Guideline on the use of Anti-D Prophylaxis for Rhesus Negative Women

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1 Guideline on the use of Anti-D Prophylaxis for Rhesus Negative Women This guidance does not override the individual responsibility of health professionals to make appropriate decision according to the circumstances of the individual patient in consultation with the patient and /or carer. Health care professionals must be prepared to justify any deviation from this guidance. Introduction Antenatal Anti-D Prophylaxis is of proven benefit and has significantly reduced the levels of Rh D sensitisation. It is recommended that routine antenatal Anti-D (RAADP) is offered to all non-sensitised women who are Rh D Negative. Anti-D prophylaxis should be given following any sensitising event. The patients covered by this guideline are all pregnant women who are Rhesus Negative (Rh Neg). This guideline is to be used in conjunction with WAHT-OBS- 119 Management Of Pregnant Women With Red Cell Antibodies This guideline is for use by the following staff groups: Registered Midwife, Medical Staff. Lead Clinician(s) Jan Macfarlane Mrs S Ghosh Antenatal Screening Specialist Midwife Consultant Obstetrician Guideline reviewed and approved by Obstetric Clinical Governance meeting on: 16 th May 2014 This guideline should not be used after: 16 th May 2017 WAHT-OBS-036 Page 1 of 11 Version 6.1

2 Key Amendments to this Document Date Amendment By: This guideline replaces the versions originally agreed in May 2003 and extended in March 2007 and a revised version approved in August /09/09 Reviewed by Julie Poultney and agreed to continue for a further period without amendments Agreed by Core MGDG to extend for further two years without amendment Reviewed by Guideline leads with minor changes Clinical lead changed to Swati Ghosh and Jan Macfarlane Anti D prophylaxis administered as a Midwife Exemption not PGD. (approved by leads) Document extended for 12 months as per TMC paper approved on 22 nd July 2015 Miss R Imtiaz Judi Barratt Swati Ghosh TMC WAHT-OBS-036 Page 2 of 11 Version 6.1

3 Guideline on the use of Anti-D Prophylaxis for Rhesus Negative Women Introduction Antenatal Anti-D Prophylaxis is of proven benefit and has significantly reduced the levels of Rh D sensitisation. It is recommended that routine antenatal Anti-D (RAADP) is offered to all non-sensitised women who are Rh D Negative. Anti-D prophylaxis should be given following any sensitising event. Guideline See appendix 3 Anti-D Administration Flow Chart 1. Rh status of all pregnant mothers is usually confirmed between weeks gestation via National Blood Service. 2. The Midwife with responsibility for booking the Rh Negative woman should discuss RAADP and the options available in order that the woman can make an informed choice. This discussion should include the circumstances where RAADP would be neither necessary nor applicable. Such circumstances might include those where the woman: Has opted to be sterilised after the birth of the baby Is in a stable relationship with the father of the child, and the father is known or found to be RhD-negative. Is certain that she will not have another child after her current pregnancy Each woman will be provided with a card identifying her rhesus status and given an information leaflet entitled. 3. The midwife will obtain verbal consent from the woman and an appointment for 28 weeks will be made directly with each Anti-D clinic site. If the woman declines RAADP each site will be informed along with clear documentation in the case notes and hand held records. 4. Women who decline Anti-D should still be offered antibody screening at both 28 and 34 wks, and should be carefully counselled. Detailed documentation is necessary. 5. Stock supplies of Anti-D will be issued to the hospital and community sites. Records of stock supplies should be maintained for each site. 6. Anti-D will be administered as Midwife Exemption (DA/ME/11) Midwives based in these clinics will be responsible for ensuring that stock levels are replenished and recorded as necessary. 7. Anti-D will be administered by the midwife via appointment in the dedicated Anti-D clinic. This maybe within a hospital or community setting provided adequate medical cover and resuscitation equipment is available. WAHT-OBS-036 Page 3 of 11 Version 6.1

4 8. At 28/40 When Blood test for Antibody Screen Dosage and Route 28 wks (up to 30 wks) YES, prior to Anti-D injection 1500 units IM Deltoid Muscle Anti-D 1500 units will be administered IM into the Deltoid Muscle. Women should remain within the clinic for a period of mins following injection for observation in the unlikely event of any reactions occurring. 9. The midwife should complete the Anti-D data sheet (see appendix 1) and return copies as instructed on form. Documentation of the Anti-D batch number and date of administration should be clearly documented in the hand held notes using Page 7, Anti-D injections section of the Pregnancy tes. Any woman not attending for this appointment will be notified to the designated community midwife and followed up accordingly. Late Bookers should be offered Prophylactic Anti-D and the single dose can be administered according to guideline. te: Doses of Anti-D given after 30 weeks can not be guaranteed to provide full cover. Guidelines for Prophylactic Anti-D For Sensitising Events 1. It is important to inform women that any potential sensitising events are reported as usual, i.e. i. Fetal loss Termination of pregnancy (TOP) Spontaneous miscarriage Missed miscarriage ii. Amniocentesis iii. Antepartum haemorrhage/bleed at any gestation, or potential for bleed e.g. following a fall or road traffic accident. iv. External Cephalic Version v. Delivery of a rhesus-positive baby 2. In the event of a sensitising event where the patient has already received prophylactic anti- D bloods should be taken for levels of anti-d and Kleihauer, Prior to the administration of additional Anti-D. 3. Women who decline prophylactic Anti-D but who agree to Anti-D in the event of a sensitising episode refer to the Patient Group Direction for Administration of Anti D for Sensitising Events (ref DA/WM/30). 4. At Delivery: Following delivery maternal bloods should be taken in accordance with local policy. Anti-D should be administered as required within 72 hrs following delivery. (Midwife Exemption DA/ME/10) WAHT-OBS-036 Page 4 of 11 Version 6.1

5 Monitoring Tool How will monitoring be carried out? When will monitoring be carried out? Retrospective case note audit Initially after 6 months then annually Who will monitor compliance with the guideline? Antenatal Screening Specialist Midwife and Antenatal Clinic Managers Item % Exceptions All Rh neg women will be offered prophylactic Anti-D 100% Woman s choice All Rh neg women should be offered prophylactic anti- D following a sensitising event 100% Woman s choice References NICE Technology Appraisal Guidance. 41. Guidance on the use of routine antenatal anti-d prophylaxis for RhD-negative women May 2002 RCOG Guideline 22. Use of Anti-D immunoglobulin for Rh prophylaxis Oct 1999 WAHT-OBS-036 Page 5 of 11 Version 6.1

6 Contribution List Key individuals involved in developing the document Name Designation Mrs R Imtiaz Consultant Obstetrician Elaine Newell Senior Midwife Julie Poultney Antenatal Screening Specialist Midwife Jamila Shahid Consultant Obstetrician Judi Barratt Clinical Midwife Specialist Circulated to the following individuals for comments Name Designation Lola Abudu PCT Public Health Consultant South Worc s PCT Valerie Lamorte Blood Bank Manager WRH Dr N Pemberton Consultant Haematologist Alexandra Hospital Dr A Sawers Consultant Haematologist, WRH Sue Jenkins PCT Lead Redditch and Bromsgrove Paul Weaver Haematology, Alexandra Hospital Ms R Duckett Consultant Obstetrician/Gynaecologist Mrs S Ghosh Consultant Obstetrician/Gynaecologist Mrs J A Byrne Matron/Supervisor of Midwives Mrs M Stewart Matron/Supervisor of Midwives Mrs J Lucas Matron/Supervisor of Midwives Mrs C Poyzer Matron/Supervisor of Midwives Mrs K Kokoska Skills Drills Trainer Sue Heslington Midwife WRH DAU R Fletcher Clinical Pharmacist Circulated to members of Guideline Group (for consultation with peers) Name Designation T Cooper Consultant Midwife M Chong Matron/Senior Midwife Delivery Suite, WRH L Coleman Community Midwife Team Leader, Worcester Team Y Cowling/H Walker Community Midwife, West Team C Crompton Team Leaders, Ward 15, Alexandra Hospital E Davis Midwife, Transitional Care Unit, WRH J S Farmer Midwife, Antenatal Clinic, WRH G Field Community Midwife Team Leader, Bromsgrove Team M Gough Midwife, Lavender Postnatal, WRH L Heywood Community Midwife, Evesham Team D Hughes Midwife, Lavender Postnatal, WRH B Kavanagh Community Midwife Team Leader, Redditch Team J Martin Midwife, Central Delivery Suite, Alexandra Hospital T Meredy Midwife, Antenatal Clinic, Alexandra Hospital K Perkes Community Midwife Team Leader, Bromsgrove Team S Tabberer Community Midwife Team Leader, Kidderminster P Taylor Community Midwife, Droitwich Team V Tristram Midwife, Kidderminster Hospital R Williams Midwife, Delivery Suite/PN Ward, WRH Circulated to the following CD s/heads of dept for comments from their directorates / departments Name Directorate / Department John Watts Clinical Director Obs and Gynae Lis Hesk Matron, Gynaecology Circulated to the chair of the following committee s / groups for comments Name Committee / group Alison Smith Drugs and Therapeutics Committee WAHT-OBS-036 Page 6 of 11 Version 6.1

7 Appendix 1 Guideline on the use of Routine Antenatal Anti-D Prophylaxis for Rh Negative Women Appendix 2 Anti-D Data Sheet Administration of Antenatal Prophylaxis Anti-D Immunoglobulin Worcestershire Acute NHS Trust Place patient detail stickers on all three copies Hospital:. Ward/Clinic:.. OR Blood group :. Rh Neg E Write Patient Name, DOB and Reg clearly in black ink EDD:. Gestation: Batch :. Dose given : 1500 units Expiry date : Given By : Date : Time:.. Top copy to be filed in patient notes/ middle copy retained by Anti D clinic/ Bottom copy send to Blood bank WAHT-OBS-036 Page 7 of 11 Version 6.1

8 Appendix 2 Intramuscular Injections - Deltoid Site Intramuscular injections into the mid-deltoid muscle, like other IM injections, should be given into the densest part of the muscle. This is located by drawing an imaginary horizontal line two to three fingers breadths cm below the lower edge of the acromion process. The injection should be given into an imaginary triangle whose base is the central half of this horizontal line and whose apex is formed inverted on the midpoint of the lateral aspect of the arm in line with the axilla. (See diagram) It has the advantage of being easily accessible whether the patient is standing, sitting or lying down. It is also a better site than the gluteal muscles for small-volume (less than 2 ml), rapid onset injections because the deltoid has the greatest blood flow of any muscle routinely used for intramuscular injections. WAHT-OBS-036 Page 8 of 11 Version 6.1

9 Pregnant Rh D Negative Woman WAHT-OBS-036 WAHT-OBS-036 Page 9 of 11 Version 6.1

10 Supporting Document 1 - Equality Impact Assessment Tool To be completed by the key document author and attached to key document when submitted to the appropriate committee for consideration and approval. Yes/ Comments 1. Does the policy/guidance affect one group less or more favourably than another on the basis of: Race Ethnic origins (including gypsies and travellers) Nationality Gender Yes Pregnant women only who are Rhesus negative Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Age 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? 4. Is the impact of the policy/guidance likely to be negative? 5. If so can the impact be avoided? N/A 6. What alternatives are there to achieving the policy/guidance without the impact? 7. Can we reduce the impact by taking different action? N/A N/A If you have identified a potential discriminatory impact of this key document, please refer it to Human Resources, together with any suggestions as to the action required to avoid/reduce this impact. For advice in respect of answering the above questions, please contact Human Resources. WAHT-OBS-036 Page 10 of 11 Version 6.1

11 Supporting Document 2 Financial Impact Assessment To be completed by the key document author and attached to key document when submitted to the appropriate committee for consideration and approval. Title of document: 1. Does the implementation of this document require any additional Capital resources 2. Does the implementation of this document require additional revenue Yes/ 3. Does the implementation of this document require additional manpower 4. Does the implementation of this document release any manpower costs through a change in practice 5. Are there additional staff training costs associated with implementing this document which cannot be delivered through current training programmes or allocated training times for staff Other comments: If the response to any of the above is yes, please complete a business case and which is signed by your Finance Manager and Directorate Manager for consideration by the Accountable Director before progressing to the relevant committee for approval WAHT-OBS-036 Page 11 of 11 Version 6.1

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