Care of Women who Decline Blood Products

A Midwifery Perspective

Patricia Hughes, Director of Midwifery & Nursing, Coombe Women & Infants University HospitalFriday 26th February 2010

Outline of Presentation

• Ms A• Midwives Role in the Care of a Woman who

Declines Blood• Organisation of our Services Currently• Recommendations for the Future

Ms A

• 24 year old Primgravid• 28 weeks gestation• No FM’s, several days• DIC• Jehovah’s witness• No consent for Blood• Consultation• Conflict amongst staff• Administration of Blood & Survival• CEMD

RCOG (2008)Standards for Maternity Care: Report of Working Group

• “Excellent maternity care must be comprehensive and flexible to respond to the clinical and social needs of women and their families. For the majority of women, pregnancy and childbirth is a totally normal and uncomplicated experience but the service must be able to respond appropriately to those who may require highly specialised care for existing medical problems, social circumstances and any complications that may develop.”

Role of the Midwife in Irish Health Services

• Midwives must be educated to meet the challenges of the changes, in particular the need to provide responsive, high-quality maternity care, which is woman-centred, equitable across different parts of the country, accessible to all, safe and accountableQuality & Fairness, a Health System for You, DoHC , 2001a, p84.

An Bord Altranais Standards & Requirements

• Provide competent, safe midwifery care to women, their babies and, where possible, their wider family circle.

• Demonstrate respect for the individuality of each woman and support shared decision-making throughout the woman’s childbirth experience.

• Promote and support lifestyle choices that enhance the health and wellbeing of women, their families and the wider community.

An Bord Altranais • December 2005

Caring for a Woman who Declines Blood at CWIUH

CWIUH (2007) Guideline re Mothers Attending the Coombe Women’s Hospital who decline Transfusion with Blood/Blood Products states that

• CWIUH is a non denominational institution and fully respects the right to religious freedom......

• CWIUH respects the right of competent adults to refuse medical treatment after appropriate counselling in this regard...

Key messages from CWIUH Guideline(2007)

• “The discussion relating to these issues should be frank, non dramatic and non judgemental”

• Open and hold the trust of the woman throughout all aspects of care

• Access to interpreter- if there are any language difficulties

• Full discussion, re mother and baby, care pathway inc all non blood interventions

• Follow up discussions• Can change mind at any time

Key Messages (CWIUH (2007) contd

• Senior staff, all disciplines• All appropriate interventions, • Close monitoring at all times• Effective communication • Professional attitude • If woman dies, the bereaved family will require

support just like any other bereaved family

Organisation of care

• Early booking advised• Access to an Interpreter • Thorough History taking• Privacy• Counselling/Time• Documentation/ may need to allocate additional

support• Prompt referral to Senior staff • Continuity of care & carer to help build trust• Plan well in advance

Reality of Maternity Care in many parts of Ireland- daily challenges

• Early booking, very difficult to achieve with rising birth rate and inadequate space and resources

• Interpreters, may not be possible to have on site, use via telephone, expensive, can’t be guaranteed / potential difficulty- correct language

• History taking is often a very hurried impersonal process in cramped conditions with little time for information sharing

• Care is fragmented and may be provided by up to 100 different personnel, over the entire episode of care /little opportunity for relationship to be established, time wasted as new staff having to constantly accustom to history. Repetitious and off putting for woman

• Little opportunity for debriefing/staff support

Suggestions for Improvements• Dedicated MDTs to include midwives to care for Dedicated

caseloads of women either by geographic location or by condition eg diabetes to cover entire popluation of the hospitals mothers

• Resource and plan more community booking clinics , this will facilitate earlier bookings, more time and more privacy

• Risk assess women and stream women out for midwifery, shared or consultant care

• Try to establish interpreter needs prior to booking appointment, standard booking form for GP thereby ensuring of access to correct language interpreter

• Team approach will markedly reduce the number of health care professional

• Early booking will facilitate timely and appropriate referrals• National IT system and effective linkages with primary care• Adequate staff support systems

Agencies in Ireland charged with Standard Setting and Monitoring

HIQA:

• The Health Information and Quality Authority was established in May 2007 as part of the government's health reform programme and is committed to operating to the highest standards of corporate governance.

National Perinatal Epidemiology Centre (NPEC)• Mission Statement•  To improve the health and wellbeing of Irish mothers and babies by

translating epidemiological data and testing new treatments to enable well-informed discussion and decision making about reproduction and perinatal health."

• HSE: Directorate of Clinical Care

‘Saving Mothers Lives’Pre-conception carePre-conception care

Access to care Access to care

Migrant womenMigrant women

Treatment of systolic hypertensionTreatment of systolic hypertension

Caesarean sectionCaesarean section

Clinical skillsClinical skills

Training of clinical staffTraining of clinical staff

Early warning scoring systemEarly warning scoring system

National guidelinesNational guidelines

Guidance & Recommendations

Summary

In summary, we should be prepared to provide sensitive, respectful and appropriate care to women who decline blood products. We can do this by learning from each other and ensuring we have agreed guidelines for practice in place. We can achieve a lot more by using our resources wisely, and to their full potential Respect and Professional attitudes are essential in ensuring appropriate care for women , their families and staff.

Thank You