Rhogam

I'm working on designing an updated informed consent/refusal form for Rhogam. What makes this process much more interesting is that I am now able to apply the info to my own pregnancy. Since I've refused prenatal Rhogam, I suppose this mean I now have to be okay with any future clients refusing it as well. How much info should I include in my form? And really, how do I break this totally confusing topic down so that everyone can understand it?

Here's a start:

Everybody has a blood type (A, B, AB, O) and an Rh factor (positive or negative). During pregnancy, there are three situations in which this knowledge is important, all of them having to do with a mother who is Rh-. (If a mother is Rh+, she and the baby are not adversely affected and she has one less thing to worry about during pregnancy).

Situation 1 - If a pregnant woman is Rh- and the father of the baby is Rh-. In this case, they're good, meaning the mother and baby don't face any risks of possible complications based on the Rh factor, since the baby will also be Rh-.

Situation 2 - If a pregnant woman is Rh- and the father of the baby is Rh+. The baby could be either Rh- or Rh+, depending on the gene the father passes on. If the baby is Rh-, they fall into situation 1. If the baby is Rh+, they fall into situation 3.

Situation 3 - If a pregnant woman is Rh- and the father of the baby is Rh+ and the father passes on the Rh+ gene to the baby. The mother and baby will have different Rh factors and things could get complicated. At the moment, there is not a non-invasive way to check the baby's status before birth, so this is where the discussion about odds and risk happen.

Normally, during pregnancy, the baby's blood and the mother's blood do not mix. If they do, however, and the baby is Rh+ while the mother is Rh-, the mother's immune system will create antibodies that can attack the red blood cells of the baby. Things that could cause the blood to mix include anything that causes trauma to the mother's abdomen, like car accidents, falling down the stairs, being hit, having an amnio, or having a miscarriage. The risk of developing antibodies during pregnancy is 1-2 per 1000.

The immune response is called Rh-sensitization and is a two part process. The first time the blood types mix, the mother's immune system creates antibodies. The second time they mix, the antibodies will attack the baby's red blood cells, decreasing the amount of oxygen the baby's brain receives. The two steps can happen in the same pregnancy but is more likely to happen in different pregnancies, which is why a first baby can be born healthy but later pregnancies may be affected.

If the blood mixes, possible complications to the baby include jaundice (mild to severe), anemia, swelling, heart failure, and death. Some babies may need blood transfusions before or after birth.

The current medical standard is to recommend that all Rh- pregnant women receive a shot of Rhogam at 28 weeks. The thought is that the shot will help prevent antibodies from forming if there is any bleeding or trauma during the last three months of pregnancy. Rhogam (which also goes by other names depending on the country and manufacturer) is a shot that destroys any cells from the baby in the mother's blood before her immune system can make antibodies that will attack them. It is made of plasma from multiple donors and is supposed to act the same way the mother's antibodies would act. Part of the controversy about it is that, if the blood was to mix, the antibodies from Rhogam could still attack the baby's cells, meaning it is not a risk free situation.

I am part of the 15% of the US population who are Rh negative, so this has become quite a personal issue for me during this pregnancy. After loads of research and talks with midwives (and Louis), I decided to decline prenatal Rhogam.

My reasons for refusing prenatal Rhogam (in no real particular order):

* It's a human blood product. It's is probably screened for HIV but there are a whole bunch of other things it's not screened for and I'm not willing to take the chance of infecting the baby and myself with anything foreign.

* Until recently, Rhogam was preserved with thimerosal, which contains mercury. The manufacturer was supposed to have pulled this ingredient out, but I don't have enough faith to believe there aren't still old supplies in use.

* I haven't had any abdominal trauma during my pregnancy and I know my placenta is posterior, further protecting it from any possible hard blows. I don't believe it's very likely for the blood to mix during a normal pregnancy.

* I believe the current medical recommendation to receive prophylactic Rhogam during pregnancy is a money-maker (~$100 a shot) and not based on hard scientific evidence (like many other pregnancy and childbirth related situations) and that pregnant women fall for it because of the fear and emotions involved in supposedly avoiding complications. Literally, I'm not buying it.

* There's just too much controversy around this issue for me to feel confident about it being necessary for my baby's health. One study about autism that I recently came across found that 62% of the kids with autism in the study group had Rh- mothers. Coincidence? Or a result of standard prenatal Rhogam?

* According to research, the majority of any blood mixing occurs during the birth itself. Since I'm planning to avoid standard medical/hospital procedures like immediate cord clamping, rough handling of the placenta, IV pitocin, and even surgical delivery, I feel like my chances of the birth practitioner causing any blood mixing problems are minimal.

After the baby is born, our midwife will collect a small sample of our baby's blood (from the umbilical cord - no needles) and take it to the lab to have the blood type and Rh factor tested right away. If the baby is Rh -, that would be great news. If the baby is Rh+, I think I will request a shot of Rhogam to help prevent against isoimmunization in any future pregnancies. This is how Rhogam was originally intended to be used. I feel it would give me a safe combo of lowering my risk as much as possible, while keeping the baby safe from whatever chemicals and side effects it could receive from prenatal Rhogam.

The stats are that without any Rhogam, there is a 10-16% chance of sensitization. With a shot of Rhogam after birth, there is a 2% chance. With both prenatal and postpartum Rhogam, there is a 0.1-0.2% chance of sensitization. By taking only the postpartum shot (and only if the baby is Rh+), I'm increasing my risk by 0.8-0.9% while keeping the controversial prenatal Rhogam away from the baby. I can live with that. I feel at peace about my informed refusal of prenatal Rhogam.