Visual Estimation Of Blood Loss Research Articles

Concordance Between Actual and Estimated Blood Loss: A Bleeding Calculation Simulation Exercise

Introduction: Historically, visual estimation of blood loss during and after delivery has been the primary method for determining obstetric blood loss. This method is quick, easy, and cost-free, and it allows for the prompt identification of suspected postpartum hemorrhage. However, the majority of clinical studies concur that this method is imprecise and may underestimate the extent of bleeding produced during vaginal delivery. Objectives: The objective of this study was to compare the concordance between the estimated blood loss observed visually by physicians and residents of Gynecology and Obstetrics and the actual bleeding observed in a simulation exercise, with the aim of calculating the bleeding. terial and methods: A quasi-experimental study was conducted through the use of a simulation model at the General Hospital of Zone 20 of the IMSS in Puebla. A visual estimation was conducted between physicians and residents using surgical material (compresses and gauze) with a certain amount of blood. The evaluation of the estimate was carried out in three stations with different bleeding levels. The estimation of total bleeding was counted in milliliters using the visual method. A comparison of means was conducted using the ANOVA statistical test to evaluate the bleeding calculation. The relative error was calculated in order to determine the extent of agreement between the estimated and actual blood values for each station. Results: A total of 94 physicians, including residents in training in the specialty of Gynecology and Obstetrics, enrolled in the study. The discrepancy between the actual and estimated blood loss in a simulation exercise among affiliated obstetrician-gynecologists was 65.3%, while in the group of resident physicians it was 145.6%. It was determined that there was an 84% overestimation of bleeding. The relative error percentage for "Scenario A" was 141%, "Scenario C" yielded a result of 85%, and "Scenario B" produced a result of 74%. Conclusion: The agreement between the actual and estimated blood loss performed by obstetrician-gynecologists assigned to a bleeding calculation simulation exercise is slightly superior to that obtained by resident physicians. The lowest percentages of relative error were obtained by fourth- and third-year residents.

Quantitative blood loss measurement methods for early detection of primary postpartum haemorrhage following vaginal birth: A scoping review.

To map the commonly used quantitative blood loss measurement methods in clinical practice and provide a solid foundation for future studies. This study adhered to the JBI methodology for scoping reviews and preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews. We conducted a literature search using five databases to retrieve articles published between January 2012 and September 2022. The search was repeated on 29 February 2024. Data extraction and verification were carried out by two independent researchers using a self-designed data extraction form. Ultimately, 26 studies published between 2012 and 2024 were considered eligible for inclusion. Six categories of methods were identified from the 26 articles. Among the included studies, only two involved randomized controlled trials, with the majority being observational studies. The World Health Organization (2012) version of the postpartum haemorrhage diagnostic criteria was predominantly used in most studies. Gravimetric and volumetric methods emerged as the most commonly used methods for quantifying postpartum haemorrhages. The timing of blood collection was inconsistent among the included studies. Only 12 studies mentioned measures for the management of amniotic fluid. This scoping review supports the replacement of the visual estimation of blood loss with quantitative assessment methods. Supporting a specific assessment approach is not feasible due to the variability of the study. Future research should focus on establishing the best practices for specific quantitative methods to standardize the management of postpartum haemorrhage and reduce the incidence of postpartum haemorrhage-related adverse outcomes. Healthcare professionals need to acknowledge the low accuracy of visual estimation methods and implement quantitative methods to assess postpartum blood loss. Given the limitations inherent in each assessment method, quantification of blood loss should be combined with assessment of maternal vital signs, physiologic indicators and other factors.

The Role Anesthesiologist in Management of Obstetric Haemorrhage: A Literature Review

Hemorrhagic shock in obstetrics is still a major cause of maternal mortality and morbidity worldwide. Recognition of bleeding in obstetric patients is complicated by the normal physiologic changes that occur during pregnancy. Visual estimates of blood loss are often erroneous and underestimated because of contamination with amniotic fluid, or internal or hidden blood loss. Thus, careful clinical observation and a high index of suspicion are required for the early detection and management of obstetric hemorrhage. The usage of ultrasound (US) is considered as the first line method for detecting abnormal condition which might serve as a predictor for hemorrhagic shock. Despite of careful risk assessment given, obstetric-specific bleeding protocols, such as resuscitation and blood transfusion, are required to facilitate the integration and timely escalation interventions. The intervention of choice for hemorrhagic shock in obstetrics encompasses a wide variety of options, such as the usage of tranexamic acid, cell salvage, resuscitative endovascular balloon occlusion of the aorta (REBOA), anesthetic management, and surgical, as well as radiological provides multiple available approach, each with their own risk and advantages. The purpose of this review is to describe the management of obstetric hemorrhage from anesthetic point of view, encompassing the identification of patients at risk, resuscitative management, and perioperative management.

Randomized Trial of Early Detection and Treatment of Postpartum Hemorrhage

(N Engl J Med. 2023;389:11–21) Postpartum hemorrhage (PPH) remains the leading cause of maternal death worldwide despite published recommendations from the World Health Organization (WHO) on prevention and treatment. There are challenges in implementing the PPH recommendations. Delay in detection as well as delay in treatment of PPH are 2 reasons the maternal death rate is high. One reason for the delay in detection is due to the ongoing use of visual estimation of blood loss, which often inaccurately underestimates the amount of lost blood. More aggressive interventions for PPH may be delayed until earlier approaches have failed in stopping the blood loss. In some cases, no effective treatment is administered at all. Finally, although the WHO has given these recommendations, not all hospitals and/or medical professionals are implementing them. This study sought to understand whether a treatment bundle referred to as E-MOTIVE could improve early detection and treatment of PPH in patients with a vaginal birth.

Development and evaluation of a wearable peripheral vascular compensation sensor in a swine model of hemorrhage.

Postpartum hemorrhage (PPH) is the leading and most preventable cause of maternal mortality, particularly in low-resource settings. PPH is currently diagnosed through visual estimation of blood loss or monitoring of vital signs. Visual assessment routinely underestimates blood loss beyond the point of pharmaceutical intervention. Quantitative monitoring of hemorrhage-induced compensatory processes, such as the constriction of peripheral vessels, may provide an early alert for PPH. To this end, we developed a low-cost, wearable optical device that continuously monitors peripheral perfusion via laser speckle flow index (LSFI) to detect hemorrhage-induced peripheral vasoconstriction. The measured LSFI signal produced a linear response in phantom models and a strong correlation coefficient with blood loss averaged across subjects (>0.9) in a large animal model, with superior performance to vital sign metrics.

P25 Assessing accuracy of visual estimation of blood loss during simulated postpartum haemorrhage scenarios

P25 Assessing accuracy of visual estimation of blood loss during simulated postpartum haemorrhage scenarios

Visual estimation of blood loss versus quantitative blood loss for maternal outcomes related to obstetrical hemorrhage

Background This study was undertaken to evaluate if there are differences between visual estimation of blood loss (EBL) and quantitative blood loss (QBL) for maternal outcomes related to obstetrical hemorrhage. Methods This retrospective study compared EBL (n = 500) to QBL (n = 501) for outcomes of length of stay, readmission within 30 days of discharge, percent receiving blood transfusions, time between delivery to receiving blood transfusion, and postpartum hemoglobin level. Results The QBL group had a significantly lower mean length of stay than the EBL group (2.6 vs 3.2 days, P < 0.001). Multivariate linear regression analysis adjusting for relevant covariates had a similar finding of lower length of stay for QBL vs EBL (B = −0.13, SE = 0.01, P < 0.001). Readmission within 30 days, blood transfusion, time to transfusion since delivery, and postpartum hemoglobin did not significantly differ between the QBL and EBL groups. Conclusion We recommend that clinicians adopt QBL over EBL as standard practice since QBL is associated with lower length of stay and does not negatively impact other clinical outcomes.

Visual estimation of blood loss on swabs by surgeons and anaesthetists in KwaZulu-Natal: an online survey study

Visual estimation of blood loss on swabs by surgeons and anaesthetists in KwaZulu-Natal: an online survey study

Detection and management of postpartum haemorrhage: Qualitative evidence on healthcare providers' knowledge and practices in Kenya, Nigeria, and South Africa.

Postpartum haemorrhage (PPH) is the leading cause of maternal death globally. Most PPH deaths can be avoided with timely detection and management; however, critical challenges persist. A multi-country cluster-randomised trial (E-MOTIVE) will introduce a clinical care bundle for early detection and first-response PPH management in hospital settings. This formative qualitative study aimed to explore healthcare providers' knowledge and practices of PPH detection and management after vaginal birth, to inform design and implementation of E-MOTIVE. Between July 2020-June 2021, semi-structured qualitative interviews were conducted with 45 maternity healthcare providers (midwives, nurses, doctors, managers) of nine hospitals in Kenya, Nigeria, and South Africa. A thematic analysis approach was used. Four key themes were identified, which varied across contexts: in-service training on emergency obstetric care; limited knowledge about PPH; current approaches to PPH detection; and current PPH management and associated challenges. PPH was recognised as an emergency but understanding of PPH varied. Early PPH detection was limited by the subjective nature of visual estimation of blood loss. Lack of expertise on PPH detection and using visual estimation can result in delays in initiation of PPH management. Shortages of trained staff and essential resources, and late inter-hospital referrals were common barriers to PPH management. There are critical needs to address context-specific barriers to early and timely detection and management of PPH in hospital settings. These findings will be used to develop evidence-informed implementation strategies, such as improved in-service training, and objective measurement of blood loss, which are key components of the E-MOTIVE trial (Trial registration: ClinicalTrials.gov: NCT04341662).

Impact of measuring quantification of blood loss versus estimation of blood loss during cesarean deliveries.

Our objective was to determine whether there is a numerical difference between quantitative blood loss (QBL) versus visual estimation of blood loss (EBL) during cesarean delivery (CD), and whether initiation of QBL leads to increased recognition and intervention for postpartum hemorrhage. A retrospective review was conducted of 250 patients undergoing CD with only EBL documented and 250 patients undergoing CD with both EBL and QBL documented at Montefiore Medical Center between October 2017 and November 2018. Since May 2018, the protocol for all CD included documentation of EBL and QBL. Average EBL when documented alone (897.0ml ± 301.0ml) trended lower than average EBL when documented with QBL (940.0ml ± 371.0ml, P=0.161). For CD with both blood loss documented, average EBL (940.0ml ± 371.0ml) was significantly lower than average QBL (1065.3ml ± 649.8ml, P=0.0001). CD with both blood loss documented had a greater number of blood transfusions (24 CD, 9.6%) versus only EBL documented (14 CD, 5.6%) (P=0.125). The use of QBL may function in the algorithm to determine up-front resuscitative intervention to improve maternal outcomes and merits further study.

Comparing Postpartum Estimated and Quantified Blood Loss Among Racial Groups: An Observational Study.

Objective: Racial and ethnic disparities in peripartum blood loss and postpartum hemorrhage (PPH) have not been adequately evaluated. We sought to compare postpartum blood loss and PPH in African American and Hispanic parturients compared to other groups.Methods: This was a secondary analysis of an observational study at a tertiary academic center of a historical (August 2016 to January 2017) and interventional (August 2017 to January 2018) cohort of 7618 deliveries. Visual estimation of blood loss (EBL) was used in the historical group and quantitative blood loss (QBL) was implemented in the intervention group. Our primary endpoint was median blood loss in African Americans versus other racial groups between cohorts.Results: A total of 7618 deliveries were evaluated; 755 (9.9%) were identified as African American with 1035 (13.6%) identifying as Hispanic. Blood loss was similar in racial groups using EBL (p=0.131), but not QBL that was 430 (227-771) in African Americans and 348 (200-612) in non-African Americans (p<0.001). PPH was greater among African Americans in both groups (10.3% vs. 6.9% in EBL cohort, p=0.023, and 16.9% vs. 11.6% in QBL cohort, p<0.001).Conclusion: Racial and ethnic differences in peripartum blood loss were more apparent with QBL than EBL. It is unknown if these differences are caused by provider cognitive bias, socioeconomic differences, language barriers and/or other factors.

Estimating blood loss during cesarean delivery: A comparison of methods

ObjectivesObstetrical hemorrhage contributes significantly to maternal morbidity and mortality. Assessment of blood loss while undergoing cesarean sections (CS) is essential in lowering the morbidity and mortality, however this amount is commonly underestimated by the surgeon and probably the anesthetist too. MethodsThis study addresses this issue by comparing three separate ways of assessing blood loss during cesarean sections. For each of 97 full-term pregnant women undergoing elective CS, blood loss was measured by the following: visual estimation by both the obstetrician and the anesthetist, weighing surgical pads pre operatively and post operatively and by calculations (multiplying the difference of pre-operative and postoperative hemoglobin values by the patient's estimated blood volume). ResultsThe results of this study indicated that the lowest estimated value for blood loss came from visual estimation, while the highest value came from the mathematical formula. Anesthetists were more accurate in their visual estimation of blood loss than were obstetricians. ConclusionThis study found the amount of blood loss during CS to be overestimated by the mathematical calculation and underestimated by obstetricians. However, the estimate given by anesthetists was close to that obtained by weighing pads. This underscores the need for more accurate methods of blood loss estimation in cesarean sections to be adopted.

Accuracy of visual estimation of blood loss in obstetrics using clinical reconstructions: an observational simulation cohort study

IntroductionPostpartum hemorrhage is the leading cause of maternal mortality worldwide, and optimal management requires accurate blood loss estimations. The aim of this study was to assess whether differences exist between visually estimated blood loss vs. actual blood loss based on delivery mode, blood volume or distribution/location and knowledge of patient’s current cardiovascular status. MethodsFor this observational cohort study, photographs were taken of 18 blood loss scenarios for vaginal delivery and cesarean delivery, and six photographs were duplicated and annotated with maternal vital signs. Scenarios were categorized into 50% (500 mL), 100% (1000 mL) and 200% (2000 mL) of the defined blood loss volume for postpartum hemorrhage and the photographs were shown to participants to visually estimate blood loss volumes. ResultsThe mean ± standard deviation estimates of actual 500 mL, 1000 mL and 2000 mL blood loss volumes were 1208 ± 438 mL, 1676 ± 630 mL and 2637 ± 1123 mL, respectively (P <0.001 among groups). The difference was significantly greater in vaginal delivery than cesarean delivery scenarios (1064 ± 849 mL vs. 284 ± 456 mL; P <0.001). Estimated blood loss volume was not influenced by blood loss distribution/location, or by provider group or experience. The cardiovascular status of the patient impacted estimations only if tachycardia and hypotension were present. ConclusionsMost providers significantly overestimated blood loss volumes (by nearly 700 mL). Provider and scenario factors that impact inaccuracies in visual estimated blood loss identified in this study can be used to guide education and training.

Risk factors for postpartum haemorrhage in the Northern Province of Rwanda: A case control study.

Postpartum haemorrhage (PPH) remains a major global burden contributing to high maternal mortality and morbidity rates. Assessment of PPH risk factors should be undertaken during antenatal, intrapartum and postpartum periods for timely prevention of maternal morbidity and mortality associated with PPH. The aim of this study is to investigate and model risk factors for primary PPH in Rwanda. We conducted an observational case-control study of 430 (108 cases: 322 controls) pregnant women with gestational age of 32 weeks and above who gave birth in five selected health facilities of Rwanda between January and June 2020. By visual estimation of blood loss, cases of Primary PPH were women who changed the blood-soaked vaginal pads 2 times or more within the first hour after birth, or women requiring a blood transfusion for excessive bleeding after birth. Controls were randomly selected from all deliveries without primary PPH from the same source population. Poisson regression, a generalized linear model with a log link and a Poisson distribution was used to estimate the risk ratio of factors associated with PPH. The overall prevalence of primary PPH was 25.2%. Our findings for the following risk factors were: antepartum haemorrhage (RR 3.36, 95% CI 1.80-6.26, P<0.001); multiple pregnancy (RR 1.83; 95% CI 1.11-3.01, P = 0.02) and haemoglobin level <11 gr/dL (RR 1.51, 95% CI 1.00-2.30, P = 0.05). During the intrapartum and immediate postpartum period, the main causes of primary PPH were: uterine atony (RR 6.70, 95% CI 4.78-9.38, P<0.001), retained tissues (RR 4.32, 95% CI 2.87-6.51, P<0.001); and lacerations of genital organs after birth (RR 2.14, 95% CI 1.49-3.09, P<0.001). Coagulopathy was not prevalent in primary PPH. Based on our findings, uterine atony remains the foremost cause of primary PPH. As well as other established risk factors for PPH, antepartum haemorrhage and intra uterine fetal death should be included as risk factors in the development and validation of prediction models for PPH. Large scale studies are needed to investigate further potential PPH risk factors.

Factors Associated with Postpartum Haemorrhage amongst Primigravidae Women; the Case of Two Hospitals within the Bamenda Health District

Background: Approximately 830 women die from pregnancy-related conditions daily with 99% of these maternal deaths occurring in low resource countries. Primary postpartum haemorrhage (PPH) accounts for 25.7% of maternal deaths in Africa. In Cameroon, postpartum hemorrhage remains the leading cause of maternal death, with little information on the primigravidae population compared to multigravida or multiparity. Objective: The aim of this study was to assess the factors associated with postpartum haemorrhage amongst primigravidae women giving birth in two hospitals within the Bamenda Health District. Methods: This study was a multicentric, non-randomized cross-sectional descriptive and analytic study. Of the 221 women interviewed regarding their willingness to participate in the study, 197 consented. Quantification of blood loss was done by visual estimate and with the assistance of the pathfinder international wall chart for visual estimation of blood loss. Data was collected using a structured questionnaire and analyzed using SPSS version 23. A P-value of sidered statistically significant. Results: The prevalence of postpartum hemorrhage in primigravidae was 7.1%. The risk factors of postpartum hemorrhage were: induction of labour (P-value (P-value macrosomia (P-value ny and obstetrical lacerations (P value Conclusion: The prevalence of postpartum hemorrhage amongst primigravidae was high. The main causes of post-partum hemorrhage were uterine atony and obstetric lacerations. PPH was associated with uterine hypotonia, retained products and genital lacerations. No maternal mortality was recorded. These findings highlight the pressing need for good quality em ergency obstetric care and the availability of more accurate techniques of postpartum blood loss measurement. Secondly, hospitals need blood banks to manage patients with severe hemorrhage.

Multidisciplinary Programed Learning Simulation to Improve Visual Blood Loss Estimation for Obstetric Trauma Scenarios.

Introduction: We designed and implemented a Programmed Learning Simulation (PLS) exercise depicting obstetric scenarios of hemorrhage to train anesthesiologists, ancillary staff, and surgeons to accurately estimate blood loss visually. We then measured the efficacy of this exercise in a clinical setting. Methods: We conducted a prospective study to assess the effect of implementing a PLS exercise on quantification of blood loss in an operative setting. The PLS exercise consisted of 13 simulation stations of varying quantities of simulated blood loss paired with standardized objects of known volume. Eighty-eight individuals participated including attending physicians, residents, medical students, and ancillary staff participated in this study. The PLS was part of regularly scheduled continuing medical education activities; thus, the sampling used was non-randomized convenience method. The percent error was calculated for each of the 13 stations. A subgroup analysis was performed to assess the effect of the years of experience, size of hemorrhage, and occupation on accuracy. Univariate analyses for continuous variables were compared using a one-way ANOVA test. For the comparison of the three groups (years of experience and size of hemorrhage), a p-value of <0.02 was considered statistically significant and for 5-way comparison (professional grouping) a p <0.01 was considered significant after application of the Bonferroni correction (α=0.05). (Part A). To determine the effect of PLS in a clinical setting, the percent error of blood loss estimation for cesarean deliveries during the two-month period after the PLS exercise was compared to the two-month period immediately prior to using the student’s t-test with p<0.05 as significant (Part B). Statistical analysis was performed using International Business Machine, Statistical Package for the Social Sciences, Version 26.0 (IBM SPSS). Results: During Part A, the baseline performance of the participants was evaluated during the PLS activity. The PLS data showed no significant difference in absolute value of mean percent error estimation (standard deviation) across professions: student 63.61% (69.74), ob/gyn 56.91% (47.72), ancillary 62.15% (77.90), general/trauma surgeon 66.70% (65.06), anesthesia 61.51% (63.12). (p = 0.681), or levels of experience 0-5: 62.21% (60.06), 6-10 years: 56.22% (52.66), greater than 10 years: 61.89% (71.89) (p = 0.831). However, mean percent error of estimation was higher when participants estimated smaller samples 77.7% (104.73) compared to either medium 56.8% (49.06) or large 57.9% (46.19) samples (p<0.001). For Part B, 179 cesarean deliveries occurred during the pre-intervention period and 193 occurred during the post-intervention period. Mean error in provider estimation of blood loss significantly improved from 47% (68.51) pre-intervention to 31% (32.70) post-intervention (p=0.009). Conclusion: We believe our described PLS activity was effective in teaching techniques for visual blood loss estimation. This was reflected by improved competency in a clinical setting, demonstrated by more accurate visually estimated blood loss during the period immediately following simulation activity compared to a prior time frame. Further research is needed to assess the impact of simulation activities on patient outcomes, such as utilization of blood products and patient morbidity.

Effectiveness of a training workshop in improving the accuracy of visual estimation of blood loss at delivery

Objectives: To explore the effectiveness of training healthcare workers in improving visual estimation of blood loss at delivery with evidence from a low resource setting. Methods: A training programme customized with local instruments used at childbirth was conducted at De Zoysa Hospital for Women in year 2019 for all categories of healthcare workers involved with obstetric care. Capacity of healthcare workers to accurately estimate blood loss was assessed before and after the training programme using simulated case scenarios with known volumes of blood. Statistical significance of the difference in pre- and posttraining scores were evaluated using related samples Wilcoxon Signed Ranked Test and the association between scores and category of healthcare workers, place of work, and duration of work experience were evaluated using independent samples median test and Spearman correlation. Results: This programme included voluntary participation of 81 healthcare workers. Median (IQR) of pre-training and post-training scores were 0.00 (0.00-20.00) and 40.00 (40.00-80.00), respectively. The post-training improvement was statistically significant across all healthcare workers categories irrespective of place of work and their work experience. Conclusions: Short term improvement in accuracy of visual estimation of blood loss by healthcare workers involved in obstetric care can be achieved by customized training irrespective of their place of work and work experience. Further research is needed to assess long term effects of training and the impact on patient outcomes in real clinical settings.

Retrospective Review of Time to Uterotonic Administration and Maternal Outcomes After Postpartum Hemorrhage

ObjectiveDespite advances in health care and ample resources, post-partum hemorrhage (PPH) rates are increasing in high income countries. Although guidelines recommend therapeutic uterotonics, timing of administration is open to judgement and most often based on (inherently inaccurate) visual estimates of blood loss. With severe hemorrhage, every minute of delay can have significant consequences. Our objective was to examine the timing of uterotonic administration and its impact upon maternal outcomes. We hypothesized that increased time to uterotonic administration following the identification of PPH would be associated with a greater decline in hemoglobin (Hb) and higher odds of hypotension and transfusion. MethodsWe reviewed all cases of PPH that occurred at an academic centre between June 2015 and September 2017. All cases of primary PPH (i.e., those declared within 24 h of delivery with estimated blood loss [EBL] >500 mL for vaginal and >1000 mL for cesarean deliveries) were analyzed. Patient records were excluded if they were missing information regarding time of PPH declaration, uterotonic administration, and/or Hb measures, or if a pre-existing medical condition could have contributed to PPH. ResultsOf 4397 births, there were 259 (5.9%) cases of primary PPH, of which 128 were included in this analysis. For these patients, each 5-minute delay in uterotonic treatment was associated with 26% higher odds of hypotension following delivery of any type. For vaginal deliveries (n = 86), each 5-minute delay was associated with 31% and 34% higher odds of hypotension and transfusion, respectively. ConclusionIn this study, delay in administration of therapeutic uterotonics was associated with a higher incidence of hypotension and transfusion in primary PPH patients.

Understanding How Health Providers Identify Women with Postpartum Hemorrhage: A Qualitative Study.

To identify how health providers recognize postpartum hemorrhage early and the difficulties involved in it. An exploratory, descriptive study using a qualitative approach through a semi-structured interview technique. In total, 27 health professionals (nursing technicians, nurses, medical residents in Gynecology and Obstetrics, hired medical doctors, and medicine professors) working in a tertiary-level hospital of reference in women's health care in the State of São Paulo, Brazil, participated in the study through an invitation. After they accepted the invitation, they signed the free and informed consent form. All interviews were recorded and transcribed, and a thematic analysis was conducted. We found three analysis categories: a) perception of the severity: "there is something wrong with the women"; b) difficulties in the early diagnosis of postpartum hemorrhage; and c) the process to improve obstetrical care. Caregivers believe teamwork and communication should be improved. Besides the visual estimation of blood loss, the nursing team is attentive to behavioral symptoms like irritability, while the medical staff follow protocols and look for objective signs, such as altered vital signs. Besides the objective evaluations, the subjective perceptions of the providers are involved in the clinical judgement regarding the diagnosis of postpartum hemorrhage, and this should be included in a broader diagnosis strategy.

Evaluation of blood transfusion rates by blood loss estimation techniques

Background Postpartum hemorrhage is a major cause of maternal morbidity and mortality. Though the American College of Obstetricians and Gynecologists and quality improvement initiatives recommend the use of a quantitative measurement of blood loss, it is not known if the quantitative measurement compared to visual estimation of blood loss improves maternal outcomes. Objective To compare rates of red blood cell transfusion between a quantitative measurement and visual estimation of blood loss. Study design This was a retrospective cohort study of all women who underwent cesarean delivery at a single academic institution from January 2012 to June 2018. Women were excluded if they received a preoperative transfusion or had missing data. Our institution implemented a quantitative measurement of blood loss in September 2015. Our primary outcome was red blood cell transfusion (intraoperative or postoperative). Women who had the quantitative measurement of blood loss (October 2015 to June 2018) were compared with those who had a visual estimation of blood loss (January 2012 to August 2015). Coarsened Exact Matching with a k-to-k solution was performed using predefined variables. Results In total, 4068 had a visual estimation of blood loss and 3117 had the quantitative measurement of blood loss; 1101 women with the quantitative measurement of blood loss were matched to 1101 women with a visual estimation of blood loss. In the unmatched cohort, women who had the quantitative measurement of blood loss compared to those who had a visual estimation of blood loss were more likely to have an increased amount of blood loss (734 ml vs. 700 ml, p < .001) and red blood cell transfusion (7.2% [223/3117] vs. 5.4% [221/4068]; crude odds ratio 1.34; 95% confidence interval 1.11–1.63). This increase in the amount of blood loss (717 ml vs. 700 ml, p < .05) and the rate of red blood cell transfusion (4.5% [49/1101] vs. 2.7% [30/1101]; crude odds ratio 1.66; 95% confidence interval 1.05–2.64) remained statically significant after matching. Conclusion Women who had the quantitative measurement compared with those who had a visual estimation of blood loss were more likely to have an increased amount of blood loss and red blood cell transfusion.