 2015: 17).

BT requires midwives to engage in a multi-step process and the use of a bedside pre-BT checklist may help minimise errors (Arriaga et al, 2013; SHOT, 2015a) (Table 1).

Clinical monitoring and adverse reactions

More than 70% of BT involves the use of red cells, while 25% involves plasma and platelets. Notably, sickle-cell disease features in the top 10 reasons for red cell transfusion (SHOT, 2015a); this is clinically relevant for midwives working in NHS Trusts where this disease is significant. Such conditions rely on skilled administration of BT; however, unnecessary BT should be avoided in pregnancy to minimise a primary or secondary immune response. This may produce unexpected antibodies against red cell antigens e.g. Kell antibodies, which can cause fetal anaemia (RCOG, 2014). Where BT is unavoidable in childbearing women, under normal circumstances, K-negative blood should be used.

The four main serious adverse reactions associated with BT are:

Given that only a small proportion of transfusions occur in maternity care, it is crucial that midwives' skill sets are maintained, especially because SHOT (2015a) reported a worrying number of adverse reactions and events specifically associated with weak clinical decisionmaking and poor communication. Maternal mortality reports required that clinical skills and training must be addressed in the ‘Back to Basics’ points for improved care (Cantwell et al, 2011). In respect of BT, midwives must undertake clinical observations using the national modified early obstetric warning score (MEOWS) chart for all pregnant or postpartum women who are unwell. The BCSH (2012: 5) recommended that:

The midwife must undertake a set of baseline vital signs. The woman's condition or adverse reaction will require further observations. Unconscious women can be difficult to assess for signs of adverse reaction and must be closely monitored during the first 15 minutes of each unit for any changes in visual or vital signs. It is important to observe the woman at regular intervals during the BT.

Transfusion rate

Midwives must assess the correct delivery rate as prolonged administration increases the risk of bacterial contamination. The rate during the initial 15 minutes should be at 20 drops per minute (BCSH, 2012). Transfusion of red cells in non-emergency situations should be completed within 4 hours from retrieval; in practice, most are completed in 3 hours. Platelets and/or plasma are transfused over 30 minutes and midwives should be aware that plasma proteins increase the likelihood of an allergic reaction.

Where large volumes of blood are required, a commercially approved blood warmer with a visible thermometer and audible warning alarm can be used. A sterile giving set must be used for red cell transfusions, with a mesh filter to collect micro-debris; giving sets should only be primed with the blood product being transfused. Where platelets are prescribed, these should be transfused before red cells, to reduce bacterial contamination (BCSH, 2012).

Monitoring and blood transfusion

Although blood is not a medicine, BT should be regarded as though the practitioner is administering a powerful drug intravenously; transfused blood is foreign tissue and, regardless of tissue typing, is not the woman's own blood (BCSH, 2012). Adverse reactions are often seen prior to any change in clinical vital signs. Therefore, delivering care in a single room, away from visual inspection, is unsafe unless one-to-one continuous care from a registered midwife is consistent. Although the first 15 minutes are crucial in determining reactions, women should be monitored throughout the whole BT process (BCSH, 2012). Following the initial 15 minutes of observation, the midwife should provide the woman with call-bell access and advise her to seek help immediately in the event of any signs or symptoms of a reaction. These include headache, shivering, facial flushing, rash, pain, difficulty breathing and agitation (NPSA, 2010).

Transfusion reaction

Appropriate pre-transfusion safety assess ments are important in minimising incom patibility reactions and it is good practice for two prac titioners to verify patient details independently (Watson et al, 2008). There are various categories of BT reaction, ranging from mild to life-threatening. Mild acute reactions are characterised by a rise in tem perature of 1.5°C > baseline, and this is usually managed by dose-adjusted (weight) paracetamol and oral fluids. If an allergic skin reaction is evident, antihistamines may be prescribed (International Haemovigilance Network and International Society for Blood Transfusion, 2011). Communication and re assurance of the woman are paramount (NMC, 2015). Midwives should be aware that mild reactions can soon become severe, and close fetal monitoring will be required.

In more acute reactions, the woman may feel hot and, as blood is administered, may experience uncomfortable venous sensations. More distressing symptoms include: dizziness, double vision, severe headache, rigors, chest/loin pain, bronchospasm/dyspnoea, new onset wheezing/cough, palpitations, confusion and loss of consciousness. These final symptoms are evidence of a life-threatening reaction and signs reflecting them are: pyrexia, urticaria, hypotension, tachycardia, haematuria and oliguria. Where there are serious signs of acute respiratory collapse, the midwife must summon a senior anaesthetist as the woman may require intubation, which is dangerous in pregnancy.

The rationale for appropriate training in clinical assessment is evident; however, midwives must not merely detect deviations from the norm, but act on them. Prompt medical attention is required to ameliorate the signs of clinical shock and treat sepsis (Tinegate et al, 2012).

There is detailed guidance on the nature of acute BT reactions and their management, of which the key principles are (Tinegate et al, 2012):

Conclusion

Blood transfusion in maternity care is not a routine event and is usually required where severe medical complications or haemorrhage occur. The administration of a BT is not an isolated clinical skill and is underpinned by a range of legislative requirements. Much of the legal framework emphasises the safety of BT, as consistent errors in administration of the wrong blood to the wrong patient are reported. Mid wives have a statutory duty to promote the safety and wellbeing of women in their care, and this relates to the safe administration of BT. The midwife must be aware of NHS training and assessment requirements, the common errors in BT and how to minimise these. The pre-transfusion risk assessment is central to this, and where transfusion reactions occur, the midwife must possess the knowledge and skills to detect them and act appropriately to manage the clinical situation effectively.

Revalidation claim: Continuing professional development/40 hours

This section (continued on p844) provides an example of how this article might be used as material for reflection for use as part of a midwife's revalidation with the Nursing and Midwifery Council (NMC). Evidence for revalidation should be linked to the NMC Code and should demonstrate the impact that the learning has had on your practice.

Key Points