Improving the accuracy of estimated blood loss at obstetric haemorrhage using clinical reconstructions

Abstract

Objectives Following the results of the Confidential Enquiries into Maternal Deaths report, which claims two maternal deaths annually in the UK from postpartum haemorrhage, our aim was to assess the accuracy of ‘visual estimation of blood loss’ and produce suitable pictorial and written algorithms to aid in the recognition and management of massive obstetric haemorrhage. Design Observational study to determine discrepancy between actual blood loss (ABL) and estimated blood loss (EBL). Setting Teaching hospital. Population Hundred and three obstetricians, anaesthetists, midwives, nurses and healthcare assistants. Methods Clinical scenarios were reproduced in the form of 12 Objective Structured Clinical Examination (OSCE) style stations augmented with known volumes of whole blood. Individual staff estimated the blood loss visually and recorded their results. Digital photographs were used to produce a pictorial ‘algorithm’ suitable for use as a teaching tool in labour ward. Main outcome measures Areas of greatest discrepancy between EBL and ABL. Results Significant underestimation of the ABL occurred in 5 of the 12 OSCE stations: 500‐ml (50‐cm diameter) floor spill, 1000‐ml (75‐cm diameter) floor spill, 1500‐ml (100‐cm diameter) floor spill, 350‐ml capacity of soaked 45‐ × 45‐cm large swab and the 2‐l vaginal postpartum haemorrhage on bed/floor. Conclusions Accurate visual estimation of blood loss is known to facilitate timely resuscitation, minimising the risk of disseminated intravascular coagulation and reducing the severity of haemorrhagic shock. Participation in clinical reconstructions may encourage early diagnosis and prompt treatment of postpartum haemorrhage. Written and pictorial guidelines may help all staff working in labour wards.

Bedside assessment of fibrinogen level in postpartum haemorrhage by thrombelastometry

“…In our series, the median CT was higher and the median clot amplitudes (CA 5 , CA 15 and MCF) were significantly lower in PPH than in controls. There were also strong correlations with the FIBTEM values and the fibrinogen levels in both groups.…”

“…Our study shows that (i) FIBTEM parameters of the ROTEM correlate well with fibrinogen levels in PPH; (ii) it is possible to define cut-off values for ROTEM parameters corresponding to transfusion threshold values of fibrinogen during PPH and (iii) early detection of fibrinogen decrease is possible by using CA 5 -FIBTEM or CA 15 …”

“…The early detection of PPH and its rapid management are important to improve prognosis. Simple measures, such as accurate quantification of immediate postpartum blood loss 15 or staff education, 16 favour the early detection of PPH. Rapid implementation of obstetrical or intensive care procedures reduces the incidence of serious cases of PPH and improves the prognosis for these patients.…”

“…Sensitivity, specificity and negative/predictive values were determined for several fibrinogen levels in both groups. Cut-off values for CA 5 and CA 15 were chosen to optimise the negative predictive value in patients with fibrinogen levels below 2 g/l. A two-tailed P-value £0.05 was considered significant.…”

Mesh repair of vaginal wall prolapse

“…Prolapse stage was assessed pre operatively and at each visit post operatively. Blood loss at the time of surgery was assessed by assessment of blood loss during surgery with the help of amount of blood soaked on various types of swabs used in surgeries, 5 measuring the preoperative haemoglobin, immediate postoperative haemoglobin, assessment of vital parameters in the immediate postoperative period.…”