When you are performing the first interview of a new patient at the high-risk obstetric clinic where I work, question No. 14 on the intake computer form is: “Do you have any prior preterm deliveries?”
Question No. 15 is: “Do you have any lung or respiratory diseases, including asthma?” (This is when everyone remembers that they do, in fact, have asthma.)
Question No. 16 is: “Would you accept a blood transfusion if you needed one to save your life?” It’s a yes/no question. If you type “No,” the line turns a brilliant and alarming red.
That question is there, of course, because of Jehovah’s Witnesses. This Christian sect was founded in 1872 by Charles Russell, and its members’ stance on blood transfusion is derived from their interpretation of Genesis 9 and Leviticus 17 to “not eat from the bread of life,” as well as the verses in Acts 15:20, Acts 21:25, and elsewhere that Christians must “abstain from ... blood.” Adherents do not accept blood products, regardless of the possibility of death. For Jehovah's Witnesses, receiving blood products may lead to excommunication from their community and fear of eternal damnation.
It’s not uncommon for my clinic to have a Jehovah’s Witness patient. These patients are often not the ones who give us the most trouble in terms of transfusion—the sickle cell patient who has been transfused so many times that it’s very hard to find blood that she’s not allergic to is another example. We work closely with the blood bank, and no transfusion is given lightly to any patient (or, unless in an emergency, without formal written consent).
Not all Jehovah’s Witnesses feel the same way about transfusion; some may opt to allow some blood products but not others, some may allow us to use certain techniques but not others. And some, when faced with the occasionally harsh and always direct discussion (and paperwork) involved in the refusal of all blood products, find that, in the end, their reservations about transfusions have left them.
But there was one patient I took care of several years ago who was especially worrisome. She was entering her third trimester with a pregnancy that had various complications related to her uterus and placenta that were going to necessitate a cesarean delivery, and quite likely a cesarean hysterectomy.
A cesarean hysterectomy is a difficult and frightening surgery. It’s daunting to try to take out the uterus of a pregnant woman right after a baby has left it: The blood vessels feeding it are bringing one-fifth of her blood volume to it every minute, and new blood vessels have formed in every direction, following no solid anatomical rules, because the pregnancy has strongly requested them since the day it set up shop. During the surgery, you clamp and tie off arteries that are the size of your pinky finger and sometimes your thumb; they bleed, you clamp and tie them again. Ultimately, the surgical saying goes, all bleeding stops. But we’d prefer it to be because we have a successful surgery and not because there’s no blood left.
For this patient, the plan for cesarean hysterectomy was made because, at this time, it was this patient’s only option. However, it is unusual to get through a cesarean hysterectomy safely without a blood transfusion. It was terrifying to me to have to consider not having the option.
There are, of course, multiple techniques that can help minimize the risk. Self-donation of blood is accepted by some Jehovah’s Witness patients; surgical tools that recirculate lost blood back into the patient’s blood stream are another.