///2009 Abstract Details
2009 Abstract Details2019-08-03T15:55:31-06:00

Institutional Establishment of a Center for Blood Conservation: Our Labor Unit's Adaptation

Abstract Number: 89
Abstract Type: Case Report/Case Series

Abigail H. Melnick MD1

The right to refuse blood transfusion is established as a legal and ethical mandate. Whether for religious purposes as with the Jehovahs Witnesses, or for other concerns such as infection transmission, patients seek out bloodless medical services. In 2004 Duke University Medical Center introduced a Center for Blood Conservation (CBC) available to any adult patient with a commitment to respect the wishes of patients refusing transfusion. In the non-obstetric population, the CBC has rolled out smoothly and has been well received by both the blood refusal and medical communities. The CBC staff formalizes all paperwork, optimizes the patient prior to admission, contacts the care team to facilitate planning, and coordinates special equipment required for appropriate care.

Labor and delivery presents unique challenges to the CBC. Policies have had to be put in place to adapt the principles of the CBC to the needs of the obstetric population. As a tertiary-care referral center, many patients are not seen at Duke prior to admission. Often at admission there is not time to process paperwork prior to emergency care. In situations where the patient is known prior to admission, delivery planning is complicated by the spontaneous nature of obstetrics. Care for the delivery of the obstetric blood-refusal patient requires expertise and experience with obstetric cell salvage and isovolemic hemodilution as well as aggressive use of uterotonics and medical hemostasis. An ethical dilemma for the medical care team is intensified by the presence of the fetus. Staff comfortable with caring for blood refusal patients is not always available on labor and delivery. A strict protocol has been established for identifying patients, preparing them for delivery, and managing their bloodless medical care during their admission. At submission, approximately 50 obstetric patients have been cared for through the CBC.

My poster will present the system in place to optimize our care of the blood-refusing obstetric patient. I will also present some representative patients.

A patient with a history of post-partum cardiomyopathy presented for her third and fourth cesarean sections after the institution of the CBC. Her fourth pregnancy was complicated by multiple gestation. For the fourth cesarean section, we performed isovolemic hemodilution. Another multiparous patient presented for her third vaginal delivery with a hematocrit of .26 L/L and a platelet count of 92x109. She refused antepartum hematocrit optimization. We aggressively utilized uterotonics and medical hemostasis. For her fourth delivery, we were able to improve her hematocrit from .29 L/L to .33 L/L with antepartum erythropoietin and IV iron.

Patients have the right to refuse blood transfusion; we have the responsibility to provide appropriate care. With the establishment of policies addressing issues unique to labor and delivery, the CBC has been successfully implemented on our unit.

SOAP 2009