Valid consent should be obtained wherever possible before resuming blood transfusion. In case of emergency situation, information about blood transfusion should be given retrospectively as it may not be possible to obtain the consent before the transfusion.

The discussion about the need for transfusion and the consent should be documented in the patients’ clinical record sheets.

In case of Jehovah’s witness the patients who decline transfusion of specific blood components need to be documented in case records. The discussions should be conveyed to all the staffs and the clinicians [6, 7].

Blood group and antibody status determined at the time of antenatal registration and at 28 weeks for all women [8, 9].

Samples used in pregnancy for screening and blood group and typing should preferably be less than 3 days old.

High-risk women like those having low-lying placenta or morbid adhesions of placenta with no significant alloantibodies should be the candidates for anticipated transfusion.

Weekly group and screen samples should be sent to exclude or identify new antibody formation and to ensure the availability of blood if the need arises.

Maternal alloantibodies can cause hemolytic disease in newborn and are of importance in selection of blood for transfusion in the mother. Care should be taken to avoid the risk of hemolytic transfusion reactions [10].

Transfusion or pregnancy may stimulate an unexpected antibody production against the red cell antigen by mounting primary or secondary immune response [11].

A 3-day rule can be formally deviated in pregnant women without clinically significant alloantibodies. In the case of major obstetric emergencies like placenta previa, once-a-week testing can be done to check for alloantibodies.

Close liaison with the hospital blood bank is necessary.

Patient should receive compatible red cells of ABO, RhD, and K (Kell) types and should be transfused appropriately.

Blood components should be screened for CMV (cytomegalovirus).

Antenatal women who are Rh-negative should be given Rh-negative blood or blood components to curtail the risk of Rh isoimmunization [11].

Immediate issue of O-negative, RhD-negative, and K-negative units should be requested in case of major obstetric hemorrhage, and their provision should be ensured in case of emergency situation till the group-specific blood is available.

Development or detection of atypical red cell antibody is done by screening for these antibodies. The relevant antibody or antibodies are detected by specific further testing. A specific red cell unit negative for red cell antigens is then selected for transfusion.

Intraoperative cell salvage (IOCS) is reserved for non-obstetric patients where the anticipated blood loss induces anemia or where expected blood loss exceeds 20% of estimated blood volume [12–14].

Current evidences recommend the usage of IOCS in obstetrics [15, 16]; however the routine practice of IOCS in obstetrics needs to be supported by more evidence from randomized controlled trials.

Cell salvage should be performed by an experienced team.

Injection anti-D 1500IU should be administered if cell salvage is used during cesarean section in RhD-negative non-sensitized women and fetal blood group is positive (cord blood).

A need for more anti-D is assessed posttransfusion by estimation of FMH >30–40 mL performed on maternal blood sample.

Postpartum blood loss can be reduced by means of mechanical measures like allowing the placenta to get separated and expelled spontaneously.

Uterine atony, bimanual uterine compression, and uterine packing are the primary measures to be taken in case of obstetric hemorrhage along with active management in the third stage of labor.

Meanwhile the pharmacological agents like oxytocic, ergometrine, and prostaglandin analogues should be administered.

Obstetricians should be trained with the surgical methods to prevent postpartum hemorrhage like uterine compression sutures and stepwise devascularization of the uterus.

A set of protocols for the management of major obstetric hemorrhage is displayed in the labor ward, and regular drills should be done as a process of audit.

The clinical and hematological judgements should be the basis of RBC transfusion [17].

The red cell transfusion is usually advised when hemoglobin levels are below 6 g%.

The organ ischemia, the rate risk of any potential or actual bleeding, the patient’s intravascular volume status, and the risk of complications due to inadequate oxygenation are guide for decision to transfuse [18].

In case of an acute hemorrhage, a patient may have normal initial hemoglobin to begin with, but the hemoglobin level can drop subsequently to a significant level below the normal. Hence clinical judgment is of utmost importance to avoid losing the vital time of resuscitation.

O- and RhD-negative red cells should be transfused in situations of severe uncontrollable hemorrhage. The risk of incompatibility may arise due to irregular antibodies where the blood group is not known. The working staff must be aware of all the available blood group types in the blood bank fridge.

Components Description

Red blood cells are derived as RBC concentrate from whole blood donations. It is prepared by centrifugation or collected by apheresis method. The addition of citrate (anticoagulant) along with one or more preservative solutions gives hematocrit ranging from approximately 50–65% to 65–80%.

An average of about 50 mL of donor plasma (147–278 mg of iron) mostly in the form of hemoglobin, with additions of preservatives and anticoagulant constitute the RBC concentrate [19, 20].

Recommendations

The aim to maintain hematocrit is minimally at 21–24%. Majority of protocols recommend 6 units of packed red blood cells be prepared [21–24].

In a 70 kg patient, a single unit of PRBCs would raise the hematocrit by approximately 3–4% [25].

However, due to rise of expanded blood volume during pregnancy, the expected increase in hematocrit may be slightly less.