Obstetric Haemorrhage
As an obstetrician and gynaecologist, one of my duties is to undertake emergency and elective Cesarean Sections (CS). A Cesarean Section is the delivery of a baby via an abdominal incision.
Because it is one of the most performed obstetric surgeries it often gives the impression of being ‘simple’. It is, like all surgeries, a fairly dangerous operation. Setting it apart from other surgeries a CS has the potential of bleeding out a patient. I have done cesarean sections for 25 years now. But every time I scrub in for a cesarean section I start with a prayer. Many are straight forward and relatively smooth. But there are those that makes the whole theatre team sweat. Some are deadly. Cesarean sections should thus be done by highly qualified personnel in an environment that can assure safety should complications occur. Of note is even the routine normal delivery can quickly turn into a haemorrhagic nightmare. The EMOTIVE bundle of managing Post Partum Haemorrhage (PPH) is being taught more and more. BUT Blood products remain key in the management of Obstetric Haemorrhage.
Blood donors for elective cesarean sections
I had deviated. I was talking about blood. When mothers who are due for an elective Cesarean Section, various hospitals now ask them to sort from their community two persons who would serve as blood donors several days or weeks before their surgery. This is to ensure that blood banks across the country are replenished should that blood is available when needed. One of the biggest demands for blood is hemorrhage associated with pregnancy. Availability of blood and blood products is often the determinant between life and death.
Kenya’s Blood Transfusion Service
So, how does the blood transfusion service work in Kenya. I had a discussion with Dr Evelynn Chege and she offered insights into the National Blood Transfusion Service, how it works and how it should be improved.
Part 1. Looking for eligible donors
As mentioned above blood can be donated at health facilities. Blood drives can also be conducted in schools for instance. Blood drives can also be done on special days like Valentines Day. A questionnaire is administered to a potential donor for screening purposes. The questionnaire has questions that can be used to exclude donors. If patients are pregnant for instance, they cannot donate. If clients have anaemia due to heavy menses, they are excluded. If clients are HIV reactive. Once a questionnaire allows one to donate the eligible donor moves to the next phase, blood donation.
Part 2. Blood donation
Blood donation can happen in one single bag or in an automated way. Automated is the best way. Components are prepared not in the manual method, because there are a lot of antibodies passing by. The red cells in a fresh frozen plasma. You do not want red cells passing because there will be a lot of haemolysis happening as well. The way forward is actual automation of that process. Zambia have done it. They are 100%. Uganda is phasing out all their manuals. They are going the automated way. South Africa is 100% automated. The question is thus why is Kenya not automated? Automation is more expensive in the short run, but in the long run it creates better quality. The kits are also more expensive. For aphaeretic platelets, one kit is KES 35,000 to prepare like 4 units automatically, an equivalent of 8 manual platelets packs. So, automation would save half the costs.
Part 3. Testing
Once the eligible donor has been identified and the components have been prepared testing needs to be done to ensure that the blood products are safe. Kenya is still doing the four TTIs i.e. HIV 1 AND 2, HBV, HCV, Syphilis. The world moved to add CMV testingespecially because we are doing more transplants in the country. This is also important for our Sickle Cell patients who receive multiple transfusions that means they become allo-immunized. When you become allo-immunized your chances of rejecting or having a blood transfusion reaction are high. You need to map out the donor for them, the one that will have less antibodies so that when you transfuse them, they do not react to that blood. Kenya needs to add testing for CMV, Malaria, Chikungunya and Dengue, especially what we see in coast.
Part 4. Storage of blood products
Kenya does not have enough storage for blood and blood products. There is need to expand the freezers, fridges and Platelet agitators. Blood and blood products must be store in the Regional Blood Transfusion Centres (RBTCs) and transfusion satellites. So, if we only store everything in the RBTCs, satellite transfusion centres suffer. Murang’a County for instance gets platelets from Embu RBTC. If there is no platelet agitator in Murang’a Hospital, those platelets will all clump and they will be useless. So, they the transfusing facility laboratory or where blood is kept before being transfused, requires to be equipped with extra items to avoid wastage of blood products.
Part 5. Blood donations
There is a need to invest in donor incentives such as T-shirts, soda and wrist bands etc. In South Africa for instance blood donor incentives include aprons for cooking, torches, coffee mugs, all branded with the blood transfusion logo. This incentivizes donors who volunteer without being called. Every 3 months (men) or 4 months (women) they volunteer at the nearest blood donation site. In Kenya we have few donation sites and thus we do a lot of mobile donations. Blood donation drives thus require fuel, biscuits, personnel, functional, well-maintained vehicles with drivers, etc.
Call for Action
The blood service in Kenya thus needs a strengthening in all the components described above. There is need to instill a blood donation culture among the population and need to establish more blood donation sites. There is need to push for automation of blood transfusion services. With the exit of donor support for BTS parliament needs to appropriate more funding for healthcare, some of which will be used for the blood transfusion services.
Dr Evelynn Chege is a pathologist, Head Of Technical Services at Kenya Tissue Transplant Authority
Dr Simon Kigondu is an Obstetrician Gynaecologist and the President of Kenya Medical Association.