Blood Transfusion at Birth

Why it comes up at all

The RCOG's patient information gives two routes to a transfusion around childbirth, and only one of them is dramatic.

The first is anaemia. Mild anaemia is common in pregnancy, and haemoglobin is checked at the first appointment and again at around 28 weeks. Severe anaemia "can make you feel very unwell with dizziness, breathlessness and chest pain". A transfusion may be offered if you are very anaemic close to your due date, or afterwards if you are unwell enough that caring for your baby is difficult. The RCOG adds a limiting principle: "You are unlikely to be offered a transfusion unless you have symptoms and feel unwell."

The second is haemorrhage. The RCOG does not soften this: "Without a transfusion to replace the blood you have lost, you could become seriously ill or even die." It also says the honest thing about prediction: "It is not possible to predict or detect a life-threatening bleed."

Who is more likely to need one

Blood loss is greater at a caesarean than at an uncomplicated vaginal birth, and both the NHS and the HSE list heavy bleeding among the risks of the operation. ACOG's patient material on caesarean birth in the United States lists blood transfusion among the possible consequences of bleeding that cannot be controlled.

NICE asks that women with antepartum haemorrhage, abruption or placenta praevia give birth at a maternity unit with on-site blood transfusion services, because they are at increased risk of losing more than a litre of blood. If you have been told to give birth at a particular unit for this reason, that is why.

Sickle cell disease and thalassaemia both raise the chance of severe anaemia in pregnancy, and the RCOG names them.

What actually happens

The RCOG describes it step by step. Your blood group is tested and matched against the donor blood. A cannula goes into a vein in your hand or arm and is attached to a drip. "Blood for transfusion is stored in small plastic bags containing a unit of blood, which is about one-third of a litre. Each unit of blood takes about 3 hours to transfuse. In an emergency, blood may be transfused more quickly."

You are monitored throughout: blood pressure, temperature and heart rate. The NHS's general information on transfusion describes the same checks "before, during and after a blood transfusion", and gives its own overall figure: a transfusion "usually takes up to 4 hours, but it can take longer depending on how much blood you need". The RCOG's roughly three hours is per unit; the NHS figure is for a whole transfusion, so they are describing different things rather than disagreeing. Most transfusions in pregnancy and after birth are red cells only; occasionally platelets and plasma are needed too.

Afterwards your haemoglobin may be rechecked, and the RCOG notes that "most women do not need another transfusion". If the transfusion was given for an emergency, you will stay in hospital afterwards, for a length of time that depends on your recovery.

Side effects and how safe the blood is

The RCOG lists mild effects — headaches, a mild fever, a rash or itching — which are treatable and improve within a day or so. It also names the rare one: "Very rarely, there may be more severe side effects, including difficulty in breathing, severe headaches and a sudden fall in blood pressure. This is called a transfusion reaction." If it happens, the transfusion is stopped immediately.

On infection, the RCOG is brief: all UK donations are tested for viruses including hepatitis and HIV, only blood free of these is used, and "the risk of getting an infection from a blood transfusion is very, very low". The NHS's general patient information on transfusion says the same and adds the routine checks made before blood is given, including checking your identity against the bag.

If you do not want one

This is written into the RCOG's leaflet rather than buried. "You may decide you do not want to have a blood transfusion. This may be because of personal reasons or because of religious beliefs."

The practical route is to say so during pregnancy. The RCOG: "During pregnancy you may be asked if you have any objections to having a blood transfusion. A management plan can be made for your pregnancy, labour and birth. Should the need for a blood transfusion arise, your doctors will respect your wishes. Other options will be discussed but, in some cases, a blood transfusion may be the only effective treatment to save your life."

And, importantly: "You can change your mind at any point about the use of blood." A refusal recorded at 20 weeks is not a cage.

The RCOG also describes what happens if you are unable to decide at the time: "In an emergency your doctors will need to act immediately. Your obstetrician and anaesthetist may need to make the decision on your behalf for you to have a blood transfusion. You and your family will be kept fully informed about the situation." This is why a documented advance decision matters — it is what speaks for you when you cannot.

The alternatives the RCOG names

Four of them, and they are not equivalent to each other.

Iron tablets or syrup. For anaemia from blood loss or iron deficiency. "It will take longer for you to feel completely well but you avoid the minimal risks associated with blood transfusion." The RCOG explicitly offers this as a reasonable choice after birth if your symptoms are mild and you have support at home.

An iron infusion. Iron given through a drip, for women who cannot take tablets or whose anaemia has not responded to them. It can be given after the first three months of pregnancy, works more quickly than tablets, and side effects are rare.

Cell salvage. At a caesarean, blood lost during the operation can sometimes be collected and returned to you. The RCOG notes the constraint: "Trained staff and specialist equipment are required for this, which may not be available in your hospital at all times."

Storing your own blood in advance. The RCOG rules this out: "It is not recommended to use your own blood for transfusion during pregnancy because it can only be stored for 5 weeks."

What to ask

Ask whether your haemoglobin has been checked recently and what it was. Ask whether iron tablets or an infusion would be a reasonable alternative in your situation. If you would decline blood in any circumstance, ask for a management plan to be written into your notes now, and ask whether cell salvage is available at your unit. And ask for the reason for any transfusion offered — the RCOG's own advice is to "ask for information about all your options" before deciding.