Rhesus Negative Mothers

Choices for Rhesus Negative Mothers

My Mother and father are both Rh+, which is dominant, right? So how did I become Rh-???? Is it because they BOTH had a recessive neg gene that they passed on to me to make me a full neg?

Yes, totally correct!

My husband is Rh positive, as are all the children; will I be forever doomed to anti-D injections, or is there a possibility I may get an Rh negative baby?

Andrea

You can only have an Rh -ve baby if your hubby is carrying a Rh negative gene… basically if you have an Rh -ve kid then either he is carrying one, or you’ve been playing away 😉 (But see Rhesus Variationsbelow.)

Angela

I thought I would share a joke with you.

‘Have you heard they have produced a new morning after pill for men? It changes their blood group!’

Debs

I recently accompanied a consultant ward round. (Consultant, Registrar, SHO’s x 3, Med students x 2, Midwife and Me [student midwife]). There was a woman who had given birth in the night and was awaiting baby’s group before having Anti D. The teaching session that followed in the corridor about Rhesus Isoimmunisation focussed on Why does it still happen, why do some women not have Anti D? And discussion about prophylaxis ante-natally. The overwhelming view from the Docs seemed to be that some irresponsible women will not do as they are told, and those who question, or worse still refuse, prophylaxis are wierdos who refuse all modern medicine has to offer. I’m afraid that I was too cowardly to challenge this view in this setting, and only managed to put the point that some women are concerned because Anti D is a blood product. It seems that the view that women should do as they are told and not ask questions is still with us. The Consultant did go on to say that he wondered if there was a place for Blood Grouping of the baby’s father antenatally, before giving routine antenatal doses. Does anyone know whether this is ever done?

Andrea.

I have heard of practitioners who do this, but it is an art. The question about testing the “father” must be done in a very trusting environment, without the partner(or anyone else!)present. This is to allow the woman a safe environment to choose gamma globulin regardless of her partner’s status,in case he is not the father of the baby. Full information must be provided (ie-NOT to husband/male partner “Do you know your blood type, negative, oh good than (to woman)you don’t need this stuff”)

Just a note.. I don’t know if it is done all over Ontario, but protocol in at least three major hospitals in the Toronto area ia a routine 28 week antenatal prophalaxis, followed by baby blood typing, and second dose for moms of Rh+ babes.

One more thought..

“Single” women may know the blood type of their partners, if they have been inseminated or have had donor sperm. This is a common occurance in the lesbian community.

Sky

Just adding my experience as a midwife and Rh negative mother of two. I was tested (as is the norm) for antibodies at 28 weeks (none present) and then the babies’ blood group was tested from cord blood after delivery. As it happened, both my boys were Rh positive, so I had anti-D. If they had been Rh neg, I wouldn’t have had it, it wouldn’t have even been offered. The only situation where I would be given anti-D “blindly” ie without knowing the blood group of the baby would be with a spontaneous or induced abortion where the blood group of the baby could not be established, or in the case of a antepartum haemorrhage.

Kirsten Blacker

I have been talking to a pregnant woman recently who is Rh negative. She has been told that her obstetrician would expect her to have anti-D post delivery. She has pointed out that her partner is also Rh negative, so the baby wil be too. At which point she was told that the medical staff had no guarantee that her partner was the baby’s father and they still recommended anti-D. She was horrified at this, especially as it was said in front of her partner. She is going to refuse the anti-D anyway. Anyone else had anything like this happen or any comments?

Jill. Student midwife.

Yes, this too happened to me when I was a student, and I too was horrified. The woman and her partner were both very angry.

However, taken in the context of hospital, with a couple arriving on the labour ward not already known to anybody working there, there is an element of common sense in the policy. It is a fact that many women have babies whose father is not their partner, without telling the partner. It is also quite likely in such a situation that the woman will not tell the midwife at booking or during antenatal visits either – would you?

Since there is no way for the hospital staff to know whether the father of the baby is actually the woman’s partner – and she is most unlikely to say any different in that context, especially in the partner’s presence – the fail safe approach is indeed to give anti-D as a routine, irrespective of the partner’s blood group. It is insulting for a couple who know without doubt that the baby belongs to them both, but these things do happen.

In a community or home birth context, where the woman hopefully knows her midwife well, and the whole rhesus negative issue has hopefully been carefully discussed, perhaps there is more of an opportunity for the truth to come out before labour. I don’t know. As an independent midwife I trust the woman to make good decisions about this. Only she knows the truth. If she wants to have anti-D then fine, and if she doesn’t I trust her to have weighed the information given in the balance and come to a responsible conclusion. Not many hospital staff feel able to do this – in their shoes I wouldn’t either, probably.

Interesting issue, and not as straightforward as at first may appear.

Melanie

I think that if a Midwife explains all aspects of care antenatally in a totally non-judgemental way, then clients are likely to say if the current ‘partner’ is not the biological father at booking or subsequent visits. I feel very uneasy reading that a failsafe approach would be to routinely give Anti -D….. Education, explanation and excellent communication skills are a failsafe approach for care surely ?

Ella Jackson

At which point she was told that the medical staff had no guarantee that her partner was the baby’s father and they still recommended anti-D.

I think this is appalling – surely to suggest something like this to a couple is defamation of character? I think the couple should be outraged and insulted and should write a very strong letter of complaint to the person who made the comment and copy it to as many different people in the hospital that they can, right up to the most senior administrators and heads of department.

Katherine Davies

I have recently changed Health Authorities – and at my new job, it is expected to give Anti-D at 28 weeks and 34 weeks to all primips and women with no live children. It is also then given postnatally as well! I feel extremely uncomfortable with this arrangement as at my last employer it was decided against as in 4 years with 2500 births a year, there had been only 2 women with antibodies detected. Imagine – 15% of these women being exposed to Anti-D for the sake of 2 women. Extreme. I suspect that my present employer sees it as a good idea as they are a referal centre for Rhesus disease. I currently spend quite a lot of time talking to the women about it, but they, mostly, have already been ‘primed’ by the GPs.

Lynn

I have been involved in raising issues for midwives and women around RhD/ Rhesus negative for some time and have articulated the shared concerns as explored on this email list BUT local voices have not been heard and this an example of communication and importance of womens health issues – the whole concept of choice is a farce at times!

The references below indicate this – plus I have networked widely with user groups etc to profile the issues. I was an active committee memeber of the British Blood Transfusion Society (BBTS) Committee of Special Interest Group on Alloimmune Diseases on the Fetus / Newborn London (1996-1998)

Published :-

Wray J Jackson-Baker A (2000) Anti-D immunolglobulin and antenatal prophylaxis. RCM Midwives Journal, February 2000, 3:2; 59-61 Wray J Benbow A (1999) In the spotlight: Current debate and issues surrounding anti-D immunoglobulin. MIDIRS Midwifery Digest 9:4; 517-519

Wray J, Vause S, Maresh M (1999) Maternity Care Audit: Management of women who are RhD negative in Northern Ireland. Project report for DoH Belfast Northern Ireland. RCOG, Clinical Audit Unit, Manchester, January 1999.

Everett C, Wray J (1998) Preventing RhD haemolytic disease of the newborn: New recommendations must be explained to GP’s and midwives (letter) British Medical Journal 3;16, 1164-65.

I am happy to debate further but we really should look at how we communicate ….

Julie Wray
Research Fellow
The University of Salford Salford M5 4QA

This has been an interesting thread. In my pratice (independent home and hospital as primary provider) I have had some exposure to women declining prenatal and postnatal Anti D.

I provide informed choice to all RhNeg women re the risks and benefits of AntiD prophylaxis. Most take it up. It is important to remember that the rate of isoimunnisation is 15%. So 85% of women do not become isoimmunised. If it was a significant risk to the population, there would be no RHneg individuals left as the numbers would have dwindled over thousands of years of reproduction!

My first experience was with a woman having her 5th child. She refused it prenatally and when the cord blood showed the newborn to be Rh+ she still declined (for religious reasons). I respected her choice, and documented it clearly.

The sticky question is when a woman and her “partner” are both Rh-, then I explain that my practice is to do cord bloods on the newborn. So far I have not had an issue with the ‘father’ not being the true father.

If the baby was Rh pos, I would approach the woman privately, and offer her Anti D.

But it is possible, in more than the usual way (wink, wink) A recent client’s husband’s sperm was treated before artificial insemination. I pointed out that there might be a small risk of error at the lab.

Freda, Ontario

In Australia over the last couple of years, the obs and gobs were routinely giving Anti D at 28/40, after every APH regardless of size of bleed and Kleihour results, they even tried to routinely give after all Rh-ve mums delivered. As a consequence Australia was very short of Anti D and loads of Rhogam was imported from the USA and of course had to be accompanied by a formal information session by the registrar and a formal consent form to be signed.

Judy

I have always told mums that Anti-D is a blood product, regardless of their religion. I just think it is an important piece of information as unless you have been told about it, you would never think of Anti-D being a blood product, it sounds like some artificially made product. I certainly did not know about it until I started my midwifery training. Until now I have not come across any women who had refused it because of it being a blood product once they know the reason why it is reccomended, but of course, there are probably some women who might refuse it, and unless we give them the information they will not have that choice.

Jo

I would suggest that you look at the following work of Sara Wickham with reference to an alternative view of RHesus incompatibility and anti-D. Sara is the only person I know challenging the belief that every Rh neg woman requires anti-D.

Wickham, S (1999) Anti-D: Exploring Midwifery Evidence MIDIRS Midwifery Digest, Vol 9, No 4, December 1999, pp 452-458.

Wickham, S (1999) Anti-D; A woman’s choice (2) Practising Midwife, Vol 2, No 6, pp 38-39.

Wickham, S (1999) Anti-D; A woman’s choice (1) Practising Midwife, Vol 2, No 5, May 1999, pp18-19.

Lorna Davies

Is it now routine everywhere to give anti – D to all neg. women. I am neg -but have not had anti -D. Both my babies were neg I presume as I was told I didnt need it. My husband is positive. Seems a shame to have something that may not be needed. Do they not test for antibodies and blood group anymore, and give only if needed?

Jane (antenatal teacher)

Here in sunny Perth, we only give Anti-D to Rh neg women if the baby is Rh pos. Perhaps this is done because we have problems with our Anti-D supply, and sometimes have to ‘resort’ to Rhogam from the US. Maybe in the UK with more plentiful supplies of Anti-D, it is more cost effective to give Anti-D than test the babies. Perhaps at least a blood group for the babies could be offered to women with reservations or objections to Anti D, so they don’t get it unless they need it.

Kirsten Blacker

Here in rainy Wales, it’s given in our area to all Rh -ve women prior to receiving cord blood results! There also appears to be moves a foot to give to all at 28/40 and at another point in Preg. New RGOG guidelines, call me cynical but all the glossy guidelines that appeared from RCOG were paid for by the drug company who produces anti-D.

Cate

In Australia over the last couple of years, the obs and gobs were routinely giving Anti D at 28/40, after every APH regardless of size of bleed and Kleihour results, they even tried to routinely give after all Rh-ve mums delivered. As a consequence Australia was very short of Anti D and loads of Rhogam was imported from the USA and of course had to be accompanied by a formal information session by the registrar and a formal consent form to be signed.

I came across a lady whose religion is Jehovah’s Witness. Fortunately the babe was Rh- too, but until I came across this situation I never considered that such a group should recieve information that anti D is a blood product and that due to their beliefs they may refuse the medication. Any thoughts…….

Robyn

Robyn, you are quite right. I knew a grand multip who was Rh- and whose religion was JW. As the last baby was born over 2 years ago, I can’t recall whether we took blood for antibody screening, or for kleihauer at delivery. I recall discussing the issues with her, and she certainly never had any Anti-D treatment. The babies I knew were all breast fed, and none had any more than the usual physiological jaundice. I really can’t remember if we knew the blood groups of these babies or not. I feel that it is important to inform all Rh-ve mums about Anti-D being a blood product.

Janet

I have recently been attending women who choose physiological 3rd stages from time to time, but as I do not routinely clamp or cut the cord I have a dilemma – when to obtain cord blood for a Kliehauer?

Although the Trust that I work for recommend all (rhesus negative) women to have anti-D, I prefer to test cord and maternal blood. Most of the time, the cord is ‘drained’ after the 3rd stage with physiological management – I worry about affecting the progress of the 3rd stage by taking blood from the cord prior to completion of the 3rd stage. Any ideas?

Lynn

The way we manage blood sampling for the direct Coombes test following birth of baby to Rhesus neg woman is to allow the cord to finish pulsating (keeping quite a close eye) and AS SOON as it has, to double-clamp the cord. As soon as the blood sample has been taken the maternal end can be released again, to allow the maximum reduction of the placenta before third stage completes. We usually seem to have enough blood left in the cord to do this, but if not, we have in the past got enough from the blood vessels in the placenta following the end of 3rd stage.

Melanie

This is an interesting issue, physiological third stage and rhesus neg mothers. Except in very rare situations I leave the 3rd stage to progress on its own. Normally if a woman is rhesus neg I just take blood from the placental vessels and cord following the birth of the placenta. I have not come across problems with this and have picked up equally both positive and rh neg babies this way.

What do other midwives do? Is there any actual evidence out there that taking blood this way for a coombs test is not reliable? I agree that flapping around as soon as the baby has joined us is distruptive and I believe unnecessary.

Susan
Independent midwife (London)

Rhesus Variation – changing from negative to positive

A funny story re Anti D happened. The mum was Rh-ve and the dad was also, but regular cord bloods showed the baby was Rh+ve. After much much discussion, tears, anger etc, the registrar finally suggested the ultimate solution: that the baby having a different Rh group from both its -ve parents, was that it was an act of God! Everyone was “relieved” and the parents were happy.

Judy

Reading Judy’s posting about the baby who was Rhesus positive but had Rhesus Negative parents (act of God) I thought it might be useful to let you know about a lady I saw in the Early Pregnancy Clinic last week.

She had an ultrasound which showed that she had had a miscarriage. She was concerned that it was because she hadn’t had anti D in the last pregnancy. This left me confused as the computer showed a Rhesus positive result for her booking bloods. Thinking that I had called up the wrong patient’s details, I printed out all the results of previous pregnancies in this lady’s name and date of birth.

They showed that in her first pregnancy she had been classified as Rhesus Negative, in her second pregnancy she had been reclassified as Rhesus positive and this was commented on – saying that a new type of test which had been introduced was more specific and she was now considered Rhesus positive. I explained this to her and gave her the printed versions with the explanations for midwives booking any future pregnancy. She seemed quite confused (as indeed I had been initially) but because her last baby had been Rhesus Negative I was able to reassure her that whatever her blood group classification she wouldn’t have received any anti-D anyway

I too came across a woman who had booked for her second pregnancy and had been found to be rh+ve whereas in her first pregnanct she was rh-ve and recieved anti-d after miscarriage. I followed this up and was told by Sheffield that on retesting her blood she was rh variant.

Louise

Links to other sources of information:

Anti-D: Exploring Midwifery Knowledge, by UK midwife Sara Wickham, on the With Woman website.
(www.withwoman.co.uk/contents/info/antid.html), and by the same author:
Routine antenatal anti-D – a review of the evidence
(www.withwoman.co.uk/contents/info/anantid.html)

From NICE – the UK’s National Institute for Clinical Excellence:

NICE press release on guidance for rhesus negative women during pregnancy – 10 May 2002 (NICE 2002/ 024).
(www.nice.org.uk/article.asp?a=31717)

Full guidance on the use of routine antenatal anti-D prophylaxis for RhD-negative women (PDF)
(www.nice.org.uk/Docref.asp?d=31686)

Assessment report of the clinical effectiveness and cost effectiveness of routine anti-D prophylaxis for pregnant women who are rhesus (RHD) negative
This document is the health technology assessment report prepared by the School of Health and Related Research at the University of Sheffield (ScHARR).
(www.nice.org.uk/pdf/prophylaxisHTAreport.pdf)

US Midwife Archives section on rhesus negative mothers
(www.gentlebirth.org/archives/genpcare.html#RhoGAM)

Detailed overview , from ‘Drugbase’ in the USA.
(www.drugbase.co.za/data/med_info/rhesus.htm)

An ‘alternative’ perspective from ‘Mango Mama’, focusses on worries about administration of Anti-D during pregnancy.
(www.geocities.com/Heartland/Woods/2924/rh.html)

AH updated 20 May 2002