Atoosa Benji

June 11, 2018

Evaluation and Management of Rh Factor in Pregnancy

Consideration in the First Trimester

What is Rhesus Factor?

Definition:
Blood is categorized into 4 types: O, A, AB and B. Just as a person has a specific blood type, a
person may have inherited a protein that resides on the surface of the red blood cells in his/her
body. This protein is referred to as Rhesus Factor or Rh. Approximately 83% of humans have
this factor on their red blood cells making them Rh (+), the other 17% or so do not have it,
making them Rh (-). (obi.og).
If both a person’s mother and father are Rh negative, a person will have a 100% chance of also
being Rh negative. If one parent is Rh (+) and the other is Rh (-), there is a 50% chance the
person will be Rh (-).
Diagnosis:
A blood test can determine both a person’s blood type and Rhesus Factor.
In an Rh (-) person, the introduction of Rh (+) blood into the system causes the body to have an
immune response. This becomes particularly relevant during pregnancy when there is a slight
chance that maternal and fetal blood mix. If the fetus has Rh (+) blood, the mother’s body (Rh
negative) will begin to make positive antibodies as the body has now detected a foreign
substance. This immune response is referred to Rh sensitization.
There are other incompatibilities that may also take place. For example, there may be
incompatibilities between ABO blood type. For example, a client with an O blood type may
become sensitized to the baby’s blood type which may be A or B or AB. While this type of
incompatibility may cause complications, most commonly, jaundice in the newborn, within 24
hours of birth- it is Rh incompatibility which is of greater concern to midwives.
This immune response can also occur in the case of an ectopic pregnancy and/or a pregnancy not
carried to term.
*There are antigens other than Anti(D) which may cause hemolytic disease of the fetus and
newborn (HDFN). These include but are not limited to Anti (K), Anti CW, Anti (C) and Anti
(E), When anti-C and anti E are combined, the chance incidence of HDFN rises.
ABO Incompatibility
ABO incompatibility is common and less severe than Rh D incompatibility. Infants at risk are:
*Type A or B babies born to O mothers with type B being more problematic
*B or AB baby born to A
*A or AB baby born to B mother
*Babies from either of these categories who become jaundiced within 24 hours of birth.
In these cases, checking into ABO incompatibility would be prudent.

ABO and Rh typing are also recommended for a person who has:
 Undergone blood transfusion
 Abortion or miscarriage after 38 days gestation
 Invasive procedure such as amniocentesis, external cephalic version
 Slight placental abruptions
 During placental detachment
 A disruption in the villous bed of placenta due to a traumatic blow to the abdomen

A person will not know if he/she is Rh (-) or (+) unless a blood test is done. There are no signs
or symptoms that would indicate a person’s blood type nor Rhesus factor. If a person knows that
both his/her parents were Rh (-), then the probability of Rh negativity is very high in that person.
A blood test would be prudent to confirm blood type and Rh Factor.
Maternal and fetal blood are completely separate during pregnancy. There are situations,
however in which there is an increased chance of cross-over. These include premature
separation of the placenta, intrauterine trauma, placenta previa, and diagnostic tests such as
chorionic villi sampling and amniocentesis. At birth, when the umbilical cord is cut and clamped
there is a chance that fetal and maternal blood will mix. In this situation, the antibodies that the
mother’s body made during the pregnancy against the Rh (+) blood will travel to the baby and
begin attacking the baby’s red blood cells. This is not of concern for the first pregnancy, it is of
concern for subsequent pregnancies where the mother is immunosensitized and the body is ready
to aggressively attach any foreign antigens. This causes a condition called hemolytic anemia
where the baby’s red blood cells are being attacked and destroyed faster than the body can
replace them. This condition can be fatal.
Management Plan for First Trimester
Therapeutic Measures
Blood testing in first trimester is recommended to ascertain Blood Type and Rh factor.
If the pregnancy person is Rh (-) and there is a chance the baby will be Rh (+), your healthcare
provider will recommend drawing blood for an Rh antibody screen- once during the first
trimester and again at the 28-week week of pregnancy.

If a person is Rh (-) there is the option to be given a shot of RhIg- Rh immunoglobulin. RhIg is a
sterilized solution made of human blood. If a person is not yet Rh sensitized, this
immunoglobulin prevents the production of Rh antibodies in the system. This will help in the
prevention of fetal hemolytic anemia later in the pregnancy.
ACOG recommends that RhIg be administered to an Rh (-) mother:
- After an abortion, miscarriage or ectopic pregnancy
- After an amniocentesis or chorionic villi sampling procedure
- At 28 weeks of pregnancy
- Within 72 hours of delivering an Rh-positive baby
If testing shows that the mother is already immunosensitized, the fetus must be closely
monitored. In cases of severe anemia, an induction of labor may be recommended or the baby
will be given a blood transfusion to replace red blood cells.
(www.acog.org)
Follow up Care
Provide evidence informed care to client and provide anticipatory guidance on making a decision
about Rhogam before the 28-week prenatal visit. Allow client to give informed consent.
Complememtery measures:
There are currently no complementary measures for immunosensitiation.
Clinical Considerations
It is important that diligence be exercised in obtaining a full client obstetrical history as well as
determining the mother’s blood type and Rh factor early in care to determine risk of Rh
incompatibility. As mentioned previously, risk to fetus is minimal in the first pregnancies, but
risk of hemolytic anemia in the fetus increases with each subsequent pregnancy.
Shared Decision Making
We will provide you with counseling and education about your treatment options. Handouts will
be provided explaining Rh incompatibility, how RhIgs work and shared decision making will be
utilized to allow client to make the best possible decision for him/herself and baby. All options
will be discussed, including the option of doing nothing at all. Risks and benefits of each option
will be discussed and client will be given the space to make an informed decision.
Our Protocol is to draw blood early in pregnancy and then again in the third trimester to ascertain
antibody production. If you are Rh (-), Rhogam (RhIg) is the best way to ensure your baby’s
health if there is a chance that the baby is Rh (+).
You can decline Rhogam if you wish to, however, in this case we will draw a sample of the cord
blood to ascertain the baby’s blood type. If the baby is Rh (-), no further treatment is needed. If
the baby is Rh (+) we will administer a shot of Rhogam within 72 hours.
The rationale behind our protocol is that we feel it is unethical to routinely administer Rhogam to
a person if there is a chance that the baby is also Rh (-). For many, the decision to use a blood
product is a difficult one. We feel that as care providers, we would be alleviating the weight of
this decision if we make other options available to our clients.
Midwifery care is synonymous with client-centered care. We are here to help you understand
your options and feel that you are making the best decisions for your own care. We are
responsible for your care and the decisions we make. We strive to provide continuity of care and
to practice within our community standards of care.
If we feel we are unable to provide you with the very best care possible, we will recommend
referral to another care provider. Clients are welcome to seek second and third opinions for
decisions pertaining to care. However, where testing of the umbilical cord blood for Rh factor
after delivery is refused by the client, recommendations will be made for referral as care can
respectfully, no longer continuity with Labor with Love Midwifery Services.
 References
Frye, A. (2007). Understanding diagnostic tests in the childbearing year: A holistic approach
(7th ed.). Portland, Or.: Labrys Press.
King, T. L., Brucker, M. C., Fahey, J., Kriebs, J. M., Varney, H., & Varney, H. (2015). Varneys
midwifery. Burlington, MA: Jones & Bartlett Learning.
Scientific Facts: Negative Blood Types. Retrieved December 05, 2017, from https://obi.org/
Sullivan, A., Kean, L. H., & Cryer, A. (2008). Midwifes guide to antenatal investigations.
Edinburgh: Churchill Livingstone/Elsevier.