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Postnatal reflection using Gibbs (1988) reflective model. Pseudonyms will be used

throughout to maintain confidentially in accordance with Nursing and Midwifery Council

(NMC,2015).

Sarah was a gravida 1 para 0 woman attending her antenatal appointment at 10 weeks

gestation. During her booking appointment Sarah informed us that she was a Jehovah’s

witness and only accepted fractions of blood products post-delivery (Bodnaruk ZM,2004).

Her religious belief is based on the prohibition of consuming blood and as one of the four

passages in the bible quotes Acts 15:29 “That ye abstain…from blood…” declares this is part

of the Jehovah’s witness moral and ethical code to adhere with their fellowship at church and

refrain from being shunned and outcast (Department of Health,2001).

I asked my mentor if Sarah could be my case holding women as her religious and ethical

beliefs were of interest and would increase my learning. Initially, I felt nervous and worried

for Sarah and was concerned that if she had a postnatal haemorrhage that she would decline a

blood transfusion to save her life and subsequently risk dying.

Following reflection and further research into the religion I was able to understand and

identify procedures and preventative measures which could be applied antenatally in

preparation for birth and the postnatal period.

What did you learn from the event or experience?

Sarah was informed of the potential risks associated with childbirth and the possibility

of a post-partum haemorrhage and she had already researched the possible impact that being

a Jehovah’s witness may have on her care and was therefore aware of alternative potential

management pathways. Sarah discussed information and presented me with the clinical

aspects of her informed choice on the subject including her decision to accept or decline
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blood products. I was able discuss her proposed plan and see how confident and prepared

making me feel confident in my role as student midwife.

A referral was made for consultant led care so a more thorough discussion could take place

(NMC,2015)

Prior to Sarah going into labour, a care plan was developed in advance as set by the

guidelines by the Trust services for Jehovah’s Witnesses. Royal College of Obstetricians and

Gynaecologists (RCOG,2002). This information stated that if any excess blood loss occurs an

action plan is to be followed taking into account both medical and ethical concerns. Sarah had

a document called an advanced directive which was secured to her hospital and antenatal

notes which displayed a sign that Sarah had an advanced decision to refuse specified medical

treatment with a detailed document the medical use of her own blood and the procedures used

by the Department of Health (DoH ,2001) This document states her informed choice was to

refuse blood transfusion and primary blood products but in the event of a major haemorrhage

blood products could be used to maintain a haemocrit above 40%. Haemocrit indicates the

percentage volume of red blood cells in plasma. Sarah also accepted cell salvage which is

procedure by which blood is recovered, washed and filtered and then returned to the women.

National Institute for Health and Clinical

Excellence(NICE,2017). The hospital committee worked closely with Sarah particularly

research and clinical practice in the area of bloodless surgery (Kicker,2003).

As this was the first time I had experienced midwifery practice with a Jehovah’s witness, I

was aware that I would need to research and expand my knowledge surrounding this.

One of the rationale for monitoring Hb(iron) levels within pregnancy is to ensure an adequate

level prior to childbirth as blood loss is expected. If the Hb(iron) levels are low prior to birth

then the women may lose a ‘normal amount of estimated blood loss but still become
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symptomatic and have a lower tolerance level. Subsequently the women may need a blood

transfusion at a sooner period. Therefore, monitoring Sarah’s Hb (iron)levels closely and

ensuring that they are at optimum levels prior to birth was essential.

Further potential treatments include cell salvage which is offered by the trust where the

women’s own blood is filtered via a machine and then put back into her body. This is usually

an accepted procedure within the Jehovah’s witness group as the blood doses not leave their

body in effect and is therefore filtered and re-circulated into their body (Zeybeck et al 2016).

Some consultants may also opt for a postnatal syntocinon intravenous infusion to assist the

involution of the uterus following birth. As I was present at the intrapartum, birth and

postnatal period I was able to see how the plan was followed. Sarah had a normal vaginal

birth with a blood loss of 400ml postnatally. Further management included an active

management of the delivery of the placenta (syntocinon IM) as active management of the

third stage has been shown to reduce the amount of post-partum haemorrhages(>1000mls).

(RCOG,2002). I also have learnt there is a 24/7 service available to health professionals to

seek additional support when providing care for Jehovah’ Witnesses which I found to be very

reassuring for all involved in Sarah’s care. Reece and Walker (2007) found that the individual

there-self is more effective at assessing their own personal and professional development

needs. Applying Benner’s (1984) five step typology of development of expertise I would

class myself in the lower novice category initially. Following discussion with colleagues and

additional research I now feel I would be within the Advanced beginner category surrounding

the care and support suitable for Jehovah’s witnesses’ will continue to develop my skills and

knowledge within the area as will I with other religions that we are exposed too.

To conclude, exposure to a wide variety of women within midwifery enables us as health

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professionals to further develop our knowledge and skills when providing care for these

women. Religion can largely impact a women’s care pathway antenatally, in labour and

postnatally. It is the health professional’s role to seek further support with this and be

sympathetic and understanding to the women’s requests and choices (Midwifery 2020,

Programme (2010).

Action Plan

 To continue to respect a woman’s individual choice for refusing certain blood

components with providing fundamentals of care effectively upholding her human

rights in her decision making throughout the antenatal, intrapartum and postnatal

period

 To ensure that I obtain informed consent to all women I care for.

 To document in the notes and ensure midwives and doctors are aware of womens’

religion and plans for birth.

 Always practice in line with the best available evidence by reading midwifery

journals, the Cochrane data base and national clinical guidelines.

 Continue to communicate effectively with the Hospital team of obstetrician’s

anaesthetists and midwives during the intrapartum and postnatal period.

Reference List

Bodnaruk ZM, Wong CJ, Thomas MJ. Meeting the clinical challenge of care for Jehovah’s
Witnesses. Transfus Med Rev. 2004; 18:105–116. [Available at
https://www..ncbi.nlm.nih.gov/pubmed/15067590.
[Accessed 12th June 2018]

Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice.
Menlo Park: Addison-Wesley, pp. 13-34.

Dreyfus.S (2004) The Five-stage Model of Adult Skill Acquisition

[Available at]
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https://www.bumc.bu.edu/facdev-medicine/files/2012/03/Dreyfus-skill-level.pdf
[Accessed 13th June 2018]

Gibbs, G (1988). Learning by doing; a guide to teaching and learning methods. London:
further Education Unit.

HMSO: London. Department of Health. (2001) 12 key points on consent: the law in England

Kickier.T(2003) Why? Bloodless medicine” and how should we do it?[Editorial]transfusion

2003;43:550

Midwifery 2020 Programme (2010): Delivering Expectations. The Stationery Office, London

National Institute for Health and Clinical Excellence (2017) Postnatal care for healthy
women and babies[online]
[Available at] https://www.nice.org.uk/guidance/cg190
[Accessed 12th June 2018]

Nursing and Midwifery Council, NMC (2015) The Code: Professional standards of practice
and behaviour for nurses and midwives[online]
[Available at] https://www.nmc.org.uk/standards/code/
[Accessed 10th June 2018]

Reece.T, Walker.S (2007) Teaching, Training and Learning. A practical guide 6th Edition>
Business Education Publishing Ltd: London

Royal College of Obstetricians and Gynaecologists 102(1): 173-80. Hawryluck L, Crippen D.

(2002) Ethics and critical care in the new millennium. Critical Care 6(1-2):1-4

The Royal College of Midwives(RCM) (2008) Blood loss, replacement and belief.[Available
at] https://www.rcm.org.uk/news-views-and-analysis/analysis/blood-loss-replacement-and-
belief
[Accessed 16th June 2018]

Zeybek,B Childress.A,Kilic.Gokhan.S,Phelps.J,Pacheco,L,Carter, M,Borahav.A(2016)

Management of the Jehovah’s Witness in Obstetrics and Gynaecology Comprehensive
Medical, Ethical and Legal Approach.Obststet Gynecol Surt 2016;71(8):488-500
[Available from] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4991563/
[Accessed 15th June 2018