1. Care of Women who Decline Blood Products A Midwifery Perspective Patricia Hughes, Director of Midwifery & Nursing, Coombe Women & Infants University Hospital Friday 26 th February 2010

2. 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

3. 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

4. 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.”

5. 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 accountable Quality & Fairness, a Health System for You, DoHC, 2001a, p84.

6. 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

7. 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...

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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.establishedstandards 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

14. ‘Saving Mothers Lives’ Pre-conception care Access to care Migrant women Treatment of systolic hypertension Caesarean section Clinical skills Training of clinical staff Early warning scoring system National guidelines

15. Guidance & Recommendations

16. 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.

17. Thank You