Transfusion – Antenatal Serology —
Training activity: 3

Details

Identify samples requiring maternal/paternal/fetal typing and recommend appropriate referral

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Considerations

• Maternal and paternal phenotyping
• Appropriate referral to fetal genotyping
• Fetal genotyping algorithm and how this informs referral
• Different referral reasons
• Genotyping for sensitised vs non sensitised women and
• Principles of cell free fetal (cff) DNA testing and impact on anti-D prophylaxis

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

What does success look like?

• Identify what is expected of you in relation to identifying samples for typing and recommending appropriate referral.
• Review learning outcomes which concern investigation, risk prediction, and advising healthcare professionals.
• What specific criteria define when maternal, paternal, or foetal typing is required, and what constitutes an appropriate referral recommendation?
• What are the expected outcomes of correctly identifying the need for typing and facilitating referral for further investigation or management?
• Discuss with your training officer to clarify the common scenarios requiring typing and referral pathways.

What is your prior experience of this activity?

• Think about what you already know about the genetic basis of red cell antigens and their inheritance.
• What factors, such as the specificity and titre/quantification of a maternal antibody, might indicate the need for paternal or foetal typing?
• Consider possible challenges you might face in identifying the need for typing, such as:
  • Rare antibodies
  • Potential zygosity issues
  • Recommending referral when clinical information is unclear

Think about how you might handle these.

• Recognise the scope of your own practice for this activity, meaning knowing when you would need to seek advice regarding complex typing scenarios or when discussing referral options with clinical teams.
• Acknowledge how you feel about this activity, which involves applying genetic principles and interacting with clinical teams.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop in interpreting maternal antibody findings in the context of potential paternal/foetal antigen status.
• Identify the specific insights you hope to gain into the clinical significance of identifying foetal risk factors (e.g., through cffDNA testing) and the process of referral to specialised services.

What additional considerations do you need to make?

• Consult actions identified following previous experience with antibody investigations or interpreting antibody significance.
• Identify important information you need to consider before embarking on the activity, such as the current guidelines for paternal/foetal typing, the availability of testing methods like cffDNA analysis, and the standard referral pathways in your institution.

In action

• Are you noticing anything surprising or different from what you anticipate whilst identifying samples requiring typing and recommending referral?
• Are you encountering situations such as:
  • Incomplete family information or the unavailability of samples complicating the assessment of genetic risk
  • A rare antibody specificity where the criteria for requiring paternal or foetal typing are not immediately clear from standard protocols
  • Ambiguity in case details e.g., concerning zygosity issues, requiring immediate analysis before referral

How are you reacting to the unexpected development?

• How is this impacting your actions? Did you adapt or change your approach to assessment and referral recommendation process in the moment?
• Consider the steps you are taking in the moment, such as:
  • Immediately reviewing the criteria for paternal or foetal typing in light of the antibody’s specificity and concentration
  • Making a real-time decision on the appropriate referral pathway e.g., to a specialist centre for cffDNA testing despite limited information
  • Thinking about who could provide guidance on the correct referral pathway for a non-standard scenario
• How are you feeling in that moment? For instance, are you finding it difficult to apply genetic principles to the serological findings? Is it affecting your confidence in justifying the recommended referral?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully applying current guidelines to identify the need for typing, or needing support when communicating recommendations for complex typing scenarios?
• What are you learning as a result of the unexpected development? For example, are you gaining a crucial insight into the clinical significance of identifying foetal risk factors or mastering the process of referral to specialised services?

On action

What happened?

• Begin by summarising the key points of the experience of identifying cases requiring red cell typing (maternal, paternal, or foetal) and recommending referral. What criteria did you use to determine the need for typing and referral?
• Consider specific events, actions, or interactions which felt important, such as moments where deciding on the appropriate typing or referral pathway felt complex. Acknowledge how you felt during these moments.
• Include any ‘reflect-in-action’ moments where you adapted to the situation as it unfolded. For instance, describe when new information e.g., confirmation of paternal phenotype led you to immediately adjust your typing or referral recommendation.

How has this experience contributed to your developing practice?

• Identify what learning you can take from this experience regarding the indications for maternal, paternal, or foetal red cell typing and the appropriate referral pathways. What skills in applying complex algorithms and communicating referral needs did you develop? Were there knowledge gaps about specific typing techniques (e.g., cffDNA testing) or referral criteria?
• Compare this experience against previous engagement with similar activities. Has your understanding of when and how to initiate typing and referral improved?
• Identify any challenges you experienced e.g., difficulty obtaining paternal sample/information, navigating referral processes and how you reacted to these. Were you able to overcome the challenges?
• Did you need to seek advice or clarification regarding the need for typing or the referral procedure? Did you ensure your recommendations were within your scope of practice?
• Acknowledge any changes in your own feelings now you are looking back on the experience regarding your confidence in identifying cases requiring typing and referral.

What will you take from the experience moving forward?

• Identify the actions or ‘next steps’ you will now take to support the assimilation of what you have learnt. For example, identifying specific areas related to red cell typing or referral processes that you need to study further e.g., cffDNA testing, complex antibody scenarios.
• How will this experience change your approach to reviewing cases for potential typing or referral needs?
• Do you need to practise any aspect of the activity further, such as evaluating patient information to inform these decisions or communicating with referral laboratories?

Beyond action

Have you revisited the experiences?

• Reflecting on your prior experiences identifying samples for and recommending maternal/paternal/foetal typing and referral, what specific areas did you aim to improve based on past reflections e.g., criteria for testing, referral pathways, understanding different typing methods? Have you successfully integrated these improvements into your practice?
• Are you now more confident and proficient in recognising when the typing and referrals are required?
• Have you engaged in professional storytelling or shared experiences of cases requiring such typing or discussed the rationale for referral with peers or senior staff? Did these discussions offer new perspectives on the key indicators for typing or the referral process?

How have these experiences impacted upon current practice?

• How does the knowledge and skill gained from repeatedly identifying samples for typing and recommending referral, supported by reflection, help you prepare for clinical experiences that might involve understanding maternal, paternal, or foetal requirements or attending a foetal medicine unit clinic?
• How has your ability to recognise the indicators for maternal/paternal/foetal typing and effectively manage the referral process evolved over time? Are you more adept at applying guidelines to determine the need for typing?
• How clear are you now on the boundaries of your scope of practice when identifying the need for complex typing or referral?

Relevant learning outcomes

#	Outcome
# 1	Outcome Practice in accordance with antenatal serology standards and guidelines.
# 2	Outcome Perform acceptance testing of samples requiring antenatal investigation.
# 3	Outcome Perform and interpret clinical and laboratory investigations to identify cases of haemolytic disease of the fetus or newborn (HDFN).
# 4	Outcome Identify sequential testing algorithms appropriate to the samples under investigation for HDFN.
# 5	Outcome Predict current and future pregnancies at highest risk of HDFN.
# 6	Outcome Identify and advise healthcare professionals on appropriate actions to manage HDFN.